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Excision and primary closure of pilonidal sinus using a drain for antiseptic wound flushing
The American Journal of Surgery 183 (2002) 209 –211
Scientific paper
Excision and primary closure of pilonidal sinus using a drain for antiseptic wound flushing Raffaele Tritapepe, M.D.*, Carlo Di Padova, M.D. Institute of General and Oncological Surgery, School of Medicine, University of Milan, Via San Calimero 7, 20122 Milano, Italy Manuscript received February 12, 2001; revised manuscript October 12, 2001
Abstract Background: In the case of pilonidus sinus treated with primary intention surgery the uneventful healing is still difficult to obtain, as indirectly proven by the number of different procedures that have been suggested, such as cyst excision with or without primary closure, excision followed by marsupialisation, and excision followed by skin flap transposition. The procedure described here involves excision and primary closure, with a drain being used to flush the operative cavity with an antiseptic solution. Methods: Two hundred and forty-three patients (173 men and 70 women) were treated by excising the pilonidal sinus and placing a 12F suction drain at the base of the wound, with its tip being brought out in the left gluteal region at least 5 cm laterally to the lower end of the suture. Suction was stopped on the first postoperative day and the drain was cut just above the skin. On day 2, a 5F catheter was inserted through the drain and the cavity was flushed with an antiseptic solution followed by sterile saline solution; the same treatment was repeated on days 4 and 6. The drain was removed on day 8 or 9, some of the stitches on day 8 or 9 and the rest on day 9 or 10. The surgery was performed on a day hospital basis in 207 cases; the remaining 36 were hospitalized overnight and discharged on the following day. Results: Healing was always by first intention, with none of the 243 patients experiencing any complications. The postoperative follow-up now ranges from 5 to 15 years, and there have not been any recurrences. Conclusions: The drainage of blood from the bottom of the wound and the use of antiseptic/saline flushing are essential for primary intention healing and the avoidance of recurrences. © 2002 Excerpta Medica, Inc. All rights reserved. Keywords: Pilonidal sinus; Suction drainage; Antiseptic/saline flushing
Pilonidal disease is a common, chronic intermittent disorder of the sacrococcygeal region. Although it has been surgically treated for more than 100 years, its management remains controversial and recent reports [1–5] have advocated various different approaches. This report describes our technique of primary intention postexcision healing and explains how we overcome the main causes of surgical failure.
Thirty-nine out of 243 underwent surgery because of recurrences: 24 patients had one recurrence, 6 had two, and 9 had three. The patients were prepared and positioned on the operating table, with tension plasters being applied to the buttocks according to standard procedures. General anesthesia was used until the end of the 1980s; since then, we have used local anesthesia. Surgical procedure
Patients and methods Between the middle of 1985 and the end of 1995, we used the procedure described below to excise the pilonidal sinus from 243 unselected patients (173 men and 70 women) with a mean age of 26.1 years (range 14 to 36).
* Corresponding author. Tel.: ⫹39-02-58309000; fax: ⫹39-0258309000.
Local anesthesia is induced using 1% xylocaine and 0.5% marcaine. Methylene blue is placed in the fistula, and an elliptical incision is made. The skin and subcutaneous layer is excised by hand using a scalpel, and then the cyst and sinus tissue is freed (down to the sacrococcygeal region if necessary) using an electrocautery knife. It is best to avoid making too wide an excision. Any tracks lying outside the main sinus are removed by means of smaller elliptical excisions at right angles to the main excision. Hemostasis
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 8 7 6 - 5
210
R. Tritapepe and C. Di Padova / The American Journal of Surgery 183 (2002) 209 –211
Patients were able to return to normal working activities immediately after the removal of the cutaneous stitches on days 8 to 10, by which time the operative scar was consolidated, although they were advised to avoid excessive physical strain and strenuous sports for the following 3 to 4 weeks. The postoperative follow-up now ranges from 5 to 15 years, and no recurrences have been recorded so far. Comments Fig. 1. The drain and the fine flushing catheter are shown.
must be thorough. A 12F suction drain is positioned along the length of the bottom of the operative cavity, and brought out in the left gluteal region 5 to 7 cm laterally to the lower end of the wound. The tension plasters are removed and, under normal traction, sutures are meticulously applied in two or more planes using 2/0 catgut and an HR30 needle. The skin is closed using separate nylon 2/0 sutures. The mean operating time is 25 minutes. Postoperative procedure Suction is stopped on the first postoperative day and the drain is cut just above the skin. On the second day, a fine 5F catheter is inserted through the drain and 3 to 4 mL of a 3.75% povidone-iodine antiseptic solution are instilled under low pressure, followed by a 3 to 4 mL sterile saline washout. The antiseptic and saline solutions easily flush out through the space between the catheter and drain, after which the fine catheter is removed (see Fig. 1). Flushing is repeated on days 4 and 6. The drain is shortened 2 to 3 cm on day 7 or 8 and removed on day 8 or 9, when alternate skin sutures can also be removed; the remaining sutures are removed on the following day. The patient can move cautiously as early as the evening of the day of surgery but, unless it is necessary, should avoid standing until day 5 or 6. A light diet should be followed for the first 2 or 3 days, after which no dietary restrictions are required. Of the present series, 207 patients (151 men and 56 women) underwent surgery in our day-hospital; owing to general anesthesia the remaining 36 were hospitalized overnight.
