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Pilonidal cysts
PILONIDAL TREATMENT
CYSTS
BY MARSUPIALIZATION
OPERATION
CHARLJS BUNCH, M.D. On Active Surgical Staffs of Mercy, Presbyterian and Good Samaritan Hospitals CHARLOTTE,
NORTH
ILONIDAL cysts or cyst teratomas, as they are also calIed, are not unusual in private practice; however, they offered a major probIem in miIitary hospitaIs. There was the question as to whether they shouId be handIed conservativeIy, or shouId be operated upon with the object of curing the condition, and just what type of operation shouId be done. The number of sick days had to be considered with the resuItant temporary loss of this man to the service, together with possibiIity of recurrence of this condition foIIowing treatment. Numerous young recruits wouId turn in for treatment before they had finished their preliminary training, others shortIy thereafter. Many had sustained a sIight injury that wouId resuIt in a ffare-up of these Iesions. Some wouId date the beginning of their compiaints to an injury received on the obstacIe course or in a physica conditioning cIass. Later in their miIitary career the injury was said to have been received whiIe riding in a smaI1 boat in a rough sea, or whiIe riding in some mechanized equipment over a rough terraine. OccasionaIIy, an actua1 faI1 would be remembered. The frequent association of the complaint with mechanized equipment Iead an author to refer to the condition as “Jeep Disease.“’ The pathoIogica1 condition was present and the trauma onIy made it apparent. The injury was onIy the exciting factor. Some few cases give no history of injury. It is rather surprising that piIonida1 cysts were not observed or at Ieast recorded in the Iiterature unti1 1867 when Warren? first mentioned them. However, he did not offer any ideas as to their origin. Nothing
P
CAROLINA
appeared in regard to this possibIe etioIogy until 1882 when LanneIongue’s3 articIe appeared which advanced the theory of this possibIe origin from ectodermal invaginations. Five years Iater Tourneaux and Herrmann suggested that presisting vestiges of the neura1 cana might be their origin. Numerous articIes have been written supporting one theory or the other. In 1934, Stone5 wrote an articIe in which he suggested that they might arise from a vestigial structure anaIogus to Preen’s gIand of birds. Fox6, in 1935, in his work in embryoIogy, gave support to the invagination theory and he concIuded that this took pIace between the third and fourth months from ceIIs destined to form hair and gIands. There is IittIe to support Stone’s5 theory; and the beIief that it is due to invagination of the ectoderma1 Iayer is concurred in by most authors, and seems to be the most pIausibIe in the Iight of experience with newer methods of surgery. PiIonidaI cysts are def?niteIy congenita1 in origin. The Iesions are seen most often in the sacrococcygea1 region as manifested on the skin by a smaII sinus or sinuses, which may or may not be in the mid-Ii&. One can get Iittle idea of the extent or direction of the cyst and its tracts usuaIIy from the externa1 appearance. They are subject to periods of more or Iess acute inffammation with increased annoyance to the patient. Often severa hairs can be seen protruding from the sinus. ActuaI abscess is sometimes formed. Often the chronic watery drainage from the area is the onIy reason for the patient to seek surgica1 reIief. In the miIitary hospitaIs abscess 229
230
American
Journal
of Surgery
Bunch-PiIonidaI
formation is the more frequent reason for treatment. The incidence of piIonida1 cyst is *fairly high. In the Navy there were more sick days from this condition in 1940 than for either hernia or syphiIis.‘O Some pediatricians report that about one baby out of ten has this Iesion present. It appears a Iittle more common in the maIe than in the femaIe. The treatment can be divided into conservative and radica1. The conservative is instituted with the idea not of curing the condition but only in getting the patient in condition to return to ordinary activity. This can be accompIished by simpIe institution of drainage usuaIIy by enIarging the sinus opening and appIication of wet heat. This was often done in the case of men in the armed services whose duties couId not spare them for a Iong period. More radical surgica1 procedures are necessary in effecting a cure. AI1 operations can be incIuded under three genera1 headings: the cIosed type, the open type and the partiaIIy cIosed type. In order to do the cIosed typ: successfuIIy it is necessary to excise a11 the cyst and its tracts, kiI1 a11 dead space and be reasonabIy sure the operative fIeId is dry and steriIe, or nearIy so. More often a IittIe serum accumuIates, plus a Iow grade infection and the entire area of operation opens up. I know of no way to be sure the area is steriIe after dirty materia1 has been excised. The cIosed method may get a patient we11 perhaps a IittIe sooner than the other types of operation, but often there is disappointment; the wound opens up and there is a very Iong period of dressings. Even wounds that for a time appear to hea after a Iapse of severa months may open and drain. Twenty-five per cent’ of patients with closed operations who show Iater drainage is a conservative figure8 in comparing reports, for according to some the figure is as high as 50 per cent.l The operations are many and closures vary in the cIosed type. A preoperative rkgime has aIso been advocated with the
Cysts
AUGUST, xg.6
object of cIearing up infection and bed position postoperativeIy has been emphasized to take pressure off the skin area. The semi-cIosed procedure is far safer in the greater percentage of cases than the cIosed. In some instances the cIosed eventuaIIy resuIts in the semi-cIosed. It is the method that many of us have empIoyed for many years. The cyst is removed, the edges brought IooseIy together and drainage instituted. In both of these methods the dissection is usuaIIy wide, sutures are uncomfortabIe and the patient bedridden, and many hypodermic for sedation are required, By marsupiIization many of these disadvantages are overcome. The wound is open, the patient is comfortabIe, rareIy requiring any postoperative sedation, he is ambuIatory and requires onIy a few days in the hospita1. The operative area is not distorted by wide dissections nor is it tense from many sutures. Buieg first mentions the marsupiaIization operation in 1937 but very few articles have appeared in the Iiterature about it. He cites1 the accompIishments by this method to be: (I) The size of the wound is reduced and there is no necessity for sacrificing much tissue; (2) after heaIing a compIete and adequate amount of tissue is Ieft to pad the sacrococcygea1 region; (3) recurrence does not foIIow when the operation if first performed for the condition; (4) the duration of the period from operation to heaIing is satisfactory; (5) no unusua1 preoperative preparation is required; (6) patients are hospitaIized for onIy a few days; (7) no strenuous management, such as “Iocking the boweIs,” compIete rest, specia1 diet, etc., is needed; and (8) postoperative discomfort is negIigibIe. The anesthetic of choice is a Iow spina1. LocaI might be used if we know for sure the cyst to be smaI1, but there is no way to be sure. The operation of marsupiaIization preserves a portion of the waI1 aIong with the base OF the cyst and utiIizes it in the
VOL.LXXII, No. z
Bunch-PiIonidaI
cIosure, the skin edges being sutured IooseIy to the waI1. This membrane wiII possess a11 the histoIogica1 structure of the skin itseIf even if it has been modified or destroyed by inflammation. An abundance of scar tissue has been repIaced and it wiII become just as efficient in the process of heahng. The technic of marsupiaIization is accompIished by inserting a probe or groove director into the opening and spIitting the skin aIong its course. MuItipIe sinuses are treated in like manner. The overhanging edges are cut away aIong with a portion of the IateraI waI1 of the cyst or sinuses. The remaining cyst and sinus are cIeaned of hair and other materia1 with gauze. It is nearIy aIways possibIe to fit the skin edges to the adjacent walIs of the cyst and they can be sutured to the edges of the remaining cyst waI1. A pIain catgut suture in Iock-stitch arrangement is best used. This aIso controIs niceIy any bIeeding from the edges. We might think of this operation as “unroofing” the cyst. ShouId any smaI1 tracts be missed at the time of operation it has been my experience that that particuIar portion wiI1 become inffamed and painfu1 and with the use of a IittIe IocaI anesthetic this portion can be unroofed in the dressing room or office and no sutures are required. This remaining portion wiII be evident on the second or third day postoperativeIy. RecentIy I have had a series of thirtyseven patients whom I operated upon by the marsupiaIization technic. The cysts ranged from very smaI1 to very Iarge. In onIy two was a tract missed and they were handIed as outIined above. Low spina anesthesia was used in aI1. No postoperative sedation was required except for those who had very large cysts. Patients were aIIowed and encouraged to be up the folIowing day and sitz-baths instituted. The average patient couId have Ieft the hospita1 the third postoperative day. The
