Turkish Journal of Surgery

Turkish Journal of Surgery

ISSN: 2564-6850
e-ISSN: 2564-7032

 

Mohamed A. Alkatta, Abdallah Mejally

Sana’a University, Medical Surgery, Sana’a, Yemen

Abstract

Objective: This study aimed to estimate simple excision and tension free primary closure and to study its effectiveness in terms of operating and healing time, duration of hospital stay, degree of post operation complications, and rate of recurrence.

Material and Methods: This is study included 78 patients, of whom 71 were (91%) males and 7 (9%) females, who underwent excision and tension free closure. The procedure was based on bilateral side flaps, which were released and dissected 2-3 cm from the edge of the wound. Patient’s age, gender, body mass index, wound healing, operation, drain removal, length of hospital stay, and complications and recurrence were analysed.

Results: The study involved 78 patients, 71 (91%) males and 7 (9%) females. Median age of the patients was 28.5 years. Mean operation time was 44.6 minutes . Sixty-one patients (78.2%) had full primary healing without any complication. No one had hematoma or seroma, but five (6.4%) cases had a minor wound infection and three (3.8%) obese patients developed recurrence. Mean length of hospital stay was 2.5 days , most patients went back to their work within 3 weeks. Median follow-up period was in a 26.2 weak range (1-51.4 weak). Five (6.41%) cases had wound infection and three (3.85%) developed recurrence.

Conclusion: Excision and tension free primary closure were found to be simple procedures associated with lower rates of wound infection, shorter hospital stay, lower recurrence, early wound recovery and short period of being absent from work. Surgery can be easily performed and preferred for cases of non-recurrent pilonidal sinus and cyst.

Keywords: Pilonidal, primary closure, natal cleft sinus, cyst

Introduction

Pilonidal sinus (PNS) is a chronic inflammatory disease associated with excessive hair growth around the infected area and can cause anxiety, perplexity and absence from work. It was first described by Hodges in 1880 (1). It mostly exists in the natal spilt of the sacrococcygeal region and it manifests like inflammation, pus discharge and sinus formation (2,3).

Onset of PNS is scarce both before adulthood and after the age of forties. Males are influenced more by this disease than females, which may be due to their more hairy nature than females (4).

Even though the progress in medical research and study, the tactic to control the pilonidal sinus illness is not well defined yet. However, the therapy regimen must perfectly decrease soreness, provide a shorter hospital stay, reduce complications and rate of recurrence, and show quick healing and return to normal life (5).

A lot of surgical procedures have been used in the caring of the pilonidal sinus disease. Incision and drainage, excision and recovery by second intention are the most commonly used practical methods (6,7), whereas, there are procedures like excision and tension free primary closure, excision with reconstructive flap techniques (8), and other less prevalently used technical methods include phenol injection, cryosurgery and electro cauterization (9,10). Our aim in this study was to estimate the technique, the excision of the pilonidal sinus or cyst, and examine its efficiency to reduce operating period, time of healing, and the duration of hospital stay, the degree of postoperative complications and recurrence rate.

Material and Methods

Seventy-eight patients suffering from un-complicated pilonidal sinus or cyst with an age ranging between 18 to 39 years participated in this prospective study. The patients were admitted to hospital from January 2013 to May 2016. Before starting our study, approval from the ethics committee of our hospital was obtained, and informed consent was taken from each patient, and their parents or partner were informed about the aim and the nature of the study, and written consent was obtained. Patient age, gender, body mass index, wound healing time, operation times, length of hospital stay, drain removal time, complications, and recurrence rates were analyzed.

Surgical Procedure

Simple excision and tension- free primary closure were performed and involved the following steps:

- Antibiotics in the form of Metronidazole (Flagyl, Sanofi-Aventis, Paris, France,) or clindamycin (Vanconex-Cp, Venus Remedies Limited, Baddi.H.P., India) And ceftriaxone (Forsef, Bilim pharmaceuticals, Maslak -Istanbul Turkey) were given to the patient half an hour before the operation.

