Management of pilonidal sinus

1. Pilonidal sinus
Dr. Zeeshan

2.  Definition: Infection of the skin and subcutaneous tissue
at or near the upper part of the natal cleft of the
buttocks.
NOT a true cyst

3. History
 1833- hair containing cyst located just below the coccyx
Mayo
 1880- Hodge coined the term “pilonidal”
Nest of hair
 In 19th
and 20th
century – considered to be congenital

4.  In WW II
 Patey and Scarf – hypothesised origin of pilonidal sinus
acquired by penetration of hair into subcutaneous tissue.

5. What causes pilonidal sinus???
 Midline holes – Hair follicles that have enlarged
Pulling forces between sacrum and skin
 Force concentrate on 1mm2 area where the narrow
gluteal crease comes in close contact with the sharp
angle of sacrum

6.  Weakest point of skin gives way first– Skin at the bottom
of the follicle.
 Primary cause – “Pit”
 Secondary casue – “ Hair follicles”

7. Cause of pilonidal sinus
 (1) Invader hair
 (2) Force causing hair penetration
 (3) Vulnerability of skin

8. Anatomy
 Intergluteal cleft: A groove between the buttocks that
extends from just below the sacrum to the perineum.
Anchoring of the deep layers of skin overlying the coccyx
to the anococcygeal raphe

9. Epidemiology
 Incidence : 26 per 100,000
 Mean age: 19 years for women and 21 years for men
 Sex: M/F ratio – 2:1 to 4:1
 Equal incidence of acute:chronic

10. Risk factors
 Overweight/ obesity
 Local trauma or irritation
 Sedentary lifestyle/prolonged sitting
 Deep natal cleft
 Family history

11. Theory
 Acquired vs Congenital
 Tendency to recur following complete excision.
 Tendency to occur in places other than natal cleft.

12. Pathogenesis
 Hair and inflammation – inciting factors
 On sitting/bending natal cleft stretches- breakage of
follicles- opening of a pore/pit- collection of debris
- pilonidal sinus - abscess
 Proof??
 Pilonidal tract extends cephalad.
 Cavity contains hair, debris or granulation tissue.

13. Clinical manifestations
 Patient presentation:
- Acute onset mild to severe pain (sitting/bending)
- Intermittent mucoid/purulent/bloody discharge
- Recurrent / persisting pain
- Fever / malaise

14. Physical examination
 One/more pits in the natal cleft +/- painless sinus opening
cephalad and lateral to cleft
 Tender mass or sinus draining mucoid/bloody or purulent
fluid

15. Diagnosis
 Clinical
- Finding a pore/sinus in the natal cleft
- No imaging required

16. Differential diagnosis
 Perianal abscess/ fistula
 Hidradenitis suppurativa
 Perianal complications of Crohn’s disease
 Skin abscess/ furuncle/ carbuncle
 Folliculitis

17. Surgical treatment
 Drainage with/ without excision
 Marsupialisation
 Excision with primary closure
 Excision with grafting
 Sinus extraction
 Sclerosing injections

18. ACUTE ABSCESS
-- Incision is performed lateral to
midline midline over area of maximum
fluctuance
- Packing of the wound
- Marsupialisation

20. Problems
 Recurrence rates are from 20 – 55 %
 During a 3 year period, 73 patients treated with I & D for
first episode of pilonidal abscess
 Healed : 42 patients (58%; 95% CI) within 10 weeks
 Recurrence : 9 patients (21%;95% CI)
 Follow up period : median of 60 months
 Constant cure rate : 76% (CI 95%) after 18 months
Prognosis after simple incision and drainage for a first-episode acute pilonidal abscess.
 Jensen SL, Harling H
 Br J Surg. 1988;75(1):60.