Cysts
American Journal of Surgery
23’
average wound was compIeteIy heaIed in three weeks. The Iargest wound was heaIed in six weeks. This patient, by the way, had been seen at one of the Iarge hospitals in the west coast and had been told that the wound would take six months to hea1. The cyst extended even down on the thigh. The patient who stayed in the hospita1 the Iongest in my service was one in whom primary closure was attempted onIy to open and drain. This wound required dressing for over three months and was sIow in granulating. Had marsupialization been done, I beIieve he wouId have been heaIed in as many weeks. Postoperative care, as mentioned, consists of sitz-baths, smaI1 dressings and the handIing of excess granuIations. The dressings are rarely very soiIed. Marsupialization offers the greatest comfort to the patient, requires fewer hospita1 days, and in my opinion, offers the greatest hope for cure. AIthough it is hard to judge the merits of a procedure from a smaI1 series of cases, this method of treatment has many distinct advantages and at the present time is the greatest advance in curing this condition. REFERENCES I. BUIE, L. A. Jeep disease. South. M. J., 37: 103, 1944. 2. WARREN, J. M. Quoted by Peterson, Paul and Ames, R. H. PiIonidal- sinuses and cysts. Am. J. Sw., 65: 384, 1944. 3. LANNELONGUE. Quoted by Picket, W. J. and Beatty, A. J. PiIonidaI cysts in the army. Am. J. Surg., 56: 375. 194.2. 4. TOURNEUXand HERMANN. Quoted by Picket, W. J. and Beatty, A. J. Pilonidal cyst in the army. Am. J. Swg., 56: 375, 1942. 5. STONE, H. B. The origin of piIonida1 cysts. Ann. Suv., 99: 585, 1934. 6. Fox, S. L. The origin of pilonida1 sinus. SUTK.. Gynec. ti Obst., 60: I 37, 1935. 7. HIPSLEY, R. W. An operation for piIonida1 sinuses. Am. J. Surg., 63: 357, 1944. 8. FELMUS, L. B., WOODS, C. C. and STRONG,D. H. Arch. Surg., 49: 316, 1944. g. BLUE, L. A. Practical ProctoIogy. P. 512. PhiladeIphia, 1937. W. B. Saunders Co. IO. LANE, W. 2. PiIonidaI cysts and sinuses in the navy. U. S. Nav. M. Bull., 41: 1284, 1943.
CYSTS
BY MARSUPIALIZATION
OPERATION
CHARLJS BUNCH, M.D. On Active Surgical Staffs of Mercy, Presbyterian and Good Samaritan Hospitals CHARLOTTE,
NORTH
ILONIDAL cysts or cyst teratomas, as they are also calIed, are not unusual in private practice; however, they offered a major probIem in miIitary hospitaIs. There was the question as to whether they shouId be handIed conservativeIy, or shouId be operated upon with the object of curing the condition, and just what type of operation shouId be done. The number of sick days had to be considered with the resuItant temporary loss of this man to the service, together with possibiIity of recurrence of this condition foIIowing treatment. Numerous young recruits wouId turn in for treatment before they had finished their preliminary training, others shortIy thereafter. Many had sustained a sIight injury that wouId resuIt in a ffare-up of these Iesions. Some wouId date the beginning of their compiaints to an injury received on the obstacIe course or in a physica conditioning cIass. Later in their miIitary career the injury was said to have been received whiIe riding in a smaI1 boat in a rough sea, or whiIe riding in some mechanized equipment over a rough terraine. OccasionaIIy, an actua1 faI1 would be remembered. The frequent association of the complaint with mechanized equipment Iead an author to refer to the condition as “Jeep Disease.“’ The pathoIogica1 condition was present and the trauma onIy made it apparent. The injury was onIy the exciting factor. Some few cases give no history of injury. It is rather surprising that piIonida1 cysts were not observed or at Ieast recorded in the Iiterature unti1 1867 when Warren? first mentioned them. However, he did not offer any ideas as to their origin. Nothing
P
CAROLINA
