0904_Surgical Treatment of the Pilonidal

7/25/2019 0904_Surgical Treatment of the Pilonidal

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ORIGINAL

CONTRIBUTION

Surgical Treatment of the PilonidalDisease: Primary Closure or FlapReconstruction After Excision

T. Mahdy, M.D.

Department of Surgery, Mansoura University Hospital, Mansoura, Egypt

PURPOSE:Controversy still exists regarding the bestsurgical technique for the treatment of pilonidal disease interms of minimizing disease recurrence and patientdiscomfort. The present study analyzes the results ofexcision with primary closure and excision with flapreconstruction in the surgical treatment of sacrococcygealpilonidal disease.

METHODS:From January 2003 to January 2006, 60consecutive patients with primary pilonidal sinus disease

received surgical treatment in the form of either excisionand primary closure (group I, n=20 patients) or excisionand flap reconstruction (group II, n=40 patients; modi-fied Limberg flap n=20, classic Limberg flap n=10 andadipo-fasciocutaneous flap n=10). Times for completehealing and return to work were recorded. To evaluatepatient comfort, all patients were asked to complete aquestionnaire including visual analog scale, time to sittingon toilet without pain, and time to walking without pain3 months after surgery.

RESULTS:Mean follow-up was 21 months. A significantdifference was observed between the two groups in terms oflength of hospital stay (P


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PATIENTS AND METHODS

The study was carried out in 60 consecutive patients withprimary nonrecurrent sacrococcygeal pilonidal sinusbetween January 2003 and January 2006. Twenty patients(group I) were treated with excision and primary closure,

whereas another 40 patients (group II) were treated withexcision and flaps reconstruction (modified Limberg flapn= 20, classic Limberg flap n= 10, and adipo-fasciocutaneousflap n=10). The nature of surgical procedures was explainedto the patients and informed consent had been obtained.

Surgical ProceduresHair of the gluteal and sacral regions was shaved a fewdays before the operations, and rectal cleansing withenemas was performed four hours preoperatively. Patientswere operated on under epidural or spinal anesthesia inthe prone jackknife position. One gram of sulbactam-ampicillin was given intravenously for prophylaxis.

Excision and Primary ClosureWide excision was followed by placement of six to eight1-0 polypropylene deep full-thickness tension suturesincluding the postsacral fascia and crossing symmetricallythrough both sides of the elliptical defect. A vacuum drainwas placed deep in the midline and the skin was closedprimarily with 3-0 polypropylene interrupted mattresssutures. Tension sutures were then softly tightened over agauze roll over the skin sutures. Tension sutures wereremoved after one week and the skin sutures after twoweeks.

Excision and Classic Limberg Flap ReconstructionA rhomboid-shaped excision was carried out (Fig. 1). Aright-sided or left-sided Limberg transposition flap,incorporating the gluteal fascia, was fully mobilized onits inferior edge and transposed medially to fill therhomboid defect; the defect on the gluteal region wasclosed primarily. The subcutaneous layers were approxi-mated with 2-0 vicryl interrupted sutures over a vacuumdrain, and the skin was closed with 2-0 proline interruptedsutures, which were removed on postoperative day 14.

Excision and Modified Limberg Flap ReconstructionWe marked and placed the inferior apex of the rhomboidexcision asymmetrically 1 to 2 cm lateral to the midline onthe side opposite to the donor area. Again, a right-sided orleft-sided Limberg transposition flap, incorporating thegluteal fascia, was fully mobilized on its inferior edge and

transposed medially to fill the rhomboid defect. Thesubsequent steps were identical to those in the classicLimberg flap (Fig.2).

