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Pilonidal cyst
PILONIDAL REPORT
OF A NEW PROCEDURE
CYST*
FOR OPERATION
AND TREATMENT
FIRST LIEUT. DAVID BREZIN, M.C. Septic SurgicaI Section, Station Hospital
Chief of
FORT BRAGG, NORTH CAROLINA E beIieve we have produced a procedure for operation and treatment of piIonida1 cyst which has materiaIIy reduced the heaIing time. The purpose of this paper is to present experiences gained in the treatment of thirty patients. The study was undertaken because previous methods were not satisfactory for use in the miIitary service. In the miIitary service the probIem of piIonida1 cyst is a prominent one. FoIIowing operation rt is the genera1 poIicy that the soIdier shaI1 not be returned to duty until convaIescence is compIete. For exampIe, the soldier cannot do duty while he has an open granuIating wound and return to the dispensary for periodic dressings. Therefore, the surgeon is confronted with the maintenance of the patient in the hospital until the wound is solidIy heaIed. The incidence of piIonida1 cysts is high in the army. This may be.expected because the recruits are in the proper age group and incidence is higher in maIes. MiId to moderate trauma is inherent in the occupation and exigencies uf modern military methods. The type of trauma may range from that gotten from vigorous calisthenics to direct injury incurred from riding over rough terrain in trucks. Trauma as a predecessor of infection draws attention to the presence of a cyst. In this series moderate to severe infection was present in a11 cysts operated upon. During the First Army Maneuvers in the CaroIinas, 33 per cent of the admissions to the Septic SurgicaI Service at this hospita1 were actuaIIy piIonida1 abscesses. Often the cavities had been extended by infection beyond the confines of the cyst waI1 and
over the buttocks. The methods previousIy used were variations of bIock excision. They were: (I) bIock excision packed open to granulate in; (2) bIock excision with mattress suture cIosure with sulfanilamide powder in the wound; or (3) cIosure where various types of reIaxing incisions had been made to cIose the wound without tension. None of these methods was entireIy satisfactory primariIy because of the proIonged heaIing time and aIso because of compIications which were inherent in heaIing of a scar in the midline crease. ConsequentIy, in order to estabIish a procedure which wouId be more idea1 we set down the foIlowing aims: First, we attempted to devise a method by which we couId be more certain of excising a11 the abnorma1 and infected tissue. This meant a procedure by which a more anatomica dissection couId be done with better visuaIization of the sac structure. Second, we sought for a method to faciIitate heaIing and reduce hospitaIization to a minimum. In genera1 to accomplish this end meant finding a substance which wouId not only reduce the possibiIity of infection but would aIso stimuIate hearing. Third, we endeavored to Ieave the soIdier with a soIidIy heaIed scar which wouId be Ieast IikeIy to break down. We beIieved that this Iatter aim couId best be accompIished by reducing the need for new epitheIium by retaining the origina thick skin.
W
* Read before the Staff CIinicaI Conference,
EXCISION BIock excision by sharp dissection or with cautery, with or without closure, has been the most popuIar procedure. This type of excision is a bIind method which
May 19, 1942, Station Hospital,
18
Fort Bragg, N. C.
NEW SERIES VOL. LIX, No.
I
Brezin-PiIonidaI
sacrifices a great deaI of surrounding norma1 tissue. Likewise because of the rigorousIy predetermined eIIiptica1 type of
Cyst
American
Journal
‘9
of Surgery
shaI1 cross the midIine crease. reason there can be no standard Often because of the number
For this incision. and the
FIG. I _ a, b, c, d, the retative positions and arrangement of the sinus openings are portrayed. The heavy bIack Iine indicates the Iine of incision and outIines the skin Sands Ieft surrounding the sinus openings.
incision, cyst waI1 and infected scar which may extend IateraIIy or down to the ana waI1, may be transected and Ieft in the depths of the wound. Not onIy may there be a Iarge percentage -of recurrences but aIso absence of heaIing. The Incision. Because heaIing and epithelization, owing to tension and maceration, are so often proIonged in the midline, the primary precept for the incision is that just as IittIe of it as possibIe shaI1 be in, or
arrangement of the sinus openings the ingenuity of the surgeon is taxed. One can aIways depend on a midIine sinus opening. However, additiona sinus openings which we shaI1 designate henceforth as accessory sinus openings may be present either in the midline or to one side of it. The midLine sinuses may be close together, two or three in number, or they may be spread apart. Accessory openings IateraI to the midline are usuaIIy found in the skin over the left
20
American
Journal
of Surgery
Brezin-PiIonidaI
buttock. These are the resuIt of an extension of the infection when midhne openings have become obIiterated through one
FIG. 2. The pedicIed flap is reflected and the cyst is exposed. The skin isIands surround the sinus openings and are dissected out attached to the cyst.