Results Healing was always by first intention, and none of the patients experienced any operative or postoperative complications or subjective disturbances such as pain, constipation, or wound infections. Analgesics were administered on request to the patients only the same day of surgery.
The treatment of pilonidal sinus by means of cyst excision and skin-flap reconstruction [1– 4] is technically complex; however, it does not take long to perform, allows healing within a few days, and leads to complication and recurrence rates that are at least no greater than those observed after other procedures [5]. These results seem to be further improved when the procedure is followed by the application of a postoperative drain [6]. Akinci et al [7] adopt a lateral rather than a median approach, and make use of an asymmetric excision and primary closure: this is certainly a simple method that rarely gives rise to complications or recurrences. Open excisions or excisions with marsupialisation lead to less frequent recurrences than excision and primary closure [8 –11], but require long healing times up to 40 to 60 days. Finally, the results of simple excision and primary closure are discouraging because of the excessively high rate of complications and recurrences [12–15]. Even if extremely thorough hemostasis is achieved, the excision of the pilonidal sinus inevitably may lead to the collection of some blood or serum at the bottom of the operative cavity. Therefore, the scrupulous drainage and the antiseptic/saline flushing of the operative cavity, as we describe here, ensure that the dead space remains clear and favor the normal healing process and the final scar formation around the suture. In our experience, the application of this simple, inexpensive, and extremely well tolerated procedure is able to abolish the occurrence of complications, which are not uncommon after this minor surgical procedure, and further improves the success rate of the surgical technique [16]. Acknowledgments This study was supported by Research Grant No. 90.03104 from the Italian National Research Council, Rome, Italy, and Research Grant No. Cat. 11 Cp 05 00003 from Cariplo, Milan, Italy. References [1] Karydakis GE. New approach to the problem of pilonidal sinus. Lancet 1973;103:1414 –5.
R. Tritapepe and C. Di Padova / The American Journal of Surgery 183 (2002) 209 –211 [2] Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust NZ J Surg 1992;62:385–9. [3] Bascon JU. Pilonidal sinus. Curr Pract Surg 1994;6:175– 80. [4] Bozkurt MK, Tezel E. Management of pilonidal sinus with the Limberg flap. Dis Colon Rectum 1998;41:775–7. [5] Senapati A, Cripps NP, Thompson NR. Bascom’s operation in the day-surgical management of symptomatic pilonidal sinus. Br J Surg 2000;87:1067–76. [6] Erdem E, Sungurtekin U, Nessar M. Are postoperative drains necessary with the Limberg flap for treatment of pilonidal sinus? Dis Colon Rectum 1998;41:1427– 43. [7] Akinci OF, Coskun A, Uzunkoy A. Simple and effective surgical treatment of pilonidal sinus: asymmetric excision and primary closure using suction drain and subcuticular skin closure. Dis Colon Rectum 2000;43:701– 6. [8] Sondenaa K, Nesvik I, Andersen E, Soreide JA. Recurrent pilonidal sinus after excision with closed or open treatment: final result of a randomised trial. Eur J Surg 1996;162:237– 40.
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[9] Fuzum M, Bakir H, Soylu M. et al. Which technique for treatment of pilonidal sinus open or closed? Dis Colon Rectum 1994;37:1148 – 50. [10] Solla JA, Rothenberger DA. Chronic pilonidal disease. An assessment of 150 cases. Dis Colon Rectum 1990;33:758 – 61. [11] Menzel T, Dorner A, Cramer J. Excision and open wound treatment of pilonidal sinus. Rate of recurrence and duration of work incapacity. Dtsch Med Wochenschr. 1997;122:1447–51. [12] Sondenaa K, Nesvik I, Andersen E, et al. Bacteriology and complications of chronic pilonidal sinus treated with excision and primary suture. Int J Colorectal Dis 1995;10:161– 6. [13] Berger A, Frileux P. Pilonidal sinus. Ann Chir 1995;49:889 –901. [14] Khaira HS, Brown JH. Excision and primary suture of pilonidal sinus. Ann R Coll Surg Engl 1995;77:242– 4. [15] Brieler HS. Infected pilonidal sinus. Langenbecks Arch Chir Suppl Kongressbd 1997;114:497–500. [16] Bascom JU. Pilonidal sinus: experience with the Karydakis flap. Br J Surg 1998;95:875.