Excision and Adipo-Fasciocutaneous FlapThe lateral advancement adipo-fasciocutaneous flap was arectangular flap containing adipose tissue with its under-lying fascia and overlying skin, and differs from theadipo-fascial turnover flap described by Onishi andMaruyama.13 A rectangular excision was used to includeall the sinuses and their ramifications and the flap wasmarked (Fig.3) and advanced medially to achieve primary

closure with an eccentric suture line. Polyglycolic acid 2-0sutures were used to fix the undersurface of the variousflaps to the presacral fascia to immobilize the flap, avoidtension, and obliterate the dead space. Mattress polypro-pylene 2-0 sutures were used for skin closure (Fig. 3).

Follow-Up and Data AnalysisOral intake was allowed 6 hours postoperatively, andpatients were encouraged to walk after 8 hours. Closedsuction drains were removed when 24-hour suctionoutput was less than 10 mL. Postoperative managementincluded pressure dressings, low residue diet until post-

operative day 5, and inspection of dressings on post-operative days 5 and 8.Instructions on discharge included avoidance of

prolonged sitting, riding bicycles or scooters until 6 weekspostoperatively to prevent wound disruption, improvinglocal hygiene, and regular removal of hairs by shaving ordepilatory cream.

Postoperative mobilization time was defined as thetime required for walking comfortably without significantpain or tension. Patients were discharged home followingremoval of vacuum drains. Postoperative infection was

FIGURE 1. Classic limberg flap.

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defined as the development of cellulitis and/or purulentdischarge from the wound edges or drains. In order todefine the postoperative time off work, the patients wereasked when they felt comfortable and convenient to starttheir daily activities. Patients were reexamined at 2 weeks, 1,3, and 12 months postoperatively, and annually thereafter.

The groups were compared in terms of the mobilizationtime, hospitalization time, wound breakdown, postopera-

tive infection, recurrence, and time off work. To evaluatesatisfaction and comfort of patient, a questionnaire includ-ing postoperative visual analog scale (VAS), time to sittingon toilet without pain, and time to walking without painwere recorded. Patients were asked to complete a 10-cmlong VAS for their health status before and after surgery thatranged from 0 for very bad to 10 for very good. Thescale was constructed with numeration, thus allowingpatients to mark a point along the scale that best representedtheir health status at that time.

Statistical AnalysisAll data were collected and analyzed by using SPSS forWindows 10.0 computer software (SPSS, Chicago, IL).Statistical analysis was performed using Chi-squared orFishers exact test to compare discrete variables and twotailed paired Students t-test to compare continuousvariables between groups. P


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hospital stay (P


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The problems related to a continuing natal cleft afterpilonidal sinus surgery has prompted surgeons to discovertechniques to eliminate the gluteal furrow. Bascomhypothesized that infection starts in the hair follicles,which have open orifices that initiate the development ofinfection and sinus. He recommended excision of the

midline pits with lateral open drainage of any associatedabscess.2 Karydakis used an asymmetric excision andprimaryclosure to prevent hair penetration into the natalcleft.22,23 With this technique, the natal cleft is flattened,and the incisional line and scar are transferred laterallyfrom the midline. To eliminate natal cleft and woundtension, various plastic reconstructive techniques such asZ-plasty, W-plasty,V-Y plasty and various flap techniqueshave been used.24 However, adipo-fasciocutaneous flap,classic Limberg flap, and modified Limberg flap tech-niques are the most recently favored techniques.

The simplest way for the treatment of the disease is

incision plus drainage, but this approach has a very highrecurrence rate.25 Hodgson and Greenstein reported thattheir cases treated by incision and drainage or excisionwith marsupialization showed a recurrence rate of 40percent. However, neither incision with drainage norshaving of the area suffices for radical treatment of thechronic disease, especially in advanced cases.26

Thus the radical treatment modality has been wideexcision of the chronic tracts. The main problem with thistreatment is the reconstruction of the excised area.Edwards27 reported a 5-year appraisal of local excisionand found an overall recurrence rate of 46 percent with amedian healing time of nearly 6 weeks. Therefore, anotherproblem is the long healing time that creates greatdiscomfort for patients.

