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Pilonidal cysts
PILONIDAL
CYSTS*
THEIR ORIGIN AND TREATMENT LIEUT.
COL.
DON
S.
WENGER,
M.C.
Kuntoul, Illinois
I
N a series of ninety consecutive patients with piIonida1 cysts and sinuses who were treated surgically it was shown that primary cIosure is the method of choice in treatment. This approximateIy divides in half the time lost from work when the Iesion is treated with some other surgical method. Choice of method of primary cIosure has IittIe to do with exceIlence of results whereas meticuIous surgica1 technic has a great influence on resuIts. There are twice as many extensions of the sinus to the Ieft as to the right of the midline. The origin of the sinus and a rationa explanation of recurrences is presented based on Kooistra’s theory of etioIogy. It has been demonstrated that when treated with primary cIosure the recurrence rate should be beIow IO per cent and that an important factor in recurrence is the size of the defect that remains after excision of the Iesion; the width of the defect is of particular importance. The Iatter concIusion has not been reported before in the Iiterature. *
*
*
*
The cases that have recurrences or compIications are on the average 20 per cent wider than those that hea without compIication. Putting it on another basis, it is shown that those defects which are over 4.2 cm. in width are twice as likely to have complications as those under this size. Choice of method of primary cIosure, tricks of surgery or fetishes of postoperative care have IittIe to do with the exceIIence of results. There is no magic highroad to success in treatment of this Iesion. Good resuIts are the reward of meticulous surgica1 technic foIIowing principles laid down by Halsted many years ago. Those principIes are sharp, gentle, atraumatic surgery; accurate compIete hemostasis; use of the finest suture commensurate with tissue strength; no wound tension or pressure and meticuIous approximation of wound and skin edges. The series upon which these concIusions are * From the SurgicaI Service,
based was done with two methods of primary cIosure. The first was by closure in the midline after undermining the skin and subcutaneous tissue to aIIow closure without tension and the second was by means of a sIiding graft from either or both buttocks to give the relaxation necessary for primary cIosure without tension. Postoperative care was designed to keep the wound cIean, dry, and pressure and tension free. Results are indicated in the foIIowing table: TABLE 1
/
~ gzinz
I
No. of cases..
23
Total hospita1 days. Average days per case No. of recurrences. No. of comphcations. Average size of defect after excision of sinus Average size of defect in recurrence or complications
873 34. g
Total
I-
I
65 1,668
3 (12%,) . 6 (24%) 8.32 by 5.20 by 3.7ocm 8.62 by 5.62 by
1 3.65cm
25.5 5 (7.7%) 6 (9.2%) 8.61 by 4.28 by 3.24cm
90
2,541
28.2 8 (8.8%) 12 (14%)
9.45 by 5.00 by 3.6ocm
A recurrence was any lesion draining after healing was once complete or any Iesion that did not hea compIeteIy prior to discharge from the hospita1. A compIication was any lesion, other than a recurrence, which deIayed heaIing or required additional treatment after surgery, for example, hematoma, infection. We found that recurrences usuaIIy came whiIe the patient was stiI1 in the hospita1 and very rareIy were the first indications deIayed until the third month. AnaIysis of our statistics gave the foIIowing items of information: (I) There are twice as many extensions of the sinus to the left as to the right. (2) The ratio between grafted repairs and midIine repairs as to recurrences is 5 : 3 and
OIiver General
242
CIosure with Graft
Hospital,
Augusta,
American
Ga.
