Pilonidal Sinus: Which Operation?

Which operation for pilonidal sinus? Open or closed? Midline or eccentric closure? An algorithm for the operative treatment of symptomatic pilonidal sinus disease is proposed. In addition to intra-operative photos of the operation of Rhomboid excision and Limberg flap.

1. PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS CONSULTANT SURGEON HEAD OF DEPARTMENT OF SURGERY AL HAMMADI HOSPITAL, NUZHA RIYADH, KSA

2. PILONIDAL SINUS (PNS) Pilonidal sinus is a blind tract between the skin and a hair nest underneath it at the natal cleft It is common in young age group, in males more than females Asymptomatic pilonidal sinus does not require treatment More than one operation exists for symptomatic PNS PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 2

3. MANAGEMENT Pilonidal abscess requires incision and drainage Recurrent symptomatic PNS disease may be considered for surgical treatment The choice of procedure depends on the site, complexity, being recurrent or not and the surgeon’s experience PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 3

4. TO REMOVE HAIR OR NOT TO? No evidence to support in asymptomatic cases for prevention of complications Following treatment of pilonidal abscess possible benefit with hair epilation Razor hair shaving may increase the risk of recurrence PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 4

5. PRIMARY CLOSURE VERSUS OPEN? Primary closure is for faster healing & return to work Open method is for less likelihood of recurrence PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 5

6. MIDLINE VERSUS OFF MIDLINE CLOSURE? Eccentric or off midline closure has a reduced complication rate, healing time and chance of recurrence. Midline simple closure has a higher risk of disruption, infection and recurrence. PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 6

7. WHAT ARE THE SURGICAL OPTIONS? Excise and leave open Marsupialization Midline simple closure Karydakis Rhomboid excision & Limberg flap Bascom Z plasty V-Y plasty PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 7

8. NEWER SURGICAL OPTIONS? Laparoscopic video assisted ablation Phenol ablation Fibrin glue sealing PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 8

9. RECURRENCE RATE Overall recurrence rate 5-10% Closed method 8.7% Open method 5.3% PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 9

10. SURGICAL SITE INFECTION (SSI) & ANTIBIOTICS? Risk Category of SSI: Contaminated Category Overall surgical site infection rate ranges between 10-25% Treatment rather than Prophylaxis Cephalosporin + Metronidazole for 5 days. PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 10

11. TO DRAIN OR NOT TO? In primary closure: Reduces fluid seroma/haematoma collection No impact on wound infection No impact on recurrence PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 11

12. PROPOSED PNS SURGERY DECISION ALGORITHM PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 12

13. RHOMBOID EXCISION & LIMBERG FLAP CASE OF A 21 YEAR OLD MALE WITH RECURRENT PILONIDAL SINUS (PNS) DISEASE FOR 3 YEARS HOW I DO IT? PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 13

14. DR. AL-GAILANI FRCS NOTE HAIR TUFT FROM CENTRAL PIT WITH AN ECCENTRIC PNS 14

15. DR. AL-GAILANI FRCS THE EXTRUDED HAIR FROM THE PNS 15

16. DR. AL-GAILANI FRCS ECCENTRIC PNS, LENGH 5 CM 16

17. DR. AL-GAILANI FRCS PROBE THROUGH THE PNS & SKIN MARKINGS OF THE PROPOSED RHOMBOID EXCISION AND LIMBERG FLAP 17

18. DR. AL-GAILANI FRCS INITIAL INCISIONS RHOMBOID EXCISION & LIMBERG FLAP 18

19. DR. AL-GAILANI FRCS THE EXCISED PNS WITHIN THE RHOMBOID EXCISION TISSUE 19

20. DR. AL-GAILANI FRCS THE OPEN WOUND FOLLOWING EXCISION OF PNS PRIOR TO CLOSURE 20

21. DR. AL-GAILANI FRCS THE COMPLETED OPERATION. NOTE THE READIVAC DRAIN SIZE 10 ON THE LEFT 21

22. POSTOPERATIVE CARE Antibiotics for 5 days Cleanse and re-dress every other day Keep drain until < 20 ml/24 hours Remove stitches after 2 weeks PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 22

23. PILONIDAL SINUS SURGICAL TREATMENT TAKE HOME MESSAGE THE FACT THAT THERE IS MORE THAN ONE SURGICAL OPTION FOR PNS TREATMENT INDICATES THAT NONE ARE PERFECT! For < 4 cm PNS, consider Open method Open method will need more time to heal, but has a lower recurrence rate Eccentric closure is preferred over Midline Choose the appropriate surgical option you are most familial with! PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 23

24. Dr. Mohamad Al- Gailani FRCS الدكتور محمد الكيلاني CONSULTANT BREAST & GENERAL SURGEON HEAD DEPARTMENT OF SURGERY IN-CHARGE MEDICAL EDUCATION & TRAINING AL HAMMADI HOSPITAL, NUZHA مستشفى الحمادي, النزهة RIYADH, KSA الرياض, المملكة العربية السعودية