TRICK OF THE TRADE

Loop drainage after debridement (LDAD): minimally invasivetreatment for pilonidal cyst

I. Qayyum1• D. Bai1 • S. S. Tsoraides1

Received: 13 January 2016 / Accepted: 29 March 2016

� Springer-Verlag Italia Srl 2016

Introduction

Pilonidal disease is a subcutaneous infection occurring in

the upper half of the gluteal cleft. Often, pilonidal disease

presents as acute pilonidal abscess and requires treatment

accordingly with an incision and drainage procedure. The

principles of the Bascom-type treatments, such as the cleft

lift, rely on the premise that pathogenesis originates at the

epidermal level of the midline pit that harbors embedded

hair follicles [1]. Definitive management of pilonidal cyst

remains a challenge and often requires morbid wounds [2].

More complex techniques do not obviate the risk of failure

or recurrence. As a result, less invasive and less complex

techniques are desirable as the first-line management of

pilonidal cyst. With this in mind, we invoke the principles

of loop drainage of abscesses as described by Tsoraides

et al. [3] in the pediatric population.

Maintaining the principles of addressing the inciting

epidermal insult, the above-mentioned strategy for

managing abscesses, and the overarching principle of

employing least invasive techniques, we describe an easy

to perform, minimally invasive approach for the treatment

of pilonidal disease that is effective and minimizes com-

plexity of care for the surgeon and patient.

Methods

This is an IRB-approved retrospective review of patients

treated for pilonidal disease within a single practice from

8/2011 to 7/2014. Patients were identified using ICD-9

codes related to pilonidal disease. All patients treated for

codes related to pilonidal cyst and all employed techniques

were included for review. Patients were selected for LDAD

based on single surgeon preference.

Technique

Skin is cleared of hair. Midline pit(s) is cored out. Counter

incision(s) of 1 cm or less are made at farthest extent of cyst

cavity (Fig. 1). Number of incisions is tailored to size and

shape of cavity. Residual hair debris is removed (Fig. 2).

Aggressive curettage and debridement are performed

through the small incisions to disrupt the walls of the cyst

cavity and promote scarring (Fig. 3). Irrigation with diluted

hydrogen peroxide is followed by saline rinse (Fig. 4).

Vessel loops are passed from themidline pit(s) to the counter

incision(s) and secured as a loop with silk suture (Fig. 5). An

absorbent dressing is applied to cover and seal the top and

sides of the wound. Dressing is changed daily. Patients are

instructed to shower and/or bathe daily and keep the entire

area clean, shaved, and covered until one week after the

drains are removed and the incisions are healed.

Results

A total of 102 patients were treated for pilonidal disease.

Eighty-five underwent traditional procedures by multiple

surgeons including drainage, unroofing, open debridement,

& I. Qayyum

imad.qayyum@gmail.com

1 University of Illinois College of Medicine at Peoria, Peoria,

IL, USA

123

Tech Coloproctol

DOI 10.1007/s10151-016-1469-8

and/or excision. Seventeen underwent LDAD procedure by

a single surgeon. Failure was considered recurrence of

disease and/or need for reoperative intervention.

Of the 85 patients undergoing traditional procedures, 55

(64.7 %) were male and 30 (35.3 %) were female. Within

the LDAD arm, 13 (76.4 %) were male and 4 (23.6 %)

were female. Mean BMI between the traditional procedure

arm versus LDAD arm was 31.9 versus 31.4. Mean age

between the two was 31.0 versus 34.6. Thirty-six (42.4 %)

of patients undergoing traditional procedures had either

recurrent or chronic disease; this was the case in 10

(58.8 %) of patients undergoing LDAD.

Success was considered healing with resolution of

symptoms and drainage without recurrence or need for

reoperation. Nine failures occurred in 102 patients (91 %

success): Six failures occurred in the group undergoing a

traditional approach (93 % success); three failures occurred

Fig. 1 Coring out of midline pit(s) with creation of counter

incision(s)

Fig. 2 Removal of residual hair debris

Fig. 3 Aggressive curettage and debridement

Fig. 4 Hydrogen peroxide irrigation followed by normal saline rinse

Fig. 5 Passage of vessel loop across cored out midline pit and

counter incision

Tech Coloproctol

123

in the LDAD group (82 % success). Mean drain duration

within the LDAD arm was 19.9 days with 8 (47 %)

needing more than one drain to control the abscess. Mean

duration of treatment from initial visit to final was 87.4 for

the traditional group and 78.4 days for the LDAD arm

(p = 0.34). This was used as a marker for complete healing

time. Mean time of follow-up was 569.7 versus 448.4 days,

respectively.

Discussion and recommendations

Our success rate using LDAD (82 %) compares well to

those reported in the literature for other techniques (84 %)

[4]. There were a total of three failures in the LDAD

treatment arm; hence one must speculate the reason for

this. In all three of these failures, these patients each

required more than one drain to control the abscess. In one

patient, a drain fell out prematurely leading to recurrence.

For him, the LDAD procedure was repeated with success.

For the other two, wide excision was employed after pro-

longed follow-up with indolent symptoms persisting (139

and 368 treatment days). Given the need for multiple

drains, and in one instance, failure after premature drain

removal, one must speculate inadequate drainage at the

index procedure as the etiology for failure. Thus, those

surgeons finding the necessity for increased number of

drains during the initial LDAD procedure should have a

higher index of suspicion for failure.

Despite limitations to this study, favorable healing times

and cosmesis with less morbid wounds warrant a role for

LDAD in the treatment algorithm for pilonidal cyst. Our

current recommendations are as follows (Fig. 6):

1. For patients with associated abscess, simple drainage

of initial pilonidal cyst abscess in the office when

appropriate.

2. Subsequent operative exploration and LDAD for above

patients and all other initial presentations (including

absence of abscess).

3. Consider more extensive procedures such as excision

and/or flap closure for failure of LDAD.

4. Wide excision and packing as last resort for failure.

Conclusion

LDAD represents a simple and minimally invasive option

for the treatment of pilonidal disease. The procedure is

easy to perform and utilizes small incisions. Postoperative

care requires little of the patient. Cumbersome and painful

packing is avoided, and patients have minimal activity

Fig. 6 LDAD algorithm

Tech Coloproctol

123

restriction. LDAD represents an attractive initial option for

management and often offers definitive treatment. Fur-

thermore, this procedure does not interfere with the ability

to perform subsequent flap or cleft lift procedure in case of

failure. As such, LDAD has evolved as the initial treatment

of choice in the senior author’s practice. Limitations

include small case number, retrospective data, length of

follow-up, and comparison to a heterogeneous treatment

group.

Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict of

interest.

Ethical approval This study was approved by the local Institutional

Review Board (IRB).

Informed consent For this type of article, informed consent is not

required.

References

1. Bascom J, Bascom T (2002) Failed pilonidal surgery: new paradigm

and new operation leading to cures. Arch Surg 137:1146–1150

2. Nelson JM, Billingham RP (2007) Pilonidal disease and hidradeni-

tis suppurativa. In: Wolff BG, Fleshman JW, Beck DE, Pemberton

JH, Wexner SD (eds) The ASCRS textbook of colon and rectal

surgery. Springer, New York, pp 228–239

3. Tsoraides SS, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK

(2010) Incision and loop drainage: a minimally invasive technique

for subcutaneous abscess management in children. J Pediatr Surg

45:606–609

4. Milone M, Di Minno MN, Bianco P, Coretti G, Musella M, Milone

F (2014) Pilonidal sinus surgery: could we predict postoperative

complications? Int Wound J. doi:10.1111/iwj.12310

Tech Coloproctol

123