- When the patient was placed under full anesthesia, he/she was put in the Jack-Knife position to expose the inter gluteal cleft, which was the main site of the operation. The gluteus muscles on both sides were abducted by adhesive strips of plaster stuck to the sides of the operation table. Probing and methylene blue (methylene blue, Navi Mumbai, Maharashtra, India) injection through the opening of the sinus to delineate the main tract and its side branches if present were done (Figure 1).

- Through the elliptical vertical wide incision, excision of the sinus tracts or cyst was performed and the dissection was continued down to the posterior sacral fascia (Figure 2).

- To avoid closure of the defect under tension, bilateral side flaps including skin layers and subcutaneous tissues were dissected and cut 2-3 cm from the edge of the elliptical wound down to the posterior sacral fascia and gluteus maximus muscle fibers with meticulous hemostasis (Figure 3).

- The residual cavity was obliterated by 1-Prolene sutures (POlYGLYCOLIC ACID, Yancheng Huida Medical Instrument Co., Ltd, China) which were taken through the skin, subcutaneous tissue and post sacral fascia (Figure 4).

- A second vertical mattress suture 2-0 silk (silk braided, Yancheng Huida Medical Instrument Co., Ltd, China) was taken to close the gap between the Prolene stitches. Closure must be tension free to prevent dehiscence of the wound and be flat as much as possible to avoid the development of intergluteal cleft, which is the site of sinus recurrence (Figure 5).

Our practice is to put a small suction drain in the depth of the residual cavity to tighten the long threads of the Prolene sutures rolled above. Povidone -iodine (Umod, ine YMCO, Medical Industries, Yemen) soaked gauze dressing was placed over the closed wound to provide some external pressure in an attempt to obliterate the potential space and to prevent the formation of seroma or hematoma. Post-operatively, the patients nursed were advised to sleep on one side and encouraged to mobilize early.

The suction drains were removed after 24-72 hours postoperatively depending on the amount of drainage, which must be less than 10 ml during the last 24 hours. Antibiotics were given pre and postoperatively for 5 days in the form of Metronidazole (Flagyl, Sanofi-Aventis, Paris, France,) or vancomycin (vancomycin, Boisar, Dist-Thane, India), and Ceftriaxone (Forsef, Blim pharmaceuticals, Maslak -Istanbul, Turkey) for 24 hours and replaced by amoxicillin-clavulinate (MAGMA, ALPHA-Aleppo pharmaceutical industries, Syria) and metronidazole for 4 days. All patients were discharged after two to three days of the operation, the sutures and rolled-in compressive gauze packing were removed 2 weeks after the operation. (Figure 6).

Postoperative follow-up was once per week for the first 4 weeks and then at three, 6 and 12 months from the date of the operation (Table 1).

Analytical Statistic Data

Statistical Package for the Social Sciences program (SPSS) ver. 20 (SPSS Inc., Chicago, IL, United State of America) for Windows 7.0 computer software was used for statistical analysis. Data were described in the form of frequency, mean, median, percentage (%) and average.

Results

This study included 78 Patients, 71 (91%) males and 7 (9%) females. Median age of the patients was 28.5 years, ranging between 18-39 years. Thirty-one (39.7%) of the patients was overweight with a BMI between 25-30 kg/m2, and 19 (24.3%) patients were obese with a body mass index of over 30 kg/m2 according to the classification of the World Health Organization of Obesity (11). Fourteen (17.9%) were males and 5 (6.4%) were females. Thirty-eight (48.7%) males had excessive hair (Table 2). The occupation of the patients mainly involved accounting and computer technologies working for more than 8 hours daily in 37 (47.4%) cases and long-distance driver more than 8 hours daily in 13 cases (16.66%). Fifty-three patients (67.95%) presented with chronic discharge, 16 (20.5%) patients presented with dull aching pain of the distended non-infected cyst and 9 (11.5%) patients had an acute abscess for which incision and drainage was performed followed by excision and primary closure 3 months later (Table 3).

All of the chronic cases except the one presented with perianal pilonidal sinus underwent excision and tension free primary closure. Mean time of the operation was 44.6 minutes, ranging between 42-57 minutes.

One of our cases, a 38-year-old male patient, was referred to us and described as a case of sinus in ano, and during the operation, we found perianal sinus tract at the level of 4 o’clock which was completely excised and proven by histopathology as pilonidal sinus (Figure 7).

