Eur J Plast Surg (1996) 19:200-203 European ~"~'1 .~0

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Oblique excision with primary closure for the treatment of pilonidal sinus

M. Talu, O. Yiicel, Y. User, A. Dede, H. Onder, S. Tolun

Haydarpa~a Numune Hospital, Istanbul, Turkey

Abstract. Although pilonidal disease of the sacrococ- cygeal region is common, controversy still exists regard- ing its treatment. The goal of treatment should be to pre- vent recurrence while minimizing the patient's postoper- ative pain and disability. During a two-year period, 32 consecutive patients (Group A) were treated for chronic pilonidal disease by oblique excision and primary clo- sure. The results were compared with 45 patients (Group B) who had been treated by vertical excision and prima- ry closure. Patients with acute pilonidal abscess or recur- rent pilonidal disease were excluded from the study. The mean follow-up was 15.9 months for Group A and 19.6 months for Group B. The average length of hospital stay and time for return to daily activities were 3.18_1.31 vs. 5.53_+4.11 days and 10.4_+14.37 vs. 12.91_+39.17 days in Groups A and B, respectively (p<0.001 and p<0.01). The overall recurrence rate was 35.5% in Group B whereas there were no recurrences in Group A. On the basis of our current experience, oblique excision with primary closure achieves the most promising treatment of this condition.

Key words: Pilonidal disease - Oblique excision - Pri- mary closure

Pilonidal disease of the natal cleft is a common, time consuming and difficult problem. Since the first descrip- tion by Anderson in 1847 [1], several differing methods of treatment have been advocated, each with substantial morbidity and recurrence.

This condition presents either as a draining sinus or as an acute abscess. The pulling forces and vacuum ef- fect created in the natal cleft by gravity and motion of the gluteal folds appear to be responsible for the devel- opment of this disease [2, 3].

Correspondence to: O. Yficel, Semsettin Gfinaltay Cad., Cemile Sultan Apt. No: 151, B Blok. D;36, Erenk6y/Istanbul, Turkey

The goal of treatment is to prevent recurrence of in- fection while minimizing the patient's postoperative pain and disability.

Treatment options vary from conservative to radical. Excision and packing with healing by open granulation [4], marsupialization [5], excision and closure [6], injec- tion [7], marsupialization and cryotherapy [8], irradia- tion [9], and various rotational flap and grafting proce- dures [10] are all used with varying rates of success and failure.

The present clinical trial was carried out between 1992 and 1994 to evaluate the short and long-term re- sults of oblique excision with primary closure for the management of pilonidal disease.

Materials and methods

Thirty-two consecutive patients (Group A) with pilonidal disease of the sacrococcygeal region were managed with oblique excision and primary closure. Results were compared with those treated by vertical excision and primary closure between 1982 and 1990 (Group B, n=45). There were 24 men and eight women with age range from 15 to 37 years (mean 24.3 years) in Group A, and 33 men and 12 women with age range from 17 to 43 years (mean 24.1 years) in Group B. Exclusion criteria included acute pilonidal abscess and recurrent pilonidal disease. Prophylactic antibiotic therapy with a second generation cephalosporin one hour prior to the operation was given in all cases. Under general anesthesia pa- tients were placed prone on the operating table and methylene blue was slowly injected into the sinus to identify all the tracts.

In Group A, an eliptical incision was designed in an oblique fashion to excise the entire cyst wall together with all external fis- tulous openings. The incisions were made 45 degrees to the inter- gluteal sulcus with the limbs extending an equal distance from the midline (Fig. la, b). The skin edges were carefully dissected off the underlying tissues, especially at the coccygeal region to re- lieve tissue tension between the coccyx and skin. This maneuver not only flattened the natal cleft but also helped to create a ten- sion-free suture line. Following excision and meticulous hemosta- sis, the remaining cavity was thoroughly irrigated with normal sa- line. Subcutaneous tissues were approximated with monofilament absorbable sutures (PDS #2-0) by taking bites from the postsacral fascia in order to obliterate the cavity. A closed suction drainage through a separate incision was reserved for those cases where the

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Fig. 1. a Diagram of the area to be excised. Note the limbs of the incision are at equal distance from the midline, b Oblique incision crosses the midline at one point

remaining cavity seemed to be large. The skin was closed with #2- 0 polypropylene monofilament sutures. Great care was undertaken to evert the skin edges especially in the region where the incision traverses the midline. The same operative technique was applied to the control group (Group B) except that the elliptical incision was made vertically over the sacrococcygeal raphe.

Drains, if placed, were left for one day and dressings were re- moved on the second postoperative day. Skin sutures were re- moved by the tenth postoperative day. The patient's medical re- cords were analyzed by two surgeons for the evaluation of early and long-term results of the two procedures. The mean follow-up period of Group A was 15.9 months (6-25 months) and Group B was 19.6 months (10-36 months). Statistical analyses were con- ducted with Student's t-test.