means or another. However, the accessory sinus may be present anywhere within a radius up to 141 inches from the origina midIine opening. The origina midIine opening is usuaIIy found at the IeveI of the sacrococcygea1 joint. (Fig. I, a, b, c, and d.) At the operating tabIe a11 sinus openings are carefuIIy probed and the direction in which the probe passes is noted. This is very important since it aIone determines the type and direction of the incision. A mixture of methyIene bIue and hydrogen peroxide is injected into any of the patent openings in order to stain the tracts for recognition during dissection. In the course of the study it became apparent that one type of incision was more frequentIy adaptabIe and efficacious than others. (Fig. I, a, b and c.) This type begins and ends on the same side of the midIine and is U-shaped. It circumscribes smaI1 eIIiptica1 pieces of skin which are Ieft about the sinus openings. Minor variations are necessary depending upon the circumstances but this type of incision permits the reflection of a
Cyst
pedicIed skin ffap. After reffection, the exposure afforded is good not onIy for tracts running IongitudinaIIy in the midline but aIso for those which have saccuIations to one side, or which may extend down and attach to the anal waI1. The pedicIed ffap Iikewise saves the origina thick skin for cIosure. A second type of incision is usuaIIy transverse or obIique and is adaptable for sinuses or sacs which have accessory sinus openings to either side of the midIine more or less at the same level of the origina midIine sinus opening. EIIipticaI pieces of skin are Iikewise Ieft about the sinus openings when this type of incision is utihzed. Here, however, instead of a pedicIed ffap the skin edges are undercut from >i to $5 inches on both sides, and turned back. This usuaIIy affords sufficient exposure and permits easier dissection. (Fig. Ed.) The Dissection. When the U-shaped incision is employed the skin edges which form the border of the skin flap are grasped in AIIis forceps and tension upward is appIied. Dissection to reflect the fIap is started at the immediate junction of skin and subjacent subcutaneous tissue. The fIap is then carefuIIy undercut. Often the cyst waI1 is immediateIy underneath the skin and the surgeon must cut cIose to or even split skin in order to avoid entering the sac. MethyIene blue aids materiaIIy in defining the boundaries but even without stains the waI1 stands out sharpIy as a smooth opaque shiny structure. If the sac is entered, any cyst waI1 tissue left on the undersurface of the flap must be excised. After reflecting the flap and undercutting the opposite skin edge for s/4 inch the excision of the cyst is begun. (Fig. 2.) When the transverse or obIique incision is used, the skin edges are undercut for s/4 to 45 inch in the same manner as the flap. In either case a probe is inserted into the sinus opening into which it passes most easiIy and kept in pIace unti1 the dissection has begun. The end of the probe denotes the IateraI and upper margin of the cyst waI1 and indicates where separation from
Brezin-PilonidaI the normaI tissue shouId begin. The most cephaIad skin isIand around the sinus opening is grasped in an AIIis forcep, tension upward is appIied and the tissue at the IateraI margin of the cyst waI1 is incised and the waI1 thus partiaIIy freed. A pIane of cIeavage is defined very shortIy; steady tension appIied to the sac makes the fibrous bands attached to the cyst waI1 stand out sharpIy. These bands are transected. The sac may be further separated by inserting a Mayo scissors IateraIIy and spreading the bIades. Where the sac waI1 is particuIarIy thick, bIunt separation with gauze over the forefinger very often materially aids in remova by sheIIing out the sac in the correct pIane of cIeavage. AIthough the sac or sinus usuaIIy originates as a midIine structure, its eventua1 outIines have been found to be quite diverse. We have found proIongations into the fatty tissue above the gIutea1 muscIes. Likewise Iarge sac-Iike proIongations have been found to extend downward onto the anaI waI1 and to be subjacent to the skin IateraI to the ana opening. The depth of the sac is aIso extremely variabIe. It may be entireIy superficia1 and foIIowing its remova onIy a smaI1 midIine defect wiI1 be Ieft in the subcutaneous fat. In other instances it may run downward and part of the cyst waI1 wiI1 be adjacent to the sacrococcygea1 ligament. It wouId appear entireIy IogicaI then that bIock excision using a set eIIiptica1 incision is the type of operation in which abnormai tissue more IikeIy wouId be transected and Ieft in the wound. On the other hand, by tracing the sac boundaries, by what we term anatomica dissection, the chances of remova of the entire sac and infected scar tissue wouId appear to be increased infiniteIy. As an instance in which this is graphicaIIy portrayed, we overIooked a smaI1 midIine sinus opening hardIy Iarger than a normaI skin pore. The U-shaped incision was used in this case and whiIe the skin flap was being reflected a smaII geIatinous sinus tract about 2 mm. in diameter was found Ieading
Cyst
American
Journal
of Surgery
21