Mean length of hospital stay was 2.5 days (range, 2-3 days). Postoperatively, sixty-one (78.2%) cases were without intraoperative, early or late postoperative complications, 5 (6.41%) cases had minor wound infection and 3 (3.85%) obese hairy patients developed recurrence, and 9 (11.54%) cases could not be reached during follow-up, which was conducted even by phone for cases living in far governorates (Table 4).

Discussion

Intergluteal pilonidal disease is an infection disease affecting the skin and subcutaneous tissue in the midline of the upper part of the natal cleft of the buttocks (12). If the depth of the intergluteal sulcus increases, it will blead to the increase in anaerobic bacteria and form a good media for growth in this area (13).

In addition, the development of pilonidal disease is thought to be a result of a vacuum effect created between heavy buttocks. The vacuum effect sucks the anaerobic bacteria, hair, and debris into the subcutaneous fat tissue. If these factors responsible for the development of the disease are not eliminated, they will play important roles in the development and recurrence of the disease (14,15).

The mainstay of operative management for chronic or persistent disease is eradication of all pilonidal sinus tracts. En bloc eradication of the entire pilonidal sinus and epithelialized tracts was performed down to the sacrococcygeal fascial level, keeping normal tissue intact as much as possible (16,17).

There are several surgical methods used in the treatment and control of sacrococcygeal pilonidal sinus, however postoperative morbidity could not be reduced by those methods and there is no agreement on the best gold standard method of surgical treatment (18). Any procedure should stress well on other parameters than postoperative morbidity and recurrence, such as simple technique, length of hospital stay, and length of absence from work (17,19). Many studies comparing various procedures have documented the relative superiority of one over the other. For simple, non-recurrent pilonidal sinus, less invasive surgery with excision and primary closure could be enough (18).

Primary closure technique is associated with earlier wound healing (complete epithelialization) and a faster return to daily work, but a delayed (open) closure is associated with a lower likelihood of pilonidal disease recurrence (12,20) .

The results of our study in which primary closure was tension free boosted these proposal. Patients walked freely without significant pain, but minor wound infection was noted in only 5 cases.

Low morbidity rate of certain surgery techniques is also naturally reflected by hospitalization time and time off work. In some papers reported for tension free primary closure, hospital stay is short and less than 5.5 days as reported by Rossi et al. (1993) for Limberg flap (21) and 5.7 days as reported by Singh et al. (2005) for adipose fasciocutaneus flap (22,23). Hospital stay in this study was shorter than 4 days and time off work was not more than three weeks. A total of 11 trial studies (n= 1729 patients) have included data for work return time, where nine studies have reported a faster return time to work following primary closure (24). The largest study including 144 patients has found that patients undergoing a primary repair have a significantly faster rate of return to work as compared to those with open wounds (11.9 versus 17.5 days, respectively) (24). Some authors say that primary closure is better and comfortable, especially in small defects. Excision surgery alone, or Excision and Primary closure of the wound, has been compared in a previous study (25). In addition, post-operative wound importance in this study was considered. Any exercise or sitting down on the wound was avoided for 3 weeks, and the patient was advised to return as slowly as possible to his/her normal activities. Hair-shaving from the edges of the wound is necessary (26,27). Shaving has to be continued for a long time or until complete healing of the wound (27). In this study, during follow-up of 12 months, only three recurrences (%4,6) in obese, hairy male patients were seen in a total of 65 (83.3%) patients at 1 year after surgery, which is in agreement with the study by Akinci et al.(1999) stating that pilonidal sinus is an acquired disease, penetration of hair is the main cause, and understanding the causes help prevent the disease (28). Time of healing was shorter after excision and closure, but recurrences occurred more as compared with excision alone. In addition, primary closure has been reported to result in a higher initial primary rate of healing with shorter and a reduced duration of hospital stay (19). For more comparisons with other studies, see Table 5.

Study Limitations

The limitation to our study includes losing contact with some patients after surgery.