Journal of Surgery
Wenger-PiIonidaI considering compIications is 3: I. (3) The average size of the midline closure that heats without trouble is shorter by 12 per cent and narrower by 20 per cent than those that give trouble. (4) In midIine closures the combined recurrence and comphcation rate is 13 per cent if the fauIt is narrower than 4.2 cm. and is 30 per cent if the fauIt after excision is wider than 4.2 cm. (5) The average grafted case was 20 per cent wider and 13 per cent deeper than the average midIine cIosure. The latter fact, rather than the fauIts of the method, may expIain the greater rate of recurrence and complication when this method was used. The origin of pilonidal cysts is a matter about which there is some disagreement. In 1887 Tourneaux and Herrman said that pieces of the invaginating neurogenic plate broke off and made these cysts. In 1924 Bookman offered a very similar theory. Fox, in the Iate twenties, differed from the earIier theorists in saying that the cysts were not neurogenic or enteric in origin but that fauIts in the process of hair and gland deveIopment gave rise to the cysts. He aIso suggested that there might be a phiIogenetic reIationship between piIonida1 cysts and the scent gIand in the sacrococcygea1 region of birds and amniotes. The pituitary gIand has been accused as an accompIice in this disease. It is this author’s opinion that the theory of Kooistra expIains observed phenomena connected with this Iesion more easiIy than other postuIations. He emphasizes the irreguIarity of the skin in the nata cIeft as being part of the etioIogic basis of these cysts. These dimpIes may be cIassed as arrests or reIicts and resuIt from imperfections in pinching off the neura1 canal. The dimpIes contain hair foIIicIes and desquamated epithelium and with trauma and poor hygiene infIammatory changes are noted. CIogging of the opening into the dimple occurs and inflammation in the dimpIe expands the structure just Iike a baIIoon expands when bIown up. The blown-up dimpIe then extends aIong the path of Ieast resistance subcutaneousIy and we have mechanicaIIy made a sinus that is Iined with epithelium. This can we11 explain recurrences and the fact that recurrences are in the midIine in the old scar. If the scar is rough (and it is) and particuIarIy if meticuIous
August,
I 930
Cysts
cIosure is not affected, there are man-made dimpies in which the process starts a11 over again. By the same theory the scarcity of the cIinica1 lesion in women is expIained by the difference in configuration resuIting in better hygiene and less trauma and, therefore, Iess inflammation. REFERENCES 1. BERKOWITZ, J. SacrococcygeaI J. Suv.,
77: 447-490,
piIonida1 cyst. Am.
1949.
z. DAVIES. L. S. and STARR. K. W. Infected
DiIonidaI sinus. Surg., Gynec. ti Obst., 81: 309-319, 1945. 3. DUNPHY, J. E. The operative treatment of piIonida1 sinus: with speciat reference to the type of suture materia1 as a factor in recurrence. Surgery, 2: 581-584, 1937. 4. Fox, S. L. Origin of piIonida1 sinus, with analysis of its comparative anatomy and histogenesis. Surg., Gynec. Ed Obst., 60: 137-149, 1935. 5. FREUND, S. J. and REDDING, M. D. MarsupiaIization; a surgica1 procedure for the eradication of pilonidal cyst and sinuses. Am. J. Surg., 76: 286-288, 1948. 6. I~OLMAN,E. PiIonidaI sinus-treatment by primary closure. Surg., Gynec. ti Obst., 83: 94-100, 1946. 7. KOOISTRA, H. P. PiIonidaI sinuses: review of the literature and report of 350 cases. Am. J. Surg., 55: 3-17, 1942. 8. LAHEY, F. H. A further suggestion for the operative treatment of piIonida1 sinuses. Surg., G.ynec. IY Obst., 54: 521-523, 1932. 9. LAHEY. F. H. An operation for pilonidal sinus. Surg., Gynec. w Ob& 48: IOI-II;, 1929. IO. LAHEY. F. H. and ECKERSON. E. B. Presacral derdoids. Am. J. Surg., 23: 30-35, 1934. I I. LARSEN, B. B. PiIonidaI cysts and sinuses: technic for excision and primary cIosure. Ann. Surg., I 23: 1ogo-I 100, 1946. 12. MACFEE. WILLIAM F. PiIonidaI cvsts and sinuses: a method of wouId cIosure. Ann. Surg., 116: 687-699, 1942. 13, ROGERS, H. and HALL, M. G. PiIonidaI sinus: surgica1 treatment and pathologica structure. Arch. Surg., 3I : 742-766, 1935. 14. SMITH, T. E. Anterior or perinea1 piIonida1 cysts. J. A. M. A., 136: 973375. 1948. 15. STONE, H. B. Cross grafting of endocrine tissues. Surg., Gynec. ti Obst., 59: 683484, 1934. 16. STONE, H. B. PiIonidal sinus. Ann. Surg., 79: 4IO-414, I924. 17. STONE, H. B. The origin of piIonidaI sinus. Ann. SUrg., 94: 317-320, 1931. 18. SWINTON, N. W. and HODGE, C. C. The treatment of piIonida1 sinus. S. Clin. North America, Ig: 699-708, 1939. 19. ZIEGLER, M. and MEEK, E. M. PiIonidaI cyst and sinus: new method of excision with primary closure. Surgery, 20: 6go-703, 1946.