into the above mentioned sinus opening. Recognition meant effective excision. It goes without saying that in order to accompIish a we11 pIanned anatomica dissection extreme care must be paid to hemostasis. VisuaIization of the fieId is imperative at a11 times. HEALING
Closure. Our cases faI1 into two cIasses: those which couId be cIosed entireIy and those in which onIy partia1 cIosure couId be accompIished. There has been a diversity of opinion concerning any cIosure. The chief objection has been that the area is aIways potentiaIIy infected, and as such one invites actua1 postoperative infection by cIosure. CompIete cIosure with primary heaIing is the most idea1 procedure foIIowing removal. We have combatted effectiveIy the incIusion of potential infection by the use of a suIfathiazoIe-cod-Iiver-oi1 ointment. We have used this ointment in the wounds of severe hand-space infections, in the muscuIature and skin foIIowing thoracotomy for empyema and in the muscuIar Iayers foIIowing drainage of a perinephric abscess in which the Iayers were sutured. Infection cIeared and heaIing occurred in a most dramatic manner. The ointment is composed of suIfathiazoIe powder IO per cent, cod Iiver oi1 IO per cent in a IanoIin base. When this study was pIanned originaIIy the procedure outIined was to cIose the skin ffap partiaIIy and permit the wound to hea as the perinea1 wound foIIowing abdomina1 perinea1 resection of the rectum. Packing permeated with the ointment was pIaced underneath the ffap. Postoperative dressings reveaIed the wound to be extremely cIean, without odor and a minimum of drainage. Aerobic and anaerobic cuItures from the depths of the wound were taken and bacteria1 contamination was found to be either absent or the coIonies at a minimum. In the case in which bacteria were present the morphoIogy was so aItered that the bacteria could not be identified and it was evident that severe
22
American Journal ~SSurgrry
Brezin-PiIonidaI
attenuation had occurred. Further terioIogic study indicated that the ment had bacteriostatic properties
bacointonIy
FIG. 3. The flap is replaced and siikworm Stewart sutures are pIaced ready for tying.
on interaction with the body tissues. Contro1 studies with the ointment used in cuhure medium did not revea1 any bacteriostatic properties at aI1. With the use of the ointment the Iogic for primary cIosure, compIete or incompIete, became apparent. Most of the incisions Primary Closure. may be cIosed compIeteIy. The type of excision does not sacrifice norma tissue and the subcutaneous structures usuaIIy may be brought together without tension. Plain No, o catgut sutures are used to cIose the defect. Suture bites about 35 inch in Iength are taken on either side and if the pacrococcygeal Iigament has been exposed by dissection, the suture is drawn through this structure as a mattress stitch, affording additiona anchorage. Experience has shown that a11 sutures shouId be placed before the ointment is instiIIed in the wound. A IittIe careful planning wiI1 usuaIIy permit the tissues to be drawn together so that the opposing sides fit without tension. The ointment is then pIaced in the cavity and the sutures are tied. CIosure squeezes out the excess ointment and during heahng the remainder of the
Cyst
oiIy substance sIowIy Ieaks out after it has reached body temperature. The skin flap or skin edges as the case may be, is repIaced and approximated with siIkworm Stewart sutures. (Fig. 3.) Sometimes the ffap must be revised in order to fit the opposite side. This may invoIve trimming away redundant skin or stretching skin edges sIightIy to fit in the upper and Iower angIes. UsuaIIy a slight midIine depression into which the skin flap faIIs, takes up any redundancy bringing the edges into perfect approximation. Extreme care must be used in approximating the skin edges because postoperative motion may puI1 the Asp so that one skin edge may override the other. Partial Primary Closure. In cases in which the defect cannot be drawn together at a11 points without tension, part of the defect is Ieft unsutured. We have had no case in which the angIes of the defect cannot be approximated, so the eventua1 dead space is Ieft in the center and is considerabIy smaIIer than the open granurating wound folIowing bIock excision. The residuaI space is hIled with the ointment and the skin flap reappIied as in the primary closure except for the suturing. Part of the skin is Ieft open at one or the other side of the midIine so that the ointment may escape as granuIation occurs from the bottom and so that ointment may be inserted daiIy. The heaIing time has been decreased in these cases not only because of the decrease in the size of the defect, but aIso because the ointment has shown itseIf to be extremeIy stimuIating to the growth of granuIations and epithelium. In two cases in the series the cyst wall extended down to the subcutaneous tissues to the right of the anus. These cases were primariIy cIosed except for a $5 inch stab wound in the skin to the right of the anus into which a smaI1 rubber drain was pIaced. The excess ointment found egress from the depths of the wound through the stab opening and heaIing was by primary intention. Pre- and Postoperative Care. These cases were a11 infected, some miIdIy some se-
NEW
SERIES
VOL. LIX. No.
