Pilonidal sinus defect closure, reconstruction methods

A breif discussion on some of the available options in the reconstruction of pilonidal sinus defect. Post excision of pilonidal sinus. A plastic surgery view of the problem.

1. RECONSTRUCTION modalities OF PILONIDAL SINUS DEFECTS Ahmed almumtin,

2. Objectives Statement of the problem General evaluation if the condition. Treatment options Some Reconstruction methods Take Home messages.

3. Statement of the Problem Pilonidal disease is a potentially debilitating condition. Cause, optimal treatment, still controversial. Presentation Male:Female Age Aetiology

4. Evidence

5. Evaluation of the disease History Physical examination

6. Treatment/Management Non-Operative Operative

7. Non-Operative management Trial of gluteal cleft shaving Phenol injection and local depilatory cream application Fibrin glue Antibiotics Perioperative prophylaxis Postoperative treatment Topical use

8. Non-Op Evidence based Grade of Recommendation Gluteal cleft shaving 1 C Strong recommendation based on low-quality evidence Fibrin Glue 2 C Weak recommendation based on low-quality evidence Phenol Injection 2 C Weak recommendation based on low-quality evidence Antibiotics 1 C Strong recommendation based on low-quality evidence

9. Operative management Acute pilonidal disease. Chronic pilonidal disease. Excise with primary closure. Excise, secondary intention.

10. Minimal surgery with trephines 1358 patients Trephines used to debride pits and sinusses and clear debris Recurrence at 1, 5 and 10 yrs 6.5, 13.2 and 16.2% Mean time to recurrence 2.7 years

11. Minimal surgery with trephines

12. VAC Alternative method. Shortened the length of hospital stay and the need for further surgery

13. Flap based procedures Limberg flap & dufourmental Karydakis flap Cleft-lift (Bascom) V-Y advancement and rotation Z-plasty Superior gluteal artery perforator flap

14. Limberg flap 110 patients, 102 males, 8 females. average age 21, 7 of them recurrent disease and 3 had previous surgeries. 107 full healing, one case; epidermolysis and 2 cases, small gaping 7 months follow up; one recurrence outside the edge! mean length hospital stay 4 days, return to work within 3 weeks.

15. Dufourmentel flap 310 patients 24 asymptomatic and 55 recurrent disease Surgery 40 minutes mean No flap necrosis Mean hospital stay 1 day (1- 11) Mean return to work 7 days (5- 30) Minimal pain (visual analogue scale) 10.6% wound complications, managed conservatively in all but 2 (0.6%) which was resutured Recurrence 7 (2.3%) of patients, all within 25 months. No further recurrence at 5, 10 and 16 yrs

16. Dufourmentel flap

17. Dufourmentel flap

18. Karydakis and basscom’s Technique for excision Karydakis excised up to the sacrum, modified by Bascom. Karydakis had less than 1% recurrence with this procedure Mean hospital stay is .76 days, Healing 11.1 days, Return to work in 17.7 day

19. –Dr. George Karydakis Karydakis Flap

20. Z-Plasty RCT 72 patients Mean follow up for both arms 22 months Hospital stay conventional treatment 1.76 (+/-0.75), Z- plasty 2.86 (+/- 0.73 days) Wound healing Conventional surgery 41days, Z- plasty 15.4 days Return to normal activity 17.5 days for conventional vs 11.9 days for Z- plasty One recurrence.

21. V-y advancement/rotation flaps 43 patients 16.3% wound complications (managed conservatively), no breakdown Mean hospital stay 3 (2- 5) days Return to work in mean 17 (13- 25) days Recurrence in 1 patient 2.3%

22. V-Y advancement

23. V-Y Rotation

24. Superior gluteal artery perforator flap 15 males were involved. Can close defects of any size Short surgical time and minimal blood loss. Shorter hospital stay, time to mobilisation and return to daily activities