Scientific paper
Excision and primary closure of pilonidal sinus using a drain for antiseptic wound flushing Raffaele Tritapepe, M.D.*, Carlo Di Padova, M.D. Institute of General and Oncological Surgery, School of Medicine, University of Milan, Via San Calimero 7, 20122 Milano, Italy Manuscript received February 12, 2001; revised manuscript October 12, 2001
Abstract Background: In the case of pilonidus sinus treated with primary intention surgery the uneventful healing is still difficult to obtain, as indirectly proven by the number of different procedures that have been suggested, such as cyst excision with or without primary closure, excision followed by marsupialisation, and excision followed by skin flap transposition. The procedure described here involves excision and primary closure, with a drain being used to flush the operative cavity with an antiseptic solution. Methods: Two hundred and forty-three patients (173 men and 70 women) were treated by excising the pilonidal sinus and placing a 12F suction drain at the base of the wound, with its tip being brought out in the left gluteal region at least 5 cm laterally to the lower end of the suture. Suction was stopped on the first postoperative day and the drain was cut just above the skin. On day 2, a 5F catheter was inserted through the drain and the cavity was flushed with an antiseptic solution followed by sterile saline solution; the same treatment was repeated on days 4 and 6. The drain was removed on day 8 or 9, some of the stitches on day 8 or 9 and the rest on day 9 or 10. The surgery was performed on a day hospital basis in 207 cases; the remaining 36 were hospitalized overnight and discharged on the following day. Results: Healing was always by first intention, with none of the 243 patients experiencing any complications. The postoperative follow-up now ranges from 5 to 15 years, and there have not been any recurrences. Conclusions: The drainage of blood from the bottom of the wound and the use of antiseptic/saline flushing are essential for primary intention healing and the avoidance of recurrences. © 2002 Excerpta Medica, Inc. All rights reserved. Keywords: Pilonidal sinus; Suction drainage; Antiseptic/saline flushing
Pilonidal disease is a common, chronic intermittent disorder of the sacrococcygeal region. Although it has been surgically treated for more than 100 years, its management remains controversial and recent reports [1–5] have advocated various different approaches. This report describes our technique of primary intention postexcision healing and explains how we overcome the main causes of surgical failure.
Thirty-nine out of 243 underwent surgery because of recurrences: 24 patients had one recurrence, 6 had two, and 9 had three. The patients were prepared and positioned on the operating table, with tension plasters being applied to the buttocks according to standard procedures. General anesthesia was used until the end of the 1980s; since then, we have used local anesthesia. Surgical procedure
Patients and methods Between the middle of 1985 and the end of 1995, we used the procedure described below to excise the pilonidal sinus from 243 unselected patients (173 men and 70 women) with a mean age of 26.1 years (range 14 to 36).
* Corresponding author. Tel.: ⫹39-02-58309000; fax: ⫹39-0258309000.
Local anesthesia is induced using 1% xylocaine and 0.5% marcaine. Methylene blue is placed in the fistula, and an elliptical incision is made. The skin and subcutaneous layer is excised by hand using a scalpel, and then the cyst and sinus tissue is freed (down to the sacrococcygeal region if necessary) using an electrocautery knife. It is best to avoid making too wide an excision. Any tracks lying outside the main sinus are removed by means of smaller elliptical excisions at right angles to the main excision. Hemostasis
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 8 7 6 - 5
210
R. Tritapepe and C. Di Padova / The American Journal of Surgery 183 (2002) 209 –211
Patients were able to return to normal working activities immediately after the removal of the cutaneous stitches on days 8 to 10, by which time the operative scar was consolidated, although they were advised to avoid excessive physical strain and strenuous sports for the following 3 to 4 weeks. The postoperative follow-up now ranges from 5 to 15 years, and no recurrences have been recorded so far. Comments Fig. 1. The drain and the fine flushing catheter are shown.
must be thorough. A 12F suction drain is positioned along the length of the bottom of the operative cavity, and brought out in the left gluteal region 5 to 7 cm laterally to the lower end of the wound. The tension plasters are removed and, under normal traction, sutures are meticulously applied in two or more planes using 2/0 catgut and an HR30 needle. The skin is closed using separate nylon 2/0 sutures. The mean operating time is 25 minutes. Postoperative procedure Suction is stopped on the first postoperative day and the drain is cut just above the skin. On the second day, a fine 5F catheter is inserted through the drain and 3 to 4 mL of a 3.75% povidone-iodine antiseptic solution are instilled under low pressure, followed by a 3 to 4 mL sterile saline washout. The antiseptic and saline solutions easily flush out through the space between the catheter and drain, after which the fine catheter is removed (see Fig. 1). Flushing is repeated on days 4 and 6. The drain is shortened 2 to 3 cm on day 7 or 8 and removed on day 8 or 9, when alternate skin sutures can also be removed; the remaining sutures are removed on the following day. The patient can move cautiously as early as the evening of the day of surgery but, unless it is necessary, should avoid standing until day 5 or 6. A light diet should be followed for the first 2 or 3 days, after which no dietary restrictions are required. Of the present series, 207 patients (151 men and 56 women) underwent surgery in our day-hospital; owing to general anesthesia the remaining 36 were hospitalized overnight.