appeared in regard to this possibIe etioIogy until 1882 when LanneIongue’s3 articIe appeared which advanced the theory of this possibIe origin from ectodermal invaginations. Five years Iater Tourneaux and Herrmann suggested that presisting vestiges of the neura1 cana might be their origin. Numerous articIes have been written supporting one theory or the other. In 1934, Stone5 wrote an articIe in which he suggested that they might arise from a vestigial structure anaIogus to Preen’s gIand of birds. Fox6, in 1935, in his work in embryoIogy, gave support to the invagination theory and he concIuded that this took pIace between the third and fourth months from ceIIs destined to form hair and gIands. There is IittIe to support Stone’s5 theory; and the beIief that it is due to invagination of the ectoderma1 Iayer is concurred in by most authors, and seems to be the most pIausibIe in the Iight of experience with newer methods of surgery. PiIonidaI cysts are def?niteIy congenita1 in origin. The Iesions are seen most often in the sacrococcygea1 region as manifested on the skin by a smaII sinus or sinuses, which may or may not be in the mid-Ii&. One can get Iittle idea of the extent or direction of the cyst and its tracts usuaIIy from the externa1 appearance. They are subject to periods of more or Iess acute inffammation with increased annoyance to the patient. Often severa hairs can be seen protruding from the sinus. ActuaI abscess is sometimes formed. Often the chronic watery drainage from the area is the onIy reason for the patient to seek surgica1 reIief. In the miIitary hospitaIs abscess 229
230
American
Journal
of Surgery
Bunch-PiIonidaI
formation is the more frequent reason for treatment. The incidence of piIonida1 cyst is *fairly high. In the Navy there were more sick days from this condition in 1940 than for either hernia or syphiIis.‘O Some pediatricians report that about one baby out of ten has this Iesion present. It appears a Iittle more common in the maIe than in the femaIe. The treatment can be divided into conservative and radica1. The conservative is instituted with the idea not of curing the condition but only in getting the patient in condition to return to ordinary activity. This can be accompIished by simpIe institution of drainage usuaIIy by enIarging the sinus opening and appIication of wet heat. This was often done in the case of men in the armed services whose duties couId not spare them for a Iong period. More radical surgica1 procedures are necessary in effecting a cure. AI1 operations can be incIuded under three genera1 headings: the cIosed type, the open type and the partiaIIy cIosed type. In order to do the cIosed typ: successfuIIy it is necessary to excise a11 the cyst and its tracts, kiI1 a11 dead space and be reasonabIy sure the operative fIeId is dry and steriIe, or nearIy so. More often a IittIe serum accumuIates, plus a Iow grade infection and the entire area of operation opens up. I know of no way to be sure the area is steriIe after dirty materia1 has been excised. The cIosed method may get a patient we11 perhaps a IittIe sooner than the other types of operation, but often there is disappointment; the wound opens up and there is a very Iong period of dressings. Even wounds that for a time appear to hea after a Iapse of severa months may open and drain. Twenty-five per cent’ of patients with closed operations who show Iater drainage is a conservative figure8 in comparing reports, for according to some the figure is as high as 50 per cent.l The operations are many and closures vary in the cIosed type. A preoperative rkgime has aIso been advocated with the
Cysts
AUGUST, xg.6
object of cIearing up infection and bed position postoperativeIy has been emphasized to take pressure off the skin area. The semi-cIosed procedure is far safer in the greater percentage of cases than the cIosed. In some instances the cIosed eventuaIIy resuIts in the semi-cIosed. It is the method that many of us have empIoyed for many years. The cyst is removed, the edges brought IooseIy together and drainage instituted. In both of these methods the dissection is usuaIIy wide, sutures are uncomfortabIe and the patient bedridden, and many hypodermic for sedation are required, By marsupiIization many of these disadvantages are overcome. The wound is open, the patient is comfortabIe, rareIy requiring any postoperative sedation, he is ambuIatory and requires onIy a few days in the hospita1. The operative area is not distorted by wide dissections nor is it tense from many sutures. Buieg first mentions the marsupiaIization operation in 1937 but very few articles have appeared in the Iiterature about it. He cites1 the accompIishments by this method to be: (I) The size of the wound is reduced and there is no necessity for sacrificing much tissue; (2) after heaIing a compIete and adequate amount of tissue is Ieft to pad the sacrococcygea1 region; (3) recurrence does not foIIow when the operation if first performed for the condition; (4) the duration of the period from operation to heaIing is satisfactory; (5) no unusua1 preoperative preparation is required; (6) patients are hospitaIized for onIy a few days; (7) no strenuous management, such as “Iocking the boweIs,” compIete rest, specia1 diet, etc., is needed; and (8) postoperative discomfort is negIigibIe. The anesthetic of choice is a Iow spina1. LocaI might be used if we know for sure the cyst to be smaI1, but there is no way to be sure. The operation of marsupiaIization preserves a portion of the waI1 aIong with the base OF the cyst and utiIizes it in the
