Treatment of pilonidal sinus by wide midline excision
The surgical treatment using this method is based on wide excision of the tissue in the natal cleft, including the pilonidal cavities and the overlying skin, extending in depth to the sacrum and the “tailbone” vertebrae of the spine.
This approach was based on the assumption that pilonidal disease is a congenital physical malformation and that it therefore needs to be removed completely and extensively in order to achieve a cure. This hypothesis was disproven and abandoned as early as the 1940s, but the principle of wide excision has remained in use to this day.
This “traditional” operation is usually performed under general or regional (spinal) anesthesia, with hospital admission. Recovery may take several weeks and sometimes even months, and is often associated with pain and discomfort and significant physical limitations during the recovery period. In addition, the operation is associated with a considerable rate of complications and a significant rate of disease recurrence.
These disadvantages have led European surgical societies to recommend avoiding such wide surgical procedures as treatment for primary chronic pilonidal disease. Nevertheless, this method is still commonly used by many surgeons worldwide.
Wide pilonidal excision with primary midline closure
Two forms of operations are common in this category, "closed" and "open": In the closed method the operation concludes with the wound being closed with sutures. Closing the wound shortens the healing period to a few weeks, but increases the risk of postoperative wound infection and the rate of recurrent disease.
A similar wide excision is performed in the open method, but the operative wound is not sutured. The remaining open wound necessitates months of local medical care and dressings until healing. Chances of wound infection and recurrent disease are reduced in the open approach.
Wide excision of pilonidal sinus with open wound healing by secondary intention
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
Treatment of pilonidal sinus with wide excision and flaps
Over the years, the basic wide excision technique underwent various modifications aimed to cope with the limited success and healing difficulties of pilonidal operations. Blame was put, in part, on the presence of the operative suture line, at the bottom of the natal cleft. Accordingly, a technique of asymmetric excision of the pilonidal area was introduced, resulting in the suture line being deviated laterally from the clefts' bottom. Indeed, deviation of the suture line laterally proved to reduce recurrence rate of the disease compared to excisions with midline suture line (Karydakys operation and Bascom cleft-lift operation).
Others ascribed the high recurrence rate and disturbed wound healing to the high tension applied on surrounding tissues approximated to cover and close the wide operative defect. Complex surgical techniques were therefore developed in which skin and underlying tissues from the buttocks are released and moved medially to cover the wound. Using such tissue flaps in techniques of plastic surgery prevents tension closure, flattens the natal cleft and moves suture line out of the cleft. The recurrence rate is thus reduced to less than 10%, but at the price of an extensive and cosmetically deforming surgical procedure, involving the buttocks.
Wide excision of pilonidal sinus (P) and reconstruction of the surgical wound using a tissue flap (X)
from the buttock
The following drawings illustrate wide excision operations for pilonidal disease using flaps from the buttocks to cover and close the operative defect. These operations may occasionally be indicated for extensive or recurrent pilonidal disease after failed previous treatments. Flap operations are not, usually, the first choice procedure for managing pilonidal disease.
Wide excision of pilonidal sinus (C) and coverage of the excised area with gluteal tissue flaps (A,B)
in a Z-plasty closure.