Compared with open packing and marsupialization,excision and primary closure is known to provide quickerhealing and quicker returnto work. Most patients returnto work in 3 to 4 weeks.28 However, a high complicationrate has been reported because of tissue tension,1

although somesurgeons have reported good results afterprimary closure.29,30 Flap techniques have been associatedwith lower infection and recurrence rates, shorter hospitalstay, and better aesthetic results. With this technique, theinternal cleft can be flattened, and tissue can be approxi-

mated without tension.1,31,32

The results of our study have also supported thesesuggestions. Patients in the primary closure group walkedfreely without significant pain after a relatively longerperiod than patients treated with flaps because of thetension created by the primary suture technique. Thehighest postoperative infection rate was also noted inprimary closure group.

The higher morbidity of surgical techniques wasnaturally reflected by hospital stay and time off work. Inour study, the hospital stay for patients treated with flapswas 2.9 days, which was shorter than 5.5 days as reported

by Rossiet al. for Limberg flap33 and 5.7 days as reportedby Singh et al. for adipo-fasciocutaneous flap.34 In ourstudy, the mean hospital stay was 4.8 days in the primaryclosure group, and the difference between the groupswas significant. Time off work was significantly shorterfor patients treated with flaps as compared with patients

treated with primary closure (14.5 vs. 25.5 days), andthis shorter duration in the flaps group was similarto that reported by Abu Galala et al.35 and Eryilmazet al.36

Some authors believe that primary closure is morecomfortable in small defects. Excision alone, or excisionand primary closure of the wound, has previously beencompared in a controlled study.37 Healing time wasshorter after excision and closure, but more recurrencesoccurred compared with excision alone. Also, primaryclosure has been reported to result in a higher initialprimary healing rate with shorter time of healing and a

reduced period of sick leave, but with high recurrencerates.38 In the current study, during a mean follow-up of21 months (range, 12 to 39), with 60 patients at 1 yearafter surgery at least, 5 recurrences (25 percent) developedin the primary closure group whereas only 2 recurrences(5 percent) developed in the flap treatment group. Thesefindings confirm that flattening the intergluteal sulcusprovides elimination of the vacuum effect and preventsrecurrences.

Excision and primary closure technique causesrestriction of activity because of tissue tension.39 Mostcomplaints by patients after pilonidal sinus surgery werecaused by wound tenderness. Holm and Hultin reportedthat 18 percent of their patients had some pain when theysat on hard chairs.30 To determine this problem in ourpatients, time to sitting on toilet and time to walkingwithout pain in both groups were analyzed. Patientstreated with flaps were found to walk and sit on toiletwithout pain earlier than patients with primary closure.To evaluate patient satisfaction with primary closure andflap techniques, the postoperative VAS scores, which areone of the best indicators of patient satisfaction, werebetter for patients treated with flaps.

The recurrence rate in the modified Limberg flapgroup was lower than the recurrence rate in the other flap

techniques. When we first began to use flap surgery, theapices of the rhomboid excisions were placed in themidline. We eventually realized that the inferior midlinewas frequently macerated, healed slowly, and might evenbe a source of recurrence. As we predicted, one recurrence,which we eventually noted in the classic Limberg group,developed on the inferior midline. This weak point waseliminated by lateralization of the inferior apex. The modi-fied Limberg flap technique appears to provide a moreefficient flattening of the natal cleft, including the mostinferior part that is inclined to invert toward the analregion.

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CONCLUSION

Shorter hospital stay, earlier healing, shorter time offwork, lower rates of recurrence, and lower pain percep-tion are the main advantages of flap techniques relative toexcision and closure in pilonidal sinus surgery. Altogether,

these parameters add to patient comfort and satisfactionafter surgical treatment. Finally, we recommend the use ofmodified Limberg flap because its results were superior tothe other flap techniques.

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0904_Surgical Treatment of the Pilonidal