KUWAIT MEDICAL JOURNAL March 200228

Original Article

Comparative Study of Closed and Open Methodsin Sacrococcygeal Pilonidal Sinus Management –

Results of Advancement Gluteal FascioCutaneous Flap – in Jahra Hospital

Address correspondence to:Dr. Maged Ali Gamal Hassan, Surgical Department, Al-Jahra Hospital, Jahra, Kuwait. Tel: (965) 457-5300; fax: (965) 458-2078; (965) 458-9414.E-mail: hnur@ lycos.com

Kuwait Medical Journal 2002, 34 (1): 28-32

ABSTRACTObjective: To assess two techniques in the managementof sacrococcygeal pilonidal sinus.Design: Prospective randomized studySetting: Al-Jahra Hospital, Kuwait.Subject: Of a total of 105 patients with chronic pilonidalsinus disease, 56 were treated by advancementfasciocutaneous flap and 49 by an open wound techniqueafter excision.Main Outcome: Morbidity and Recurrence Result: The study was carried out between March 1997and April 2000. The mean hospital stay was 3.7 days forthe advancement fasciocutaneous flap and 7 days for theopen wound method. The mean operative time was onehour for the flap method and 20 minutes for the caseswhere the wound was left open. The mean follow up

Magid AG Hassan, Ali Mohmed Ali Nur, Vinod K Grover, Ibrahim Wafai,Majid Mahmoud Nasr, Mohamed Nabeel Riyad Surgical Department, Al–Jahra Hospital, Jahra, Kuwait

was 20 months (range 6-40 months). A total of 10 cases(18%) that underwent the flap technique had minorcomplications in the form of wound seroma andinfection, bursting of skin sutures, local numbness andchronic pain while 12 cases (24%) of the open woundtechnique had complications in the form of bleeding,pain and chronic infection. Delayed healing, up to 11months, was noted in seven cases (18.4%) of the openmethod cases. Recurrence occurred in two cases (3.6%) ofthe advancement flap technique, and nine cases (19.4%)of the open method technique.C o n c l u s i o n : Excision and closure by gluteal fasciocutaneous flap compares favorably with leaving thewound open after excision in the treatment ofsacrococcygeal pilonidal sinus.

INTRODUCTIONSince first reported 130 years ago by Anderson[1],

the surgical treatment of sacrococcygeal pilonidalsinus, a benign yet troublesome disability of youngadults, is not a minor procedure. It is characterizedby a diversity of approaches and techniques, whichimplies that no single method of therapy has beencompletely satisfactory.

Excision and leaving the wound open was thetreatment method favored by the surgeons at ourhospital before the start of this study in 1997, butthe recurrence rate was high. Our group used manytechnically demanding techniques in the primaryclosure of the wound after excision but these weredifficult to apply in the general hospital. In theliterature, it is recommended that these techniquesbe done in recurrent and complicated cases[2,3]. Westarted a randomized trial in March 1997 to studythe results of excision and primary closure byadvancement glueteal fasciocutaneous flapcompared with excision and leaving the wound to

determine the most appropriate method, whichwould not only eradicate the obvious lesion butalso have a low recurrence.

PATIENTS AND METHODFrom March 1997 to April 2000, 105 cases with

symptomatic chronic pilonidal sinus of the natalcleft were treated. The duration of symptomsranged from 1 month to 2 years (mean = 7 months).All cases were followed until the end of the study.A total of 99 men (mean age = 26 years) and sixwomen (mean age 22 years) were randomized toreceive either excision and closure by glutealadvancement fasciocutaneous flap or excisionwithout closure. Assigning the techniquealternately randomized the cases. When there wasonly one case on the operation list, it was done bythe flap method. The study protocol was given tothe patient in the surgical outpatient clinic prior totheir enrollment in the study.A single team handledall cases. A total of 56 cases underwent

KEYWORDS: advancement gluteal fasciocutaneous flap, chronic pilonidal sinus, open wound technique recurrence