I
Brezin-PiIonidaI
vereIy. Preoperative drainage was encouraged if possibIe through the origina sinus openings which were probed open. The patient received hot sitz baths several times daiIy until inflammation cIeared; no specific time interval was aIIowed preoperativeIy. In most instances the sitz bath rkgime Iasted onIy a few days. An enema was given the night before operation. Preoperative medication was a grain and a half of secona1 one hour before operation, morphine suIfate gr. >i and atropine gr. ${50 one-half hour before. At the operating tabIe spina novocain IOO mg. was used for anesthesia. The patient was pIaced on his stomach, the buttocks heId apart by adhesive straps, stuck to the side of the operating table. The fieId was prepared by cIeaning with ether and painting with tincture of merthiolate. FoIIowing operation one ounce of minera1 oi1 was given dairy for four days. Bathroom priviIeges were permitted but the patient was otherwise restricted to bed for four to five days. Postoperative medication for pain was aImost entireIy unnecessary because of the soothing properties of the ointment. In the cases in which the incision had been compIeteIy cIosed, unless there was a temperature elevation, the first dressing was done on the seventh postoperative day at which time the sutures were removed and a SuIfathiazoIe-cod-Iiveroi1 ointment dressing reapplied. In the cases in which the incision had been Ieft partiaIIy open the first dressing was done on the third postoperative day when more ointment was instiIIed in the dead space through the sIitIike opening in the skin. We found the subsequent daiIy instillation of the ointment couId be accompIished more effectiveIy by injecting it through a meta ear syringe. Sutures were removed on the seventh postoperative day. In these Iatter cases it was found that granuIation often heaped through the skin defect or that the skin edges turned down. Intervention was found unnecessary since nature revised the wounds in a11 cases. GranuIation shrunk back into the wound and the
Cyst
skin edges were epitheIia1 tissue.
American Journal of Surgery
bridged
over
23
by smooth
RESULTS
In comparison with other methods the heaIing time foIIowing excision of piIonida1 cysts by this method has been markedly reduced. The average heaIing time in thirty cases, incIuding those of primary cIosure and of partia1 primary cIosure was twentysix days. The range in heaIing time i-s from ten to forty-three days. Forty per cent of the series were heaIed and discharged from the hospita1 in from ten to twenty days; 30 per cent in from twenty to thirty days, and 30 per cent in from thirty to forty-three days. In 30 per cent of the cases in which compIete primary cIosure was effected, foIIowing remova of the sutures on the seventh postoperative day, the skin edges at the Iower angIe of the incision separated for $4 to 45 inch. This aIways occurred where the incision crossed the midline which further substantiates the rationare for using an incision which does not necessitate as much midIine heaIing as is necessary in the block excision. The particuIar stress exerted on the skin edges at this point is the same as that exerted on the granuIation and epitheIium throughout the entire course of the midIine foIlowing the oId types of excision. Retention of sutures for a Ionger period of time, or adhesive strapping which kept the buttocks from spreading, tended to avoid this separation. However, when sutures are retained for more than seven days they show a marked tendency to cut through the skin flap. When separation does occur, the smaII size of the midIine aperture, its transverse position, and the fact that the ointment not onIy stimuIates healing but aIso keeps the wound free of infection, make subsequent heaIing a matter of a short additional time. There was one case of gross wound infection in a patient who deveIoped generaIized furuncuIosis two days after operation. The wound in this case was opened wideIy and packed with the oint-
24
Am&can
Journal
UCSurgery
Brezin-PiIonidaI
ment daiIy. HeaIing occurred in thirty-six days. The heared wounds have remained soIidIy heaIed folIowing discharge from the hospita1. There has been no instance in which splitting of the incision has occurred; there has been no superficial maceration, no abscess formation and no tenderness or pain. Sufficient time has not eIapsed so that an evaluation of end results can be made, although immediate resuits have proved to be very good. In a second series of cases which we have started the resuIts appear even more promising. SUMMARY I. A new type of operation and treatment for excision of piIonida1 cyst is presented. We argue that the chances for compIete remova of cyst and infected tissue are increased by an “anatomical dissection.”
Cyst
JANUARY* ,gqj
2. A new type of incision avoids the midIine except where it crosses it in the transverse direction. 3. The method used retains origina skin, sacrifices IittIe norma tissue and the defect is closed partiaIIy or compIeteIy. 4. Healing is stimuIated and the possibility for infection is reduced by instiIIing a suIfathiazoIe-cod-Iiver-oiI-Ianolin ointment in the wound previous to cIosure. This substance is also used for subsequent dressings. 3. HeaIing time is markedIy reduced by decreasing the necessity for granulation and by retention of origina skin. 6. Immediate resuIts indicate a soIidIy heaIed wound and absence of complications attendant upon midline healing. REFERENCES I. KOOISTRA,H. P. Pilonidal sinuses. Am. J. Surg., 35: 3-17. ‘942. 2. ROGERS, H. and DWIGHT, R. W. PiIonidaI sinus. Ann. Surg., 107: 400-418, 1938.