CYSTS*
THEIR ORIGIN AND TREATMENT LIEUT.
COL.
DON
S.
WENGER,
M.C.
Kuntoul, Illinois
I
N a series of ninety consecutive patients with piIonida1 cysts and sinuses who were treated surgically it was shown that primary cIosure is the method of choice in treatment. This approximateIy divides in half the time lost from work when the Iesion is treated with some other surgical method. Choice of method of primary cIosure has IittIe to do with exceIlence of results whereas meticuIous surgica1 technic has a great influence on resuIts. There are twice as many extensions of the sinus to the Ieft as to the right of the midline. The origin of the sinus and a rationa explanation of recurrences is presented based on Kooistra’s theory of etioIogy. It has been demonstrated that when treated with primary cIosure the recurrence rate should be beIow IO per cent and that an important factor in recurrence is the size of the defect that remains after excision of the Iesion; the width of the defect is of particular importance. The Iatter concIusion has not been reported before in the Iiterature. *
*
*
*
The cases that have recurrences or compIications are on the average 20 per cent wider than those that hea without compIication. Putting it on another basis, it is shown that those defects which are over 4.2 cm. in width are twice as likely to have complications as those under this size. Choice of method of primary cIosure, tricks of surgery or fetishes of postoperative care have IittIe to do with the exceIIence of results. There is no magic highroad to success in treatment of this Iesion. Good resuIts are the reward of meticulous surgica1 technic foIIowing principles laid down by Halsted many years ago. Those principIes are sharp, gentle, atraumatic surgery; accurate compIete hemostasis; use of the finest suture commensurate with tissue strength; no wound tension or pressure and meticuIous approximation of wound and skin edges. The series upon which these concIusions are * From the SurgicaI Service,
based was done with two methods of primary cIosure. The first was by closure in the midline after undermining the skin and subcutaneous tissue to aIIow closure without tension and the second was by means of a sIiding graft from either or both buttocks to give the relaxation necessary for primary cIosure without tension. Postoperative care was designed to keep the wound cIean, dry, and pressure and tension free. Results are indicated in the foIIowing table: TABLE 1
/
~ gzinz
I
No. of cases..
23
Total hospita1 days. Average days per case No. of recurrences. No. of comphcations. Average size of defect after excision of sinus Average size of defect in recurrence or complications
873 34. g
Total
I-
I
65 1,668
3 (12%,) . 6 (24%) 8.32 by 5.20 by 3.7ocm 8.62 by 5.62 by
1 3.65cm
25.5 5 (7.7%) 6 (9.2%) 8.61 by 4.28 by 3.24cm
90
2,541
28.2 8 (8.8%) 12 (14%)
9.45 by 5.00 by 3.6ocm
A recurrence was any lesion draining after healing was once complete or any Iesion that did not hea compIeteIy prior to discharge from the hospita1. A compIication was any lesion, other than a recurrence, which deIayed heaIing or required additional treatment after surgery, for example, hematoma, infection. We found that recurrences usuaIIy came whiIe the patient was stiI1 in the hospita1 and very rareIy were the first indications deIayed until the third month. AnaIysis of our statistics gave the foIIowing items of information: (I) There are twice as many extensions of the sinus to the left as to the right. (2) The ratio between grafted repairs and midIine repairs as to recurrences is 5 : 3 and
OIiver General
242
CIosure with Graft
Hospital,
Augusta,
American
Ga.