Conclusion

Excision and tension-free primary closure of the pilonidal disease is effective with low complication rates, short hospitalization, low recurrence rates, earlier healing and shorter time off work. The surgery can be easily performed. It is now clearly shown that there is better patient satisfaction with primary wound closure rather than leaving it open.

Cite this article as: Alkatta MA, Mejally A. Excision and tension-free primary closure of pilonidal disease. Turk J Surg 2019; 35 (4): 278-284.

Ethics Committee Approval

Approval from the ethics committee of our hospital was obtained.

Peer Review

Externally peer-reviewed.

Author Contributions

: Concept - M.A.; Design - M.A.; Supervision - M.A.; Resource - M.A.; Materials - M.A.; Data Collection and/or Processing - M.A., A.M.; Analysis and/or Interpretation - M.A., A.M.; Literature Search - M.A.; Writing Manuscript - M.A.; Critical Reviews - M.A.

Conflict of Interest

The authors have no conflicts of interest to declare.

Financial Disclosure

The authors have no conflicts of interest to declare.

References

  1. Hodges R. Pilonidal sinus. Boston Med Surg J 1880:485-586.
  2. Bertelsen CA. Cleft-lift operation for pilonidal sinuses under tumescent local anesthesia: a prospective cohort study of peri- and postoperati- ve pain. Diseases of the Colon & Rectum 2011;54(7):895-900.
  3. Surrell JA. Pilonidal disease. Surg Clin North Am 1994;74(6):1309-15.
  4. Sondenaa K, Andersen E, Nesvik I, Soreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis 1995;10(1):39-42.
  5. 5Karaca AS, Ali RR, Çapar M, Karaca S. Comparison of Limberg flap and excision and primary closure of pilonidal sinus disease, in terms of quality of life and complications. Journal of the Korean Surgical So- ciety 2013;85(5):236-9.
  6. Kumar S, Haboubi N, Chintapatla S, Safarani N. Sacrococcygeal pilo- nidal sinus: historical review, pathological insight and surgical opti- ons. Techniques in Coloproctology 2003;7(1):3-8.
  7. Lee HC, Ho YH, Seow CF, Eu KW, Nyam D. Pilonidal disease in Singapo- re: clinical features and management. The Australian and New Zea- land Journal of Surgery 2000;70(3):196-8.
  8. Müller K, Marti L, Tarantino I, Jayne DG, Wolff K, Hetzer FH. Prospecti- ve analysis of cosmesis, morbidity, and patient satisfaction following limberg flap for the treatment of sacrococcygeal pilonidal sinus. Dise- ases of the Colon & Rectum 2011;54(4):487-94.
  9. Shafik A. Electrocauterization in the treatment of pilonidal sinus. In- tern Surg 2017;81(1):83-4.
  10. Duchateau J, De Mol J, Bostoen H, Allegaert W. Pilonidal sinus. Excision--marsupialization--phenolization? Acta Chirurgica Belgica 2017;85(5):325-8.
  11. World Health Organization. BMI classification. Pharmacotherapy 2006:4-9.
  12. Khanna A, Rombeau J. Pilonidal Disease. Clinics in Colon and Rec- tal Surgery [Internet]. 2011 Mar 23 [cited 2018 May 10];24(1):046- 53.Available from: http://www.thieme-connect.de/DOI/DOI? 10.1055/s-0031-1272823
  13. Miocinović M, Horzić M, Bunoza D. The prevalence of anaerobic infec- tion in pilonidal sinus of the sacrococcygeal region and its effect on the complications. Acta medica Croatica : casopis Hravatske akade- mije medicinskih znanosti. 2001;55(2):87-90.
  14. Bascom J. Pilonidal disease: origin from follicles of hairs and results of follicle removal as treatment. Surgery. 1980;87(5):567-72.
  15. Schoeller T, Wechselberger G, Otto A, Papp C. Definite surgical tre- atment of complicated recurrent pilonidal disease with a modified fasciocutaneous V-Y advancement flap. Surgery. 1997;121(3):258-63.