21. Chronic pilonidal sinus
Surgical approaches:
- Excision
- Wound closure
(1)Primary closure in midline/ off midline
> Z plasty
> V-Y advancement flap
> Rhomboid flap (limberg)
(2) Reconstruction using flaps

22. Karydakis surgery
 Karydakis believed that hair insertion is the cause for
pilonidal sinus
 Low recurrence rates due to:
- Wound placed away from midline
- Resulting new natal cleft was shallower
 Problems
- Sutured taken over the presacral fascia causing pain
- Patients requiring GA
- Prolonged hospital stay

24. Modified Karydakis/Basscom II/Cleft
lip
 Use of shallow cleft
 Under LA
 Causes less pain as presacral fascia not included

25. Z- plasty

26. Z-plasty for pilonidal sinus

27. 
 V-Y Plasty

28. Limberg flap

30. Primary versus delayed closure
 Time to wound healing:
- Total of 13 trials done (n= 1421) included data for time
for wound healing (not aggregrated due to high
heterogeneity)
- 9 trials reported a faster time to wound healing following
primary closure.
- Largest trial (n=380) found that patients undergoing
primary repair had a significant faster wound healing rate
compared to open wounds(14.5 versus 60 days)
- Excision with or without primary closure for pilonidal sinus disease.
- Al-Salamah SM, Hussain MI, Mirza SM; J Pak Med Assoc. 2007 Aug;57(8):388-91.

31.  Time to return to work:
- A total of 11 trials done (n=1729)
- 9 studies reported a faster return to work following
primary closure
- The largest study (n=144) found that patients had a faster
return to work following primary repair compared to
delayed closure.(11.9 versus 17.5 days)
Comparison of outcomes in Z-plasty and delayed healing by secondary intention of
the wound after excision of the sacral pilonidal sinus: results of a randomized,
clinical trial.
Fazeli MS, Adel MG, Lebaschi AH
Dis Colon Rectum. 2006 Dec;49(12):1831-6.

32.  Recurrence rates:
- Based on 16 trials including 1666 patients , the overall
recurrence rate was 6.9%.
- Primary wound closure was associated with a HIGHER
recurrence rate compared to delayed wound closure.
(8.7 versus 5.3 percent, relative risk RR [1.5] CI1.08-2.17

33.  Rate of surgical site infection:
- Based on 10 trials including 1231 patients
NO SIGNIFICANT DIFFERENCE between primary and
delayed wound closure and risk of SSI
(8 versus 10% , RR 0.76, CI 0.54-1.08)

34. Off midline versus midline primary
sutured closures
 Sutured off midline wounds – less time to heal (n=100 ,
mean difference 5.4 days, 95% CI 2.3-8.5)
 Risk of SSI was significantly lower for off midline wounds
(n=541, RR 0.27, CI 0.13-0.54)
 Risk of recurrence LOWER for off midline wounds
(n=574, RR=0.22, CI 0.11-0.43)
 The overall complication rate was LOWER for off
midline wounds (n=461, RR=0.23, CI0.08-0.66)

35. Types of off-midline closure
 While an off midline approach is superior , optimal off
midline approach has not been identified.
 Two trials were perfomed to determine recurrence and
complications rates between lateral advancement flaps
( modified Karydakis) and modified Limberg’s flap

36. N = 120 Karydakis lateral
advancment flap
Limberg’s
flap
Wound disruption 0 patients 9 patients
Rate of
complications
23 % 40 %
Wound infection 3% 5%
Subcutaneous fluid
collection
5% 0%
Hypoaesthesia 10% 23%
Recurrence rates 3% 2%
Comparison of short-term results between the modified Karydakis flap and the modified Limberg flap in the
management of pilonidal sinus disease: a randomized controlled study.
Bessa SS
Dis Colon Rectum. 2013;56(4):491.

37. N=295 Karydakis flap Limberg
Seroma formation 19.8% 7.4%
Wound dehiscence 15.4% 3.7%
Flap maceration 11% 3.7%
Which flap method should be preferred for the treatment of pilonidal sinus? A prospective randomized study.
Arslan K, Said Kokcam S, Koksal H, Turan E, Atay A, Dogru O
Tech Coloproctol. 2013 Feb;

38. In summary
 Patients with acute pilonidal sinus – I & D
 For patients with chronic pilonidal sinus – An excision of
the sinus and all tracts
 A primary closure is associated with faster wound healing
– however a delayed closure is associated with less
recurrence
 For patients undergoing primary wound closure – off
midline closure recommended

39. Role of Abx
 Generally limited to clinical setting of cellulitis
 Indications:
- Immunosuppresion
- High risk for Endocarditis
- MRSA
- Concurrent systemic illness