Oblique Excision and Primary Closure of Pilonidal Sinus (Sacrococcygeal)
Al-Metwaly Ragab Ragab Ibrahim
Pilonidal sinus is a chronic disease of young age located at the sacrococcygeal region and is found mostly in males. The pathogenesis is generally accepted as the invagination of hair into the skin, followed by foreign body reaction leading to inflammation and abscess formation. The best surgical technique for sacrococcygeal pilonidal sinus is still controversial. The aim of this study was to examine outcome of oblique excision and primary closure of pilonidal sinus on recurrence rate. Between November 2008 and December 2010, 84 patients (69 male, 15 female; average age = 22.4 (12-42 years) were operated on for primary pilonidal sinus. An oblique fusiform-shaped incision was made and the skin with sinus was completely excised. The operation was completed with insertion of subcutaneous suction drain and primary closure of subcutaneous and skin. Patients follow up was made at the end of the 4 weeks and 2, 4, 6, 12 and 18 months after surgery. Duration of symptoms ranged from 1 to 73 months (mean 20.02±7.87). Hospital stay duration ranged from 2 to 5 days (mean of 3.21±0.67), drain duration ranged from 3 to 11 days (mean 5.78±1.29). Wound dehiscence developed in 4 patients (4.8%). Healing by secondary intention occurred in 3 patients (3.5%) and recurrence in one patient (1.2%). The technique of oblique excision and primary closure may be considered one of the best operations for pilonidal sinus resulting in a low recurrence rate.
March 11, 2012; Accepted: May 17, 2012;
Published: June 22, 2012
Sacrococcygeal Pilonidal Disease (SPD) is a disease arises in hair follicle
in the buttock cleft at the bottom of the sacral area. It is an acquired chronic
inflammatory disease (Muzi et al., 2010). It
is seen in young adults and the estimated incidence is 26 per 100,000 people
and the condition is most frequent among men in their third decade of life.
It carries high postoperative morbidity and patient discomfort (McCallum
et al., 2007).
The etiology of SPD is unknown but it may relate to the implantation of loose
hair into the depth of the natal cleft. A deep natal cleft is one of favorable
environments for factors enhance SPD, e.g., sweating, maceration, bacterial
contamination and penetration of hairs. Factors that influence SPD are the force
of implantation, the nature of the hair and the vulnerability of the skin (Golberg
et al., 1980; Aydede et al., 2001;
Aldemir et al., 2003). During World War II, 78,924
patients were treated for SPD. Buie (1944) described
the disease as Jeep disease because it was believed to be caused
by sitting in vehicles for a long time. The condition is also known to occur
in the interdigital spaces in barbers (Patey and Scraff,
1948), sheep shearers (Phillips, 1966) and dog groomers
(Mohanna et al., 2001). A pilonidal dimple discovered
accidentally without symptoms not require any treatment, but pain and purulent
discharge with recurring acute abscess symptoms requires definitive treatment
(Krand et al., 2009).
A wide variety of treatments have been advocated for SPD ranging from conservative
nonsurgical treatments to extensive resections (McCallum et
al., 2007, 2008). The management is controversial
as many treatment options are available. It includes excision with primary closure,
cleft lift (Bascom and Bascom, 2007), transposed rhomboid
flap (Arumugam et al., 2003), Limberg flap (Erylimaz
et al., 2003), VY fasciocutaneous flap (Schoeller
et al., 1997) or Z-plasty (Sharma, 2006).
However, there is no clear consensus as to optimal treatment and none of these
approaches eliminates the risk of recurrence (McCallum
et al., 2007; Aldemir et al., 2003;
Aydede et al., 2001; Holzer
et al., 2003; Abu Galala et al., 1999;
Chintapatla et al., 2003).
Holmebakk and Nesbakken (2005) indicated that traditional
midline techniques for pilonidal sinus repair give a high wound infection rate,
high recurrence rate and a long time to heal. The ideal treatment should be
simple, with low morbidity and recurrence rates, hospitalizations should be
short with painless postoperative periods and good wound healing and the patient
should have an early return to normal activity (Al-Jaberi,
2001). However, the major concern in this type of surgical procedure is
disease recurrence. The recurrences can be reduced by avoidance of vertical
midline wound in the natal cleft. The second concern is prolonged wound healing
either because of the infection or excess tension (Unalp
et al., 2007). The aim of the present study was to evaluate the results
of oblique excision and primary closure technique for treatment of sacrococcygeal
MATERIALS AND METHODS
This study included 84 patients who underwent surgery for primary pilonidal sinus disease in sacrococcygeal region. All procedures were performed in the Department of General Surgery at El-Azhar University Hospital (Damietta) between November 2008 and December 2010. The data obtained were age, gender, body mass index, duration of the symptoms, past history of drainage, duration of hospital stay and duration of removal of drain. Follow-up examinations were conducted at 4 weeks and 2, 4, 6, 12 and 18 months after surgery. All patients were operated on under spinal anesthesia. A single dose of second generation cephalosporin 1 g was administered i.v., 30 min before skin incision for prophylaxis against wound infection and continued postoperatively for 2 days (i.v., B.I.D), followed by oral rout for 7 days. Postoperative pain management consisted of diclofenac sodium 75 mg i.m., B.I.D, for 2 days followed by oral administration of (NSAID) for 5 days.