OF A NEW PROCEDURE
CYST*
FOR OPERATION
AND TREATMENT
FIRST LIEUT. DAVID BREZIN, M.C. Septic SurgicaI Section, Station Hospital
Chief of
FORT BRAGG, NORTH CAROLINA E beIieve we have produced a procedure for operation and treatment of piIonida1 cyst which has materiaIIy reduced the heaIing time. The purpose of this paper is to present experiences gained in the treatment of thirty patients. The study was undertaken because previous methods were not satisfactory for use in the miIitary service. In the miIitary service the probIem of piIonida1 cyst is a prominent one. FoIIowing operation rt is the genera1 poIicy that the soIdier shaI1 not be returned to duty until convaIescence is compIete. For exampIe, the soldier cannot do duty while he has an open granuIating wound and return to the dispensary for periodic dressings. Therefore, the surgeon is confronted with the maintenance of the patient in the hospital until the wound is solidIy heaIed. The incidence of piIonida1 cysts is high in the army. This may be.expected because the recruits are in the proper age group and incidence is higher in maIes. MiId to moderate trauma is inherent in the occupation and exigencies uf modern military methods. The type of trauma may range from that gotten from vigorous calisthenics to direct injury incurred from riding over rough terrain in trucks. Trauma as a predecessor of infection draws attention to the presence of a cyst. In this series moderate to severe infection was present in a11 cysts operated upon. During the First Army Maneuvers in the CaroIinas, 33 per cent of the admissions to the Septic SurgicaI Service at this hospita1 were actuaIIy piIonida1 abscesses. Often the cavities had been extended by infection beyond the confines of the cyst waI1 and
over the buttocks. The methods previousIy used were variations of bIock excision. They were: (I) bIock excision packed open to granulate in; (2) bIock excision with mattress suture cIosure with sulfanilamide powder in the wound; or (3) cIosure where various types of reIaxing incisions had been made to cIose the wound without tension. None of these methods was entireIy satisfactory primariIy because of the proIonged heaIing time and aIso because of compIications which were inherent in heaIing of a scar in the midline crease. ConsequentIy, in order to estabIish a procedure which wouId be more idea1 we set down the foIlowing aims: First, we attempted to devise a method by which we couId be more certain of excising a11 the abnorma1 and infected tissue. This meant a procedure by which a more anatomica dissection couId be done with better visuaIization of the sac structure. Second, we sought for a method to faciIitate heaIing and reduce hospitaIization to a minimum. In genera1 to accomplish this end meant finding a substance which wouId not only reduce the possibiIity of infection but would aIso stimuIate hearing. Third, we endeavored to Ieave the soIdier with a soIidIy heaIed scar which wouId be Ieast IikeIy to break down. We beIieved that this Iatter aim couId best be accompIished by reducing the need for new epitheIium by retaining the origina thick skin.
W
* Read before the Staff CIinicaI Conference,
EXCISION BIock excision by sharp dissection or with cautery, with or without closure, has been the most popuIar procedure. This type of excision is a bIind method which
May 19, 1942, Station Hospital,
18
Fort Bragg, N. C.
NEW SERIES VOL. LIX, No.
I
Brezin-PiIonidaI
sacrifices a great deaI of surrounding norma1 tissue. Likewise because of the rigorousIy predetermined eIIiptica1 type of
Cyst
American
Journal
‘9
of Surgery
shaI1 cross the midIine crease. reason there can be no standard Often because of the number
For this incision. and the
FIG. I _ a, b, c, d, the retative positions and arrangement of the sinus openings are portrayed. The heavy bIack Iine indicates the Iine of incision and outIines the skin Sands Ieft surrounding the sinus openings.
incision, cyst waI1 and infected scar which may extend IateraIIy or down to the ana waI1, may be transected and Ieft in the depths of the wound. Not onIy may there be a Iarge percentage -of recurrences but aIso absence of heaIing. The Incision. Because heaIing and epithelization, owing to tension and maceration, are so often proIonged in the midline, the primary precept for the incision is that just as IittIe of it as possibIe shaI1 be in, or
arrangement of the sinus openings the ingenuity of the surgeon is taxed. One can aIways depend on a midIine sinus opening. However, additiona sinus openings which we shaI1 designate henceforth as accessory sinus openings may be present either in the midline or to one side of it. The midLine sinuses may be close together, two or three in number, or they may be spread apart. Accessory openings IateraI to the midline are usuaIIy found in the skin over the left
20
American
Journal
of Surgery
Brezin-PiIonidaI
buttock. These are the resuIt of an extension of the infection when midhne openings have become obIiterated through one
FIG. 2. The pedicIed flap is reflected and the cyst is exposed. The skin isIands surround the sinus openings and are dissected out attached to the cyst.
