Wide Excision Surgeries — Methods & Pros/Cons
Surgical treatment using this method is based on a wide excision of the tissue in the buttock area, including the pilonidal spaces and the skin over them, to a depth that reaches the sacrum and the "tail" vertebrae of the spine.
This approach was based on the historical hypothesis that pilonidal disease is a congenital physical defect, and therefore must be removed completely and extensively in order to achieve a cure. This hypothesis was refuted and abandoned in the 1940s, but the principle of wide excision remains accepted to this day and is the most common surgery in the world for the treatment of pilonidal disease.
Wide resections are usually performed under general or regional anesthesia, usually as an inpatient hospital stay. Recovery can take several weeks or even months, and often involves pain, discomfort, and significant physical limitation during the recovery period. In addition, the surgery carries a significant rate of complications and the possibility of disease recurrence.
There are two types of wide excision surgeries:
1. Medial wide resection surgery (open and closed).
2. Wide excision surgery is performed off the middle of the gluteal fossa and closed by a local flap.
Wide pilonidal excision with primary midline closure
1. Medial wide resection surgeries
Two common surgeries in this category, " closed " and " open ":
In "closed" surgery, the incision area and surgical wound are closed with stitches at the end of the surgery. Closing the surgical wound shortens the recovery time but increases the chance of local infection in the days following surgery and increases the chance of the disease recurring in the future.
In the "open" surgery, a similar wide excision is performed, but the surgical wound is not sutured. The wound is left open and requires continued local treatments and dressings, until it gradually closes, a process that can last weeks and months. The chance of infection and recurrence of the disease is smaller with this method than with the "closed" method.
Wide excision of pilonidal sinus with open wound healing by secondary intention
The complications of midline resection surgery and the high recurrence rate have led surgical associations around the world to recommend avoiding the use of this type of surgery as the primary treatment for pilonidal disease.
Asymmetric wide local excision of pilonidal sinus with lateralization (off-midline displacement) of the suture line outside the natal cleft bottom – "Karydakis", "Bascom" (Cleft Lift) method
2. Treatment of pilonidal sinus with wide excision with local flaps
The partial success and difficulty in healing of pilonidal surgeries have been attributed over the years, at least in part, to the presence of the incision and surgical scar in the gluteal fossa, with the natural tendency of the skin in the fossa to morbidity and inflammation. Accordingly, methods were developed for asymmetric, non-central excision of the pilonidal area. The excised area is covered using a local tissue flap from the contralateral buttock, and the suture line is shifted laterally, out of the natal cleft (Karydakys method and Bascom method - Cleft-lift operation).
Shifting the suture line using a local flap has been shown to reduce the chances of recurrence to less than 10% (in experienced hands).
In the presence of complex pilonidal disease, the recommendation of the world's surgical associations is to use this type of excision surgery with a flap rather than the traditional midline excision.
Additional flap surgeries
Another type of flap surgery recommended for complex pilonidal disease is plastic and reconstructive surgery. These are complex surgical methods in which the wide central excision is performed without change, but the closure of the surgical area is performed by shifting tissues from the sides of the buttocks to the area of the socket. Shifting the tissues with these methods reduces the tension of closing the incisions, allows the surgical incision to be "extracted" from the gluteal socket, and allows the depth of the gluteal socket to be flattened and reduced. All of these do indeed reduce the recurrence rate of the disease to less than 10%, but at the cost of a very extensive surgery that also invades the gluteal areas, surgical morbidity, and significant aesthetic disturbance.
Wide pilonidal excision (P) and covering the surgical wound with a "rhomboid" tissue flap (X) from the buttock.
The following surgical images demonstrate wide excision of pilonidal disease with coverage and closure of the resected areas by tissue flaps from the adjacent buttocks. These surgeries are not commonly used for pilonidal disease and are sometimes performed in cases of very widespread disease or in cases of recurrent, stubborn disease after previous surgeries.
Wide excision of pilonidal sinus (C) and coverage of the excised area with gluteal tissue flaps (A,B)
in a Z-plasty closure.