Surgical technique: Following medical evaluation, the patients were
admitted to the hospital the night before operation. The sacrococcygeal area
was shaved one hour before surgery. After satisfactory spinal anesthesia, the
patients were placed in the prone, jackknife position, with the buttocks strapped
apart with the use of adhesive bands. The extent of sinus was determined by
injection of methylene blue through the opening of sinus and palpation. The
site of skin incision was marked by an oblique fusiform line (Fig.
1), which include all opening of sinus and its extension. After sterilization
and d r aping, skin incision was taken down with subcutaneous tissue until complete
excision of sinus and surrounding subcutaneous tissue en bloc (Fig.
2), taking care to avoid cutting through the sinus which identified by bluish
discoloration of track or leak of dye. Warm wet packs were applied for 5 min
and then hemostasis was accomplished by electrocauterization. After removing
the specimen, subcutaneous suction drain was inserted through separate stab,
followed by wound closure achieved by deep mattress stitches using polypropylene
0 through the skin, subcutaneous tissue and floor of the wound which lifted
untied to allow subcuticular skin closure of wound using polypropylene (2/0)
followed by tying mattress stitches (Fig. 3).
||The site of skin incision marked by an oblique fusiform dotted
line, which include all opening of sinus and its extension
||The wound after Complete excision of sinus and surrounding
subcutaneous tissue en bloc
||Wound closure achieved by deep mattress sutures of the skin,
subcutaneous tissue and floor of the wound with polypropylene 0 and subcuticular
skin closure with polypropylene 2/0
All patients were permitted to rest for 20 days after the operation for wound
healing. Sutures were removed 15-21 days after surgery. After suture removal,
the patients were able to return to their normal daily activities.
The present study included 84 patients, 69 (82.1%) were males and 15 (17.9%) were females. The most observed symptoms alone or together were pain in 63 cases (75%), swelling in 42 cases (50%) and occasional discharge in 34 cases (40.7%). Wound dehiscence developed after the removal of sutures in 4 patients (4.8%), no hematoma occurred. Healing by secondary intention occurs in 3 patients (3.5%) (Fig. 4) and recurrence occurred in one patient (1.2%), (Table 1).
Fourteen cases (16.6%) had a history of abscess drainage before the definitive surgery, while 70 patients (83.3%) had not undergone abscess drainage before the definitive surgery (Data not presented).
The average age was 22.41±5.59 (range, 12-42) years. Weight ranged from
40 to 100 kg with a mean of 69.25±7.42 kg, height ranged from 1.50 to
1.83 m with a mean of 1.70±0.056 m. The BMI ranged from 17.87-32.65 with
a mean 23.88±1.40 kg m-2. Duration of symptoms ranged from
1 to 73 months with a mean of 20.02±7.87 months.
|| Frequencies of gender, complaint and complications after
||Female patient in which complete healing of the wound by secondary
intention occur after wound dehiscence 2
||Descriptive statistics of age, patients some morphological
description and duration of symptoms and hospital stay in studied cases
The duration of hospital stay ranged from 2 to 5 days with a mean of 3.21±0.67
days while duration of drain ranged from 3 to 11 days with a mean of 5.78±1.29
days (Table 2).
Chronic SPS is a frequent disease among young male adults resulting in distressing
symptoms and long-term loss of working ability. A pilonidal dimple discovered
accidentally and had no symptoms require no treatment, but pain and purulent
discharge with recurring acute abscess symptoms requires definitive treatment
(Krand et al., 2009). Primary closure was reported
to be the method of choice in treatment of pilonidal disease. It has the advantage
of shorter wound healing and less time off from work. However, the recurrence
potential of the disease is still a major problem (Unalp
et al., 2007; Mentes et al., 2006;
Akinci et al., 2000).
The midline excision was reported to have a high rate of complications and
recurrences. The depth of the intergluteal sulcus and the vacuum effect created
between the buttock and incision scar in the intergluteal line are responsible
for recurrence (Mentes et al., 2008).
On the other hand, we choose the technique of oblique incision as it provides
less tension on the incision, shorter healing time and no remaining incision
scar on the intergluteal line. The present study included 84 patients, 69 (82.1%)
were males and 15 (17.9%) were females and these results are in agreement with
that reported by Guyuron et al. (1983) who reported
that, sacrococcygeal pilonidal disease afflicts mainly young adults after puberty
and occurs predominantly in males (80%). In addition, a Norwegian study estimated
the incidence of disease at 25 per 100,000 (Sondenaa et
al., 1995). The patient population is predominantly males. On the other
hand, Mentes et al. (2006) reported that, of
the 493 patients, 490 (99.4%) were males and 3 (0.6%) were females. Their results
reflected a fact that the disease is nearly exclusive to males and the percentages
of males are higher that reported in the present work. This wide difference
may be attributed to different sociocultural factors and to small sample size
of the present study in comparison to their study.