KUWAIT MEDICAL JOURNAL 29March 2002

advancement gluteal fasciocutaneous flapoperation (52 males and 4 females) while 49 casesunderwent the excision and open wound operation(47 males and 2 females). Multiple sinus openingswere found in 72 cases (43 in flap cases and 29 openwound cases). Lateral openings were found in 24cases (11 in flap cases and 13 open wound cases).Two flap cases and three open wound cases hadearlier undergone drainage of pilonidal abscess. Allpatients were admitted to the hospital the daybefore the operation. They were allowed fluidsonly after lunch and rectal enemas were given inthe afternoon. On the morning of the operation, thenatal cleft was shaved and disinfected withchlorhexidine solution and covered with sterilegauze. All patients received a single dose ofceftriaxone, 1 gm, before induction of anesthesia.

Technique of operation:Both operations were done in the pro n e

position. The buttocks were strapped apart, and theskin was prepared. The sinuses were probed to planthe extent and direction of skin excision. Ellipticalincision was done involving the diseased skin anddeepened down perpendicular to the skin incisionto the fascia covering the sacrum. The medial tissuewas excised in block, looking for granulation tissueand sinus tracts at the lateral edges. The excised

specimen was checked for incomplete excision. Ifso, the wound was explored for more lateralexcision. These steps were done before use of thediathermy for hemostasis. The open wound casesended at that stage when the wound was packedwith sterile gauze.

In the gluteal fasciocutaneous advancement flapcases (Fig. 1), the lateral crest of the sacrum and thedeep fascia over the gluteus maximum muscle onboth sides was identified. This fascia was elevatedon either side by undermining and was separatedfrom the sacral fascia and underlying muscle for atleast 5 cm or until it become mobile. The dissectionwas done at the upper and lower end also.Hemostasis is crucial. Closure of any lateral deadspace on both sides was done by vicryl/oo. The twofascial flaps overlapped in the midline, and weresutured together (double-breasted) and fixed to thesacral fascia. Closure of the subcutaneous tissue inthree layers was done in order to evert the skin flap.The skin was closed using interrupted orsubcuticular stitches. No drains were used (Fig. 1).

The following protocol was strictly adhered topostoperatively in both techniques: The patient wasnursed on his/her side, or prone, for the first 24hours. The wound was exposed on the secondpostoperative day and, if found clean, the patientwas discharged home that day. Daily dressing inthe clinic was advised to patients with the openwound technique and every third day for flap casesuntil sound healing was realized.

Follow - upThe patient were seen in the surgical outpatient

clinic for wound inspection and removal of stitchesafter 10 days from the operation day in flap casesand inspection of open wound in the open woundcases weekly. All symptoms, signs, the time ofcomplete healing and recurrence were recorded inan analysis scheme for each case every 3, 6, 12weeks and then every 3 months. The patients wereinstructed to shave the natal cleft monthly for sixmonths after the operation

RESULTSThe operating time for open wound cases was 20

minutes (range 15 to 30 minutes) and one hour forflap cases (45 minutes to 2 hours). The follow upresults of the 105 patients after a median of 20-month follow up (range 6 – 40) are shown in Table 1.

In flap cases, seroma collections were treated byaspiration once in two cases and three times in onecase. Wound infection and abscess formation of thethree cases were treated by removal of the skinsutures, daily dressing and antibiotics according tothe culture and sensitivity of the organism. Allhealed in 2-3 weeks. The seven cases of minor

Fig. 1 a: Patient in jack knife position with buttocks taped laterally.Fig. 1 b: Flaps of gluteal fascia developed for primary closure.Fig. 1 c: A proxinmation of flap in midline (from mandels Rand Thomas,CG, JR Surg Gyneco Obst 134,449).