  16. Bascom J. Pilonidal disease: long-term results of follicle removal. Dise- ases of the Colon and Rectum 1983;26(12):800-7.
  17. Oncel M, Kurt N, Kement M, Colak E, Eser M, Uzun H. Excision and mar- supialization versus sinus excision for the treatment of limited chronic pilonidal disease: a prospective, randomized trial. Techniques in Co- loproctology 2002;6(3):165-9.
  18. Saber A. Evidence-based management of sacrococcygeal pilonidal sinus. Jurnalul de Chirurgie. OMICS International; 2014;10(1):1-4.
  19. Petersen S, Koch R, Stelzner S, Wendlandt TP, Ludwig K. Primary clo- sure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Diseases of the Colon and Rectum 2002;45(11):1458-67.
  20. Lee HC, Ho YH, Seow CF, Eu KW, Nyam D. Pilonidal disease in Singapore: clinical features and management. Aust N Z J Surg 2000;70(3):196-8.
  21. Rossi P, Russo F, Gentileschi P, Quintigliano D, Cicardo G, Nasrollah N, et al. The pilonidal sinus: its surgical treatment, our experience and a review of the literature. Il Giornale di Chirurgia 1993;14(2):120-3.
  22. Singh R, Pavithran NM. Adipo-fascio-cutaneous flaps in the tre- atment of pilonidal sinus: experience with 50 cases. Asian J Surg 2005;28(3):198-201.
  23. Morell V, BL C, Deshmukh N. Surgical treatment of pilonidal disease: comparison of three different methods in fifty-nine cases. Military Me- dicine 1991;156(3):144-6.
  24. Fazeli MS, Adel MG, Lebaschi AH. Comparison of outcomes in Z-plasty and delayed healing by secondary intention of the wound after exci- sion of the sacral pilonidal sinus: results of a randomized, clinical trial. Diseases of the Colon and Rectum 2006;49(12):1831-6.
  25. Kronborg O, Christensen K, Zimmermann-Nielsen C. Chronic pilonidal disease: a randomized trial with a complete 3-year follow-up. Br J Surg 1985;72:303-4.
  26. Jamal A, Shamim M, Hashmi F, Qureshi MI. Open excision with secon- dary healing versus rhomboid excision with Limberg transposition flap in the management of sacrococcygeal pilonidal disease. JPMA 2009;59(3):157-60.
  27. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am 2002;82(6):1169-85.
  28. Akıncı F, Mikda Ö, Bozer M, Uzunköy A, Düzgün SA, Coşkun A, et al. Incidence and aetiological factors in pilonidal sinus among Turkish soldiers. Eur J Surg 1999;165(4):339-42.
  29. Urhan MK, Kücükel F, Topgul K, Ozer I, Sari S. Rhomboid excision and Limberg flap for managing pilonidal sinus: results of 102 cases. Disea- ses of the Colon and Rectum 2002;45(5):656-9.
  30. Ciccolo A, Rossitto M, Panacea D, Manfrè A, Buonamonte S, Ardizzone A. Treatment of pilonidal disease in short-stay surgery: personal met- hod. Annali Italiani di Chirurgia 2004;75(5):603-5.
  31. Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, Oguz M. Mo-dified limberg transposition flap for sacrococcygeal pilonidal sinus. Surgery Today 2004;34(5):419-23.
  32. Katsoulis IEE, Hibberts F, Carapeti EAA. Outcome of treatment of pri- mary and recurrent pilonidal sinuses with the Limberg flap. Surgeon 2006;4(1):7-10.
  33. Akin M, Gokbayir H, Kilic K, Topgul K, Ozdemir E, Ferahkose Z. Rhom- boid excision and Limberg flap for managing pilonidal sinus: long- term results in 411 patients. Colorectal Disease 2008;10(9):945-8.
  34. Toccaceli S, Persico Stella L, Diana M, Dandolo R, Negro P. Treatment of pilonidal sinus with primary closure. A twenty-year experience. Chir Ital 2008;60(3):433-8.
  35. Aslam MN, Shoaib S, Choudhry AM. Use of Limberg flap for pilonidal sinus--a viable option. Journal of Ayub Medical College 2009;21(4):31-3
  36. el-Khadrawy O, Hashish M, Ismail K, Shalaby H. Outcome of the rhom- boid flap for recurrent pilonidal disease. World J Surg 2009;33(5):1064- 8.