Weight ranged from 40 to 100 kg with a mean of 69.25±7.42 kg, height
ranged from 1.50 to 1.83 m with a mean of 1.70±0.056 m. The BMI ranged
from 17.87±32.65 with a mean 23.88±1.40 kg m-2. These
results are in agreement with that reported by Mentes
et al. (2006) who reported that, the mean Body Mass Index (BMI) of all
cases was 24.66 T 2.65 (range, 17.72-34.16) kg m-2.
In addition, Cubukcu et al. (2001) emphasized
that obesity alone is not a predisposing factor. Majority of our patients had
normal BMI. This supports the opinion that obesity is not a predominant factor
for pilonidal sinus but pilonidal sinus occurs as a result of the combination
of factors such as local trauma, poor body hygiene, too much sweating, deep
natal cleft and excessive exercise.
Duration of symptoms ranged from 1 to 73 months with a mean of 20.02±7.87
months, indicating the chronicity of the disease process. These results are
in accordance with that reported by Mentes et al.
(2006) who reported that, the mean duration of symptoms was 22.09±17.12
(range, 1-120) months.
In the present study, the most observed symptoms alone or together were pain
in 63 cases (75%), swelling in 42 cases (50%) and occasional discharge in 34
cases (40.7%). These results are comparable to those reported by Mentes
et al. (2006) who reported that, the most observed symptoms alone
or together were pain in 82%, mass or swelling in 80% and occasional discharge
in 36%. On the other hand, Sondenaa et al. (1995)
noted discharge in 66%, swelling in 50% and pain in 35% of patients with chronic
pilonidal disease at presentation. This difference reflects the wide variation
of presentation of chronic pilonidal sinus.
In the present work, the duration of hospital stay ranged from 2 to 5 days
with a mean of 3.21±0.67 days. These results are in agreement with Akinci
et al. (2000) who operated on 92 patients using an asymmetric elliptical
excision and primary closure and the mean length of hospital stay was 2.8 days.
In addition, Al-Hassan et al. (1990) operated
on 46 patients with excision and closure and the mean length of hospital stay
was 3 days. On the other hand, These results are shorter than those reported
by Mentes et al. (2006) who reported that, the
mean duration of hospital stay was 5.51±2.85 (range, 2-17) days. This
may attributed to the large number of cases they included in their study with
increased number of complicated cases that needs other surgical interference.
They reported that, twenty-two patients (4.4%) had recurrent disease and required
one or more additional procedures. The recurrence rate in the present study
was only 1.2%.
In the present series, no hematoma or seroma occurred due to presence of suction
drain. Erdem et al. (1998) performed the closed
suction drainage on solely half of their patients; however, they did not find
any statistically significant differences between the two groups regarding the
length of hospital stay, infection and the rate of hematoma. Krand
et al. (2009) believed that performing a fastidious hemostasis by
electrocautery and reduction of dead sections in the surgical area reduces the
development of hematoma or seroma to a minimum and eliminates the need for drainage.
In the present study, wound dehiscence developed after the removal of sutures
in 4 patients (4.8%), repeated daily dressing for 40-60 days till complete healing
which occurred in 3 patients. These results agreed with that reported by Mentes
et al. (2006) who reported that, wound dehiscence was less prevalent
in comparison to other studies after the removal of sutures because the majority
of their patients BMI was within the normal range.
No infection after operation was reported in the present study. These results
are in contradiction to those reported by Petersen et
al. (2002) found infection in 11.1% of 1731 patients. Spivak
et al. (1996) and Akinci et al. (2000)
found infection rates of 14% and 3.2%, respectively. A second generation cephalosporin
1 g twice daily for 2 days followed by oral administration for 7 days. This
treatment regimen was found effective for controlling the postoperative infection
In the present study, recurrence occurred in one patient (1.2%). This value
is lower than that reported in the literature. They reported that, recurrence
rate for oblique excision and primary closure varies from 9.4 to 11% (Akinci
et al., 2000; Petersen et al., 2002).
Sondenaa et al. (1995) operated on 120 patients
with a median follow-up time of 4.2 years and recurrence was noted in 5%. Al-Hassan
et al. (1990) operated on 46 patients with a median follow up of
33 months and recurrence was noted in 20%. Al-Jaberi (2001)
operated on 46 patients with recurrence noted in 4%. In addition, it was reported
that, the recurrence rate for primary midline closure was reported as 9 to 17.9%
(Topgul et al., 2003), whereas the recurrence
rate for oblique excision with primary closure was 0.9 to 5.6% (Mentes
et al., 2006; Akinci et al., 2000).
These data reflects the best results of oblique incision in comparison to primary
The technique of oblique excision and primary closure is simple, with low morbidity and recurrence rates with short hospitalizations and painless postoperative periods with good wound healing. Patients returned early to their normal activity. So, it considered one of the best operations for pilonidal sinus.
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