25. –Superior gluteal artery perforator flap

26. Lumbar adipofascial turnover flap Excision of pilonidal cyst up to lumbosacral fascia Undermining of the skin in the intermediate subcutaneous tissue Flap developed in 2 (length) to1(base) ratio When desired length is obtained, cut up to the lumbar fascia Flap then elevated of the erector spine muscles and turned over into soft tissue defect Skin sutured over this

27. Lumbar adipofascial turnover flap 10 patients Mean hospital stay of 4 days Mean time of work 15 days Acceptable cosmesis No recurrence

28. ok? leave it open? 18 studies, 12 RCTs open vs closure (10 vs 2) (mid-line/off-midline). 6 studies mid-line vs off-midline. rapid healing after closure, same infection rate. Recurrence was less likely to occur after open healing. Earlier return to work with closure.

29. primary closure or open healing by secondary intention. mid-line or off-midline “so; Take it Home!”

30. Off-midline closure should be the standard management when primary closure is the desired surgical option

31. References JB Lynch; AJ Laing; PJ Regan. Vacuum-Assisted Closure Therapy: A New Treatment Option for Recurrent Pilonidal Sinus Disease Report of Three Cases. Dis Colon Rectum 2004; 47: 929–932 JH Armstrong; PJBarcia. Pilonidal Sinus Disease The Conservative Approach. Arch Surg. 1994;129:914-918 E Tezel; H Bostanci; Z Anadol. Cleft Lift Procedure for Sacrococcygeal Pilonidal Disease. Dis Colon Rectum 2009; 52: 135- 139 M Gips; Y Melki; L Salem: Minimal Surgery for Pilonidal Disease Using Trephines: Description of a New Technique and Long-Term Outcomes in 1,358 Patients. Dis Colon & Rect Vol 51: 1656–1663 (2008) E Aygen; K Arslan; O Dogru. Crystallized Phenol in Nonoperative Treatment of Previously Operated, Recurrent Pilonidal Disease. Dis Colon Rectum 2010; 53: 932–935 JN Lund, D.M; S Leveson. Fibrin Glue in the Treatment of Pilonidal Sinus: Results of a Pilot Study. Dis Colon Rectum 2005; 48: 1094– 1096 R Eryilmaz; I Okan; A Coskun. Surgical Treatment of Complicated Pilonidal Sinus with a Fasciocutaneous V-Y Advancement Flap. Dis Colon Rectum 2009; 52: 2036–2040 Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006213. doi: 10.1002/14651858.CD006213.pub3. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Al-Khamis A1, McCallum I, King PM, Bruce J.

32. Continue references World J Surg. 2013 May;37(5):1115-20. doi: 10.1007/s00268-013-1950-8. Karydakis flap for recurrent pilonidal disease. Iesalnieks I1, Deimel S, Schlitt HJ. J Plast Reconstr Aesthet Surg. 2010 Jan;63(1):133-9. doi: 10.1016/j.bjps.2008.07.017. Epub 2008 Nov 14.Superior gluteal artery perforator flap in the reconstruction of pilonidal sinus. Acartürk TO1, Parsak CK, Sakman G, Demircan O. N Sungur; U Kocer; A Uysal. V-Y Rotation Advancement Fasciocutaneous Flap for Excisional Defects of Pilonidal Sinus. Plast. Reconstr. Surg. 117: 2448, 2006 Y Bas; H Canbaz; A Aksoy. Reconstruction of Extensive Pilonidal Sinus Defects With the Use of S-GAP Flaps. Ann Plast Surg 2008;61: 197–200 A Turan; C Isler,; SC Bas. A New Flap for Reconstruction of Pilonidal Sinus Lumbar Adipofascial Turnover Flap. Ann Plast Surg 2007;58: 411–415 Comparison of Limberg and Dufourmentel flap in surgical treatment of pilonidal sinus disease Ali Tardu1, Adnan Haşlak2, Beyza Özçınar2, Fatih Başak11İstanbul Eğitim ve Araştırma Hastanesi, Genel Cerrahi, İstanbul, Türkiye 2Ergani Devlet Hastanesi, Genel Cerrahi, Diyarbakır, Türkiye

33. Thank you ..