VOL.LXXII, No. z
Bunch-PiIonidaI
cIosure, the skin edges being sutured IooseIy to the waI1. This membrane wiII possess a11 the histoIogica1 structure of the skin itseIf even if it has been modified or destroyed by inflammation. An abundance of scar tissue has been repIaced and it wiII become just as efficient in the process of heahng. The technic of marsupiaIization is accompIished by inserting a probe or groove director into the opening and spIitting the skin aIong its course. MuItipIe sinuses are treated in like manner. The overhanging edges are cut away aIong with a portion of the IateraI waI1 of the cyst or sinuses. The remaining cyst and sinus are cIeaned of hair and other materia1 with gauze. It is nearIy aIways possibIe to fit the skin edges to the adjacent walIs of the cyst and they can be sutured to the edges of the remaining cyst waI1. A pIain catgut suture in Iock-stitch arrangement is best used. This aIso controIs niceIy any bIeeding from the edges. We might think of this operation as “unroofing” the cyst. ShouId any smaI1 tracts be missed at the time of operation it has been my experience that that particuIar portion wiI1 become inffamed and painfu1 and with the use of a IittIe IocaI anesthetic this portion can be unroofed in the dressing room or office and no sutures are required. This remaining portion wiII be evident on the second or third day postoperativeIy. RecentIy I have had a series of thirtyseven patients whom I operated upon by the marsupiaIization technic. The cysts ranged from very smaI1 to very Iarge. In onIy two was a tract missed and they were handIed as outIined above. Low spina anesthesia was used in aI1. No postoperative sedation was required except for those who had very large cysts. Patients were aIIowed and encouraged to be up the folIowing day and sitz-baths instituted. The average patient couId have Ieft the hospita1 the third postoperative day. The
Cysts
American Journal of Surgery
23’
average wound was compIeteIy heaIed in three weeks. The Iargest wound was heaIed in six weeks. This patient, by the way, had been seen at one of the Iarge hospitals in the west coast and had been told that the wound would take six months to hea1. The cyst extended even down on the thigh. The patient who stayed in the hospita1 the Iongest in my service was one in whom primary closure was attempted onIy to open and drain. This wound required dressing for over three months and was sIow in granulating. Had marsupialization been done, I beIieve he wouId have been heaIed in as many weeks. Postoperative care, as mentioned, consists of sitz-baths, smaI1 dressings and the handIing of excess granuIations. The dressings are rarely very soiIed. Marsupialization offers the greatest comfort to the patient, requires fewer hospita1 days, and in my opinion, offers the greatest hope for cure. AIthough it is hard to judge the merits of a procedure from a smaI1 series of cases, this method of treatment has many distinct advantages and at the present time is the greatest advance in curing this condition. REFERENCES I. BUIE, L. A. Jeep disease. South. M. J., 37: 103, 1944. 2. WARREN, J. M. Quoted by Peterson, Paul and Ames, R. H. PiIonidal- sinuses and cysts. Am. J. Sw., 65: 384, 1944. 3. LANNELONGUE. Quoted by Picket, W. J. and Beatty, A. J. PiIonidaI cysts in the army. Am. J. Surg., 56: 375. 194.2. 4. TOURNEUXand HERMANN. Quoted by Picket, W. J. and Beatty, A. J. Pilonidal cyst in the army. Am. J. Swg., 56: 375, 1942. 5. STONE, H. B. The origin of piIonida1 cysts. Ann. Suv., 99: 585, 1934. 6. Fox, S. L. The origin of pilonida1 sinus. SUTK.. Gynec. ti Obst., 60: I 37, 1935. 7. HIPSLEY, R. W. An operation for piIonida1 sinuses. Am. J. Surg., 63: 357, 1944. 8. FELMUS, L. B., WOODS, C. C. and STRONG,D. H. Arch. Surg., 49: 316, 1944. g. BLUE, L. A. Practical ProctoIogy. P. 512. PhiladeIphia, 1937. W. B. Saunders Co. IO. LANE, W. 2. PiIonidaI cysts and sinuses in the navy. U. S. Nav. M. Bull., 41: 1284, 1943.