Results

Preoperative physical examinat ion revealed that ten pa- tients in Group A and 16 patients in Group B had more than one sinus opening to the skin. The distance between the openings and the midline was within 3 cm in all pa- tients. There were no operative complicat ion in either group. Minor pulmonary atelectasis occurred in one pa- tient in Group A, this was successfully managed by medication. Wound dehiscence occurred by the third postoperative day in a Group A patient and was treated with daily dressings. Within the early postoperative peri-

Fig. 2. Recurrences after vertical excision and primary closure al- most always takes place at the inferior portion of the incision

Fig. 3. Oblique excision and primary closure keeps the scar away from the midline and flattens the natal cleft

od, 13 wound infections with purulent discharge were noted in Group B and skin sutures were removed. These wounds were left open and daily baths were instituted. Six o f these patients finally developed recurrence (46.1%) despite the use of broad spectrum antibiotics and proper wound management . Mean hospitalization period was 3.18 (2-7) and 5.53 (2-11) days for Group A and B, respectively (p<0.001).

Pain was not a major problem in either group and was easily controlled with NSAIDS ' s . The patients were fully mobile within seven to 21 days (mean 10.40) in Group A, and seven to 34 days (mean 12.91) in Group B (p<0.01).

Sixteen patients in Group B (13 men, 3 women) de- veloped recurrence during the fol low-up period (35.5%). All recurrences were located at the most inferior portion o f the incision. No recurrences were noted in Group A (Figs. 2, 3).

Discussion

There are multiple treatments for pilonidal sinus. The aim of treatment is to achieve a low recurrence rate with-

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out increasing the morbidity, hospitalization and conva- lescence. It is not surprising that there is so much con- troversy concerning the management of this disease when one realizes there is no universally accepted etiol- ogy for the formation of cysts in the median sacrococ- cygeal raphe. It has been hypothesized that hairs become imbedded in the median sacrococcygeal raphe by punc- ture of the skin or by a local suction mechanism [11]. Bascom claimed that hair follicles in the median raphe are responsible for the development of pilonidal sinuses [12]. When considering how to treat sacrococcygeal pi- lonidal disease, it is important to remember that the con- dition is simply a particular form of foreign body granu- loma [13].

No medical or surgical method satisfies all require- ments for the ideal treatment of this disease. Although the recurrence rate in some series is low, the procedures involved are complex, potentially morbid and require prolonged hospitalization. Postoperative wound care should also be easy, painless and comfortable for the pa- tient.

There have been numerous reports of laying open the pilonidal sinus tract [14, 15]. The healing time of the open wound is lengthy and involves patient disability, it also requires frequent dressings [5]. Results suggest that the average healing time for this approach is 43 days [16-18]. The average healing time is reduced to 27 days if the wound is partially closed by attaching the skin edges to the postsacral fascial (marsupialization) [18].

The use of skin flaps to cover a sacral defect after wide excision has the advantage of keeping the scar away from the midline and of flattening the natal cleft, thereby reducing skin friction and accumulation of hair [19]. Monrow and McDermott utilized a Z-plasty to flat- ten the natal cleft and they reported no recurrences. This technique of transposing two triangular flaps with nar- row apices invites complications, and flap tip necrosis has been reported in up to 20% of the cases [20]. Rota- tion flaps and Z-plasty techniques may be useful for spe- cific patients with complex pilonidal disease or recurrent pilonidal disease which has failed to respond to conser- vative operative techniques. These operations have the disadvantage of leaving large scars over the gluteal re- gion.

Oblique or vertical excision and primary closure has the advantage of shortened hospitalization and relatively easy wound management. However, vertical excision with primary closure carries a very high incidence of wound disruption [21] and recurrence rate [22]. Recur- rence rates with this technique vary from 1.2% [23] to 40% [24]. In Group B, there was a 35.5% recurrence rate with a longer hospitalization and convalescence period.

In the vertical closure technique, local forces encour- age gaping and wound disruption which was proved ex- perimentally and led Alday to suggest a 45 degree ellip- tical excision to alleviate such distracting forces [25]. Asymmetrical [23] or oblique elliptical skin incisions [26] have been advocated as an adjunct to primary clo- sure in order to keep the incision away from the natal cleft and to flatten the natal cleft to reduce buttock fric- tion. Results of asymmetric or oblique/transverse inci-

sions suggest recurrence and failure rates ranging from 0% to 20% and 0% to 5%, respectively [26, 27]. In the clinical trail there was a 3.1% failure rate with no recur- rence.

Reliable healing with low risk of recurrence, shorter hospitalization, minimal patient inconvenience and time off work are the aims of the ideal treatment for pilonidal disease.

Although no method satisfies all criteria, there are several points that should be taken into account when dealing with this problem. When healing time is pro- longed and the wound is not kept clean and free of hair, new sinus tracts and cysts may be formed. The object should be to create as small a wound as possible and ob- tain healing as rapidly as possible. It is important to alter the natal cleft contour in order to prevent local accumu- lation of debris and buttock friction. Whatever technique is used, careful follow-up is essential. The patient should be instructed to keep the area clean and dry, to avoid di- rect trauma, and to shave the skin or apply a depilatory to prevent further entrapment of hair. In our experience, oblique excision and primary closure with improved pa- tient hygiene is an effective means of treating pilonidal disease of the sacrococcygeal region.

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