means or another. However, the accessory sinus may be present anywhere within a radius up to 141 inches from the origina midIine opening. The origina midIine opening is usuaIIy found at the IeveI of the sacrococcygea1 joint. (Fig. I, a, b, c, and d.) At the operating tabIe a11 sinus openings are carefuIIy probed and the direction in which the probe passes is noted. This is very important since it aIone determines the type and direction of the incision. A mixture of methyIene bIue and hydrogen peroxide is injected into any of the patent openings in order to stain the tracts for recognition during dissection. In the course of the study it became apparent that one type of incision was more frequentIy adaptabIe and efficacious than others. (Fig. I, a, b and c.) This type begins and ends on the same side of the midIine and is U-shaped. It circumscribes smaI1 eIIiptica1 pieces of skin which are Ieft about the sinus openings. Minor variations are necessary depending upon the circumstances but this type of incision permits the reflection of a
Cyst
pedicIed skin ffap. After reffection, the exposure afforded is good not onIy for tracts running IongitudinaIIy in the midline but aIso for those which have saccuIations to one side, or which may extend down and attach to the anal waI1. The pedicIed ffap Iikewise saves the origina thick skin for cIosure. A second type of incision is usuaIIy transverse or obIique and is adaptable for sinuses or sacs which have accessory sinus openings to either side of the midIine more or less at the same level of the origina midIine sinus opening. EIIipticaI pieces of skin are Iikewise Ieft about the sinus openings when this type of incision is utihzed. Here, however, instead of a pedicIed ffap the skin edges are undercut from >i to $5 inches on both sides, and turned back. This usuaIIy affords sufficient exposure and permits easier dissection. (Fig. Ed.) The Dissection. When the U-shaped incision is employed the skin edges which form the border of the skin flap are grasped in AIIis forceps and tension upward is appIied. Dissection to reflect the fIap is started at the immediate junction of skin and subjacent subcutaneous tissue. The fIap is then carefuIIy undercut. Often the cyst waI1 is immediateIy underneath the skin and the surgeon must cut cIose to or even split skin in order to avoid entering the sac. MethyIene blue aids materiaIIy in defining the boundaries but even without stains the waI1 stands out sharpIy as a smooth opaque shiny structure. If the sac is entered, any cyst waI1 tissue left on the undersurface of the flap must be excised. After reflecting the flap and undercutting the opposite skin edge for s/4 inch the excision of the cyst is begun. (Fig. 2.) When the transverse or obIique incision is used, the skin edges are undercut for s/4 to 45 inch in the same manner as the flap. In either case a probe is inserted into the sinus opening into which it passes most easiIy and kept in pIace unti1 the dissection has begun. The end of the probe denotes the IateraI and upper margin of the cyst waI1 and indicates where separation from
Brezin-PilonidaI the normaI tissue shouId begin. The most cephaIad skin isIand around the sinus opening is grasped in an AIIis forcep, tension upward is appIied and the tissue at the IateraI margin of the cyst waI1 is incised and the waI1 thus partiaIIy freed. A pIane of cIeavage is defined very shortIy; steady tension appIied to the sac makes the fibrous bands attached to the cyst waI1 stand out sharpIy. These bands are transected. The sac may be further separated by inserting a Mayo scissors IateraIIy and spreading the bIades. Where the sac waI1 is particuIarIy thick, bIunt separation with gauze over the forefinger very often materially aids in remova by sheIIing out the sac in the correct pIane of cIeavage. AIthough the sac or sinus usuaIIy originates as a midIine structure, its eventua1 outIines have been found to be quite diverse. We have found proIongations into the fatty tissue above the gIutea1 muscIes. Likewise Iarge sac-Iike proIongations have been found to extend downward onto the anaI waI1 and to be subjacent to the skin IateraI to the ana opening. The depth of the sac is aIso extremely variabIe. It may be entireIy superficia1 and foIIowing its remova onIy a smaI1 midIine defect wiI1 be Ieft in the subcutaneous fat. In other instances it may run downward and part of the cyst waI1 wiI1 be adjacent to the sacrococcygea1 ligament. It wouId appear entireIy IogicaI then that bIock excision using a set eIIiptica1 incision is the type of operation in which abnormai tissue more IikeIy wouId be transected and Ieft in the wound. On the other hand, by tracing the sac boundaries, by what we term anatomica dissection, the chances of remova of the entire sac and infected scar tissue wouId appear to be increased infiniteIy. As an instance in which this is graphicaIIy portrayed, we overIooked a smaI1 midIine sinus opening hardIy Iarger than a normaI skin pore. The U-shaped incision was used in this case and whiIe the skin flap was being reflected a smaII geIatinous sinus tract about 2 mm. in diameter was found Ieading
Cyst
American
Journal
of Surgery
21