Journal of Surgery
Wenger-PiIonidaI considering compIications is 3: I. (3) The average size of the midline closure that heats without trouble is shorter by 12 per cent and narrower by 20 per cent than those that give trouble. (4) In midIine closures the combined recurrence and comphcation rate is 13 per cent if the fauIt is narrower than 4.2 cm. and is 30 per cent if the fauIt after excision is wider than 4.2 cm. (5) The average grafted case was 20 per cent wider and 13 per cent deeper than the average midIine cIosure. The latter fact, rather than the fauIts of the method, may expIain the greater rate of recurrence and complication when this method was used. The origin of pilonidal cysts is a matter about which there is some disagreement. In 1887 Tourneaux and Herrman said that pieces of the invaginating neurogenic plate broke off and made these cysts. In 1924 Bookman offered a very similar theory. Fox, in the Iate twenties, differed from the earIier theorists in saying that the cysts were not neurogenic or enteric in origin but that fauIts in the process of hair and gland deveIopment gave rise to the cysts. He aIso suggested that there might be a phiIogenetic reIationship between piIonida1 cysts and the scent gIand in the sacrococcygea1 region of birds and amniotes. The pituitary gIand has been accused as an accompIice in this disease. It is this author’s opinion that the theory of Kooistra expIains observed phenomena connected with this Iesion more easiIy than other postuIations. He emphasizes the irreguIarity of the skin in the nata cIeft as being part of the etioIogic basis of these cysts. These dimpIes may be cIassed as arrests or reIicts and resuIt from imperfections in pinching off the neura1 canal. The dimpIes contain hair foIIicIes and desquamated epithelium and with trauma and poor hygiene infIammatory changes are noted. CIogging of the opening into the dimple occurs and inflammation in the dimpIe expands the structure just Iike a baIIoon expands when bIown up. The blown-up dimpIe then extends aIong the path of Ieast resistance subcutaneousIy and we have mechanicaIIy made a sinus that is Iined with epithelium. This can we11 explain recurrences and the fact that recurrences are in the midIine in the old scar. If the scar is rough (and it is) and particuIarIy if meticuIous
August,
I 930
Cysts
cIosure is not affected, there are man-made dimpies in which the process starts a11 over again. By the same theory the scarcity of the cIinica1 lesion in women is expIained by the difference in configuration resuIting in better hygiene and less trauma and, therefore, Iess inflammation. REFERENCES 1. BERKOWITZ, J. SacrococcygeaI J. Suv.,
77: 447-490,
piIonida1 cyst. Am.
1949.
z. DAVIES. L. S. and STARR. K. W. Infected
DiIonidaI sinus. Surg., Gynec. ti Obst., 81: 309-319, 1945. 3. DUNPHY, J. E. The operative treatment of piIonida1 sinus: with speciat reference to the type of suture materia1 as a factor in recurrence. Surgery, 2: 581-584, 1937. 4. Fox, S. L. Origin of piIonida1 sinus, with analysis of its comparative anatomy and histogenesis. Surg., Gynec. Ed Obst., 60: 137-149, 1935. 5. FREUND, S. J. and REDDING, M. D. MarsupiaIization; a surgica1 procedure for the eradication of pilonidal cyst and sinuses. Am. J. Surg., 76: 286-288, 1948. 6. I~OLMAN,E. PiIonidaI sinus-treatment by primary closure. Surg., Gynec. ti Obst., 83: 94-100, 1946. 7. KOOISTRA, H. P. PiIonidaI sinuses: review of the literature and report of 350 cases. Am. J. Surg., 55: 3-17, 1942. 8. LAHEY, F. H. A further suggestion for the operative treatment of piIonida1 sinuses. Surg., G.ynec. IY Obst., 54: 521-523, 1932. 9. LAHEY. F. H. An operation for pilonidal sinus. Surg., Gynec. w Ob& 48: IOI-II;, 1929. IO. LAHEY. F. H. and ECKERSON. E. B. Presacral derdoids. Am. J. Surg., 23: 30-35, 1934. I I. LARSEN, B. B. PiIonidaI cysts and sinuses: technic for excision and primary cIosure. Ann. Surg., I 23: 1ogo-I 100, 1946. 12. MACFEE. WILLIAM F. PiIonidaI cvsts and sinuses: a method of wouId cIosure. Ann. Surg., 116: 687-699, 1942. 13, ROGERS, H. and HALL, M. G. PiIonidaI sinus: surgica1 treatment and pathologica structure. Arch. Surg., 3I : 742-766, 1935. 14. SMITH, T. E. Anterior or perinea1 piIonida1 cysts. J. A. M. A., 136: 973375. 1948. 15. STONE, H. B. Cross grafting of endocrine tissues. Surg., Gynec. ti Obst., 59: 683484, 1934. 16. STONE, H. B. PiIonidal sinus. Ann. Surg., 79: 4IO-414, I924. 17. STONE, H. B. The origin of piIonidaI sinus. Ann. SUrg., 94: 317-320, 1931. 18. SWINTON, N. W. and HODGE, C. C. The treatment of piIonida1 sinus. S. Clin. North America, Ig: 699-708, 1939. 19. ZIEGLER, M. and MEEK, E. M. PiIonidaI cyst and sinus: new method of excision with primary closure. Surgery, 20: 6go-703, 1946.