Results Healing was always by first intention, and none of the patients experienced any operative or postoperative complications or subjective disturbances such as pain, constipation, or wound infections. Analgesics were administered on request to the patients only the same day of surgery.
The treatment of pilonidal sinus by means of cyst excision and skin-flap reconstruction [1– 4] is technically complex; however, it does not take long to perform, allows healing within a few days, and leads to complication and recurrence rates that are at least no greater than those observed after other procedures [5]. These results seem to be further improved when the procedure is followed by the application of a postoperative drain [6]. Akinci et al [7] adopt a lateral rather than a median approach, and make use of an asymmetric excision and primary closure: this is certainly a simple method that rarely gives rise to complications or recurrences. Open excisions or excisions with marsupialisation lead to less frequent recurrences than excision and primary closure [8 –11], but require long healing times up to 40 to 60 days. Finally, the results of simple excision and primary closure are discouraging because of the excessively high rate of complications and recurrences [12–15]. Even if extremely thorough hemostasis is achieved, the excision of the pilonidal sinus inevitably may lead to the collection of some blood or serum at the bottom of the operative cavity. Therefore, the scrupulous drainage and the antiseptic/saline flushing of the operative cavity, as we describe here, ensure that the dead space remains clear and favor the normal healing process and the final scar formation around the suture. In our experience, the application of this simple, inexpensive, and extremely well tolerated procedure is able to abolish the occurrence of complications, which are not uncommon after this minor surgical procedure, and further improves the success rate of the surgical technique [16]. Acknowledgments This study was supported by Research Grant No. 90.03104 from the Italian National Research Council, Rome, Italy, and Research Grant No. Cat. 11 Cp 05 00003 from Cariplo, Milan, Italy. References [1] Karydakis GE. New approach to the problem of pilonidal sinus. Lancet 1973;103:1414 –5.
R. Tritapepe and C. Di Padova / The American Journal of Surgery 183 (2002) 209 –211 [2] Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust NZ J Surg 1992;62:385–9. [3] Bascon JU. Pilonidal sinus. Curr Pract Surg 1994;6:175– 80. [4] Bozkurt MK, Tezel E. Management of pilonidal sinus with the Limberg flap. Dis Colon Rectum 1998;41:775–7. [5] Senapati A, Cripps NP, Thompson NR. Bascom’s operation in the day-surgical management of symptomatic pilonidal sinus. Br J Surg 2000;87:1067–76. [6] Erdem E, Sungurtekin U, Nessar M. Are postoperative drains necessary with the Limberg flap for treatment of pilonidal sinus? Dis Colon Rectum 1998;41:1427– 43. [7] Akinci OF, Coskun A, Uzunkoy A. Simple and effective surgical treatment of pilonidal sinus: asymmetric excision and primary closure using suction drain and subcuticular skin closure. Dis Colon Rectum 2000;43:701– 6. [8] Sondenaa K, Nesvik I, Andersen E, Soreide JA. Recurrent pilonidal sinus after excision with closed or open treatment: final result of a randomised trial. Eur J Surg 1996;162:237– 40.
211
[9] Fuzum M, Bakir H, Soylu M. et al. Which technique for treatment of pilonidal sinus open or closed? Dis Colon Rectum 1994;37:1148 – 50. [10] Solla JA, Rothenberger DA. Chronic pilonidal disease. An assessment of 150 cases. Dis Colon Rectum 1990;33:758 – 61. [11] Menzel T, Dorner A, Cramer J. Excision and open wound treatment of pilonidal sinus. Rate of recurrence and duration of work incapacity. Dtsch Med Wochenschr. 1997;122:1447–51. [12] Sondenaa K, Nesvik I, Andersen E, et al. Bacteriology and complications of chronic pilonidal sinus treated with excision and primary suture. Int J Colorectal Dis 1995;10:161– 6. [13] Berger A, Frileux P. Pilonidal sinus. Ann Chir 1995;49:889 –901. [14] Khaira HS, Brown JH. Excision and primary suture of pilonidal sinus. Ann R Coll Surg Engl 1995;77:242– 4. [15] Brieler HS. Infected pilonidal sinus. Langenbecks Arch Chir Suppl Kongressbd 1997;114:497–500. [16] Bascom JU. Pilonidal sinus: experience with the Karydakis flap. Br J Surg 1998;95:875.