into the above mentioned sinus opening. Recognition meant effective excision. It goes without saying that in order to accompIish a we11 pIanned anatomica dissection extreme care must be paid to hemostasis. VisuaIization of the fieId is imperative at a11 times. HEALING
Closure. Our cases faI1 into two cIasses: those which couId be cIosed entireIy and those in which onIy partia1 cIosure couId be accompIished. There has been a diversity of opinion concerning any cIosure. The chief objection has been that the area is aIways potentiaIIy infected, and as such one invites actua1 postoperative infection by cIosure. CompIete cIosure with primary heaIing is the most idea1 procedure foIIowing removal. We have combatted effectiveIy the incIusion of potential infection by the use of a suIfathiazoIe-cod-Iiver-oi1 ointment. We have used this ointment in the wounds of severe hand-space infections, in the muscuIature and skin foIIowing thoracotomy for empyema and in the muscuIar Iayers foIIowing drainage of a perinephric abscess in which the Iayers were sutured. Infection cIeared and heaIing occurred in a most dramatic manner. The ointment is composed of suIfathiazoIe powder IO per cent, cod Iiver oi1 IO per cent in a IanoIin base. When this study was pIanned originaIIy the procedure outIined was to cIose the skin ffap partiaIIy and permit the wound to hea as the perinea1 wound foIIowing abdomina1 perinea1 resection of the rectum. Packing permeated with the ointment was pIaced underneath the ffap. Postoperative dressings reveaIed the wound to be extremely cIean, without odor and a minimum of drainage. Aerobic and anaerobic cuItures from the depths of the wound were taken and bacteria1 contamination was found to be either absent or the coIonies at a minimum. In the case in which bacteria were present the morphoIogy was so aItered that the bacteria could not be identified and it was evident that severe
22
American Journal ~SSurgrry
Brezin-PiIonidaI
attenuation had occurred. Further terioIogic study indicated that the ment had bacteriostatic properties
bacointonIy
FIG. 3. The flap is replaced and siikworm Stewart sutures are pIaced ready for tying.
on interaction with the body tissues. Contro1 studies with the ointment used in cuhure medium did not revea1 any bacteriostatic properties at aI1. With the use of the ointment the Iogic for primary cIosure, compIete or incompIete, became apparent. Most of the incisions Primary Closure. may be cIosed compIeteIy. The type of excision does not sacrifice norma tissue and the subcutaneous structures usuaIIy may be brought together without tension. Plain No, o catgut sutures are used to cIose the defect. Suture bites about 35 inch in Iength are taken on either side and if the pacrococcygeal Iigament has been exposed by dissection, the suture is drawn through this structure as a mattress stitch, affording additiona anchorage. Experience has shown that a11 sutures shouId be placed before the ointment is instiIIed in the wound. A IittIe careful planning wiI1 usuaIIy permit the tissues to be drawn together so that the opposing sides fit without tension. The ointment is then pIaced in the cavity and the sutures are tied. CIosure squeezes out the excess ointment and during heahng the remainder of the
Cyst
oiIy substance sIowIy Ieaks out after it has reached body temperature. The skin flap or skin edges as the case may be, is repIaced and approximated with siIkworm Stewart sutures. (Fig. 3.) Sometimes the ffap must be revised in order to fit the opposite side. This may invoIve trimming away redundant skin or stretching skin edges sIightIy to fit in the upper and Iower angIes. UsuaIIy a slight midIine depression into which the skin flap faIIs, takes up any redundancy bringing the edges into perfect approximation. Extreme care must be used in approximating the skin edges because postoperative motion may puI1 the Asp so that one skin edge may override the other. Partial Primary Closure. In cases in which the defect cannot be drawn together at a11 points without tension, part of the defect is Ieft unsutured. We have had no case in which the angIes of the defect cannot be approximated, so the eventua1 dead space is Ieft in the center and is considerabIy smaIIer than the open granurating wound folIowing bIock excision. The residuaI space is hIled with the ointment and the skin flap reappIied as in the primary closure except for the suturing. Part of the skin is Ieft open at one or the other side of the midIine so that the ointment may escape as granuIation occurs from the bottom and so that ointment may be inserted daiIy. The heaIing time has been decreased in these cases not only because of the decrease in the size of the defect, but aIso because the ointment has shown itseIf to be extremeIy stimuIating to the growth of granuIations and epithelium. In two cases in the series the cyst wall extended down to the subcutaneous tissues to the right of the anus. These cases were primariIy cIosed except for a $5 inch stab wound in the skin to the right of the anus into which a smaI1 rubber drain was pIaced. The excess ointment found egress from the depths of the wound through the stab opening and heaIing was by primary intention. Pre- and Postoperative Care. These cases were a11 infected, some miIdIy some se-
NEW
SERIES
VOL. LIX. No.