1 a:

1 b: 1 c:

Comparative Study of Closed and Open Methods in Sacrococcygeal Pilonidal Sinus Management – Results of Advancement Gluteal Fascio Cutaneous Flap – in Jahra Hospital March 200230

sinus but should also aim to eliminate factors thatp redispose the formation of another sinus [ 8 ].M e r s h[ 5 ] extensively surveyed the literature onvarious operations and their results. In general, thecurrent approaches are one of the three differentoperative procedures: excision and open woundwhich ends with healing by secondary intentionwithout a change of anatomy; excision withmarsupialization in which the sinus or sinuses aresplit over the probe and edges of the skin aresutured to the margin of the remnant of cyst orsinus; and excision with primary closure either byleveling the internal groove or the completeobliteration of the natal cleft[5]. Judging the resultsof the different procedures is difficult because fewauthors have given adequate consideration to allthe medical, economic and social aspects of theseprocedures. Spivak[9] described important factorsthat should be considered in evaluating differentprocedures (Table 2)

In our study, we used two techniques, whichw e re applied randomly on 105 patients. Openwound method, which was used by Hopping in1 9 5 4[ 1 0 ] and dealt only with the pilonidal cyst. Therationale of this pro c e d u re is the avoidance ofprimary closure of a contaminated wound[ 9 ]. Theother method used was excision of pilonidal sinusand closure by advancement gluteal fasciocutaneousflap, which was initially described by Holman in

wound breakdown healed on daily dressing withintwo weeks. The numbness over the sacral areaimproved in 4–6 weeks time. The cases of delayedhealing due to breakdown of the wound or as aresult of wound infection healed without leading toestablished recurrence.

In the open wound technique cases, woundbleeding was encountered in four cases (8%).Bleeding stopped with packing except in one casewhere exploration of the wound under anesthesiaand ligation of the bleeding vessel was required.Wound breakdown, after complete healing,persisted for three months in two cases. Delayhealing developed up to 11 months in two caseswith established recurrence.

Only two of the 56 cases (3.6%) who underwentexcision and flap closure developed re c u r re n c e .Both underwent exploration at 3 and 6 monthsand overlooked tracts to the anore c t a lintersphincteric space and ischiorectal fossa werefound, which were respectively drained and thewound was left open. Nine cases (18.4%) tre a t e dwith excision and open wound techniquedeveloped re c u r rence; seven of them establishedafter an average delayed healing of 11 months(range 6-18 months). The other two casesdeveloped after 21 and 30 months. The meanhospital stay was 3.7 days (range 2 to 8 days) forthe patient whom the flap method was used and 7days (range 2 to 17 days) for the patient treated bythe open wound method.

Patient satisfaction was 98% in the flap methodand only 75% in the open wound method. Thepatients who underwent the excision and openwound technique were reported absence from workup to 45 days (range = 21 to 60 days) but the caseswho underwent flap technique reported absencef rom work up to 20 days (range = 15 to 30 days).

DISCUSSIONPilonidal sinus disease is a common condition

described by Mayo[4] more than 160 years ago. It canbe associated with considerable morbidity andhave significant socioeconomic impact on affectedi n d i v i d u a l s[ 5 ]. The etiology of this disease isdebatable. Hodges in 1880 introduced the termpilonidal and proposed a theory of congenitalo r i g i n[ 6 ]. A century later, Patey[ 7 ] postulated thetheory of an acquired condition which is nowwidely accepted. The major cause of pilonidal sinusunderlying this theory involves the insertion ofloose hair that collect in gluteal furrow[8].