I
Brezin-PiIonidaI
vereIy. Preoperative drainage was encouraged if possibIe through the origina sinus openings which were probed open. The patient received hot sitz baths several times daiIy until inflammation cIeared; no specific time interval was aIIowed preoperativeIy. In most instances the sitz bath rkgime Iasted onIy a few days. An enema was given the night before operation. Preoperative medication was a grain and a half of secona1 one hour before operation, morphine suIfate gr. >i and atropine gr. ${50 one-half hour before. At the operating tabIe spina novocain IOO mg. was used for anesthesia. The patient was pIaced on his stomach, the buttocks heId apart by adhesive straps, stuck to the side of the operating table. The fieId was prepared by cIeaning with ether and painting with tincture of merthiolate. FoIIowing operation one ounce of minera1 oi1 was given dairy for four days. Bathroom priviIeges were permitted but the patient was otherwise restricted to bed for four to five days. Postoperative medication for pain was aImost entireIy unnecessary because of the soothing properties of the ointment. In the cases in which the incision had been compIeteIy cIosed, unless there was a temperature elevation, the first dressing was done on the seventh postoperative day at which time the sutures were removed and a SuIfathiazoIe-cod-Iiveroi1 ointment dressing reapplied. In the cases in which the incision had been Ieft partiaIIy open the first dressing was done on the third postoperative day when more ointment was instiIIed in the dead space through the sIitIike opening in the skin. We found the subsequent daiIy instillation of the ointment couId be accompIished more effectiveIy by injecting it through a meta ear syringe. Sutures were removed on the seventh postoperative day. In these Iatter cases it was found that granuIation often heaped through the skin defect or that the skin edges turned down. Intervention was found unnecessary since nature revised the wounds in a11 cases. GranuIation shrunk back into the wound and the
Cyst
skin edges were epitheIia1 tissue.
American Journal of Surgery
bridged
over
23
by smooth
RESULTS
In comparison with other methods the heaIing time foIIowing excision of piIonida1 cysts by this method has been markedly reduced. The average heaIing time in thirty cases, incIuding those of primary cIosure and of partia1 primary cIosure was twentysix days. The range in heaIing time i-s from ten to forty-three days. Forty per cent of the series were heaIed and discharged from the hospita1 in from ten to twenty days; 30 per cent in from twenty to thirty days, and 30 per cent in from thirty to forty-three days. In 30 per cent of the cases in which compIete primary cIosure was effected, foIIowing remova of the sutures on the seventh postoperative day, the skin edges at the Iower angIe of the incision separated for $4 to 45 inch. This aIways occurred where the incision crossed the midline which further substantiates the rationare for using an incision which does not necessitate as much midIine heaIing as is necessary in the block excision. The particuIar stress exerted on the skin edges at this point is the same as that exerted on the granuIation and epitheIium throughout the entire course of the midIine foIlowing the oId types of excision. Retention of sutures for a Ionger period of time, or adhesive strapping which kept the buttocks from spreading, tended to avoid this separation. However, when sutures are retained for more than seven days they show a marked tendency to cut through the skin flap. When separation does occur, the smaII size of the midIine aperture, its transverse position, and the fact that the ointment not onIy stimuIates healing but aIso keeps the wound free of infection, make subsequent heaIing a matter of a short additional time. There was one case of gross wound infection in a patient who deveIoped generaIized furuncuIosis two days after operation. The wound in this case was opened wideIy and packed with the oint-
24
Am&can
Journal
UCSurgery
Brezin-PiIonidaI
ment daiIy. HeaIing occurred in thirty-six days. The heared wounds have remained soIidIy heaIed folIowing discharge from the hospita1. There has been no instance in which splitting of the incision has occurred; there has been no superficial maceration, no abscess formation and no tenderness or pain. Sufficient time has not eIapsed so that an evaluation of end results can be made, although immediate resuits have proved to be very good. In a second series of cases which we have started the resuIts appear even more promising. SUMMARY I. A new type of operation and treatment for excision of piIonida1 cyst is presented. We argue that the chances for compIete remova of cyst and infected tissue are increased by an “anatomical dissection.”
Cyst
JANUARY* ,gqj
2. A new type of incision avoids the midIine except where it crosses it in the transverse direction. 3. The method used retains origina skin, sacrifices IittIe norma tissue and the defect is closed partiaIIy or compIeteIy. 4. Healing is stimuIated and the possibility for infection is reduced by instiIIing a suIfathiazoIe-cod-Iiver-oiI-Ianolin ointment in the wound previous to cIosure. This substance is also used for subsequent dressings. 3. HeaIing time is markedIy reduced by decreasing the necessity for granulation and by retention of origina skin. 6. Immediate resuIts indicate a soIidIy heaIed wound and absence of complications attendant upon midline healing. REFERENCES I. KOOISTRA,H. P. Pilonidal sinuses. Am. J. Surg., 35: 3-17. ‘942. 2. ROGERS, H. and DWIGHT, R. W. PiIonidaI sinus. Ann. Surg., 107: 400-418, 1938.