Despite numerous studies that have beenconducted so far, there has not been universalagreement about the perfect surgical procedure forpilonidal sinus, probably because there is none[9].Surgery should not only eradicate the presenting

Table 1Follow up results of both operations figures expressed asnumber and (%) of patients

Early Complication Excision and gluteal Excision and lay(Total cases =105) fasciocutaneous flap opening

(n = 56) ( n = 49)n (%) n (%)

BleedingMinor wound break downSeromaWound infection or abscessHaematomaChronic PainNumbnessInduration of the woundDelay healingTotal number of patients

07 (13)3 (5)3 (5)1 (2)2 (4)4 (7)6 (11)4 (7)

10 (18)

4 (8)6 (12)08 (16)06 (12)2 (4)5 (10)9 (18)

12 (24)

Table 2Important factors to be considered in evaluating differentprocedures[9]

Procedure Post operative Healing Wound RecurrenceComplication time care rate

Primary closure +++ + + ++Secondary intention ++ +++ +++ ++Marsupialization + ++ ++ +

KUWAIT MEDICAL JOURNAL 31March 2002

1 9 4 6[ 11 ] and then modified by Stanley in 1972[ 1 2 ] but isnot widely practiced. This procedure removes thepathology and deals the etiological factors bystrengthening and leveling the natal cleft[12]. Forease of comparison, the results of both techniquesare shown in Figures 2-4.

Operative time for primary closure was longerthan open wound, but it reduced after the first fivecases from 90 minutes to one hour or less. Thesurvey of Mersh reported the same re s u l t s[ 5 ]. Themain complication in our study was delayedhealing in open wound cases, which ended inestablished re c u r rence in seven cases and woundinfection. In most series, primary wound infectionand delay healing outnumber re c u r re n c e s[ 11 ]. Themain complication of the flap technique, which isnot a completely tension-free re p a i r, was woundb reakdown, which improved with wound carewithout any other complication. Numbnesso c c u r red in four cases (7%), which is less than 50%reported by other pro c e d u res of primaryc l o s u re[ 1 3 ].

In this study, the recurrence in the flap methodis low (3.6%). Stanley[12] found no recurrence onapplication of this procedure. On the other hand,the recurrence rate of the open wound method was18.4% (7 cases). One pertinent fact in reviewing theliterature is an almost linear decrease in the numberof recurrences for open wound method. In thestudy of Hadar et al[9], a 13% recurrence rate wasreported. It has been observed that recurrencesdeveloped within the first year after primaryc l o s u re and re c u r rences after the open woundtreatment often appear later[14]. The two cases ofrecurrence in the flap technique of our study werecaused by overlooked sinuses. It was reported byKronborg[15] that recurrence within three months iscaused by an overlooked sinus.

Open wound technique suffers thedisadvantage of prolonged mean hospital staywhen compared with the flap technique (7:3.7days). The patients after open wound techniqueneed clinic attendance for many painful dressingchanges, causing burden to the patient and surgeonfor months until healing is absolutely sound.Disability recorded in our study is 45 days asc o m p a red to 20 days for the flap method.However, it is questionable whether or not thesepatients were able to return to full employmentwith sensitive open wounds. It would seem that theperiod of true disability was not fully explained inmost of these studies[5]. It is obvious in our studythat the patient accepted and were satisfied withthe closing of wound by a simple procedure ratherthan leaving the wound open to heal by secondaryintention (98%:75%). This is also better than the67% reported after Z-plasty [16].

Fig. 2: Operative time in minutes

Fig. 3: Comparison of complication, recurrences and patients satisfactionof the two procedure

Fig. 4: Mean hospital stay and absence of work in days for the twooperation

CONCLUSIONThis study has shown that the excision of

s a c rococcygeal pilonidal sinus and closure byadvancement gluteal fasciocutaneous flap ispreferable to excision and leaving the wound inmany aspects; less bleeding, lower infection rate,reduced wound pain, fewer post operative visits,faster healing time, shorter time off work and lessrecurrent rate. This method also eliminates some of

Comparative Study of Closed and Open Methods in Sacrococcygeal Pilonidal Sinus Management – Results of Advancement Gluteal Fascio Cutaneous Flap – in Jahra Hospital March 200232

the factors that predispose to the recurrence andcan be practiced by general surgeons. In any event,the patient should be aware of the potentialcomplications, recurrence rate, post-operative careand expected healing time of the diff e re n talternatives.

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