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A rare case of umbilical pilonidal sinus is reported--the only documented case of barber's pilonidal of the umbilicus. Possible mechanisms of formation are described. It is suggested that this possibility should be considered in cases of resistant or recurrent omphalitis. Definitive treatment consists of sinus excision with cosmetic umbilical reconstruction. Total omphalectomy is probably only justified for recurrence.
BACKGROUND AND AIMS: Hair entry into the midline is the generally accepted theory in pilonidal sinus formation. This theory is also involved in the pathogenesis of the recurrence after different types of operations for pilonidal sinus disease. The relationship of the suture lines and the midline was evaluated in this study. PATIENT AND METHODS: Thirty-four patients with stage 4 or recurrent pilonidal sinus disease who underwent V--Y advancement flap closure were randomized into two groups: vertical suture line unrelated to midline (VLUM, n=18) and vertical suture line related to midline (VLRM, n=16). RESULTS: None of the patients with or without a suction drain developed flap necrosis, local haematomas or seromas. The median length of the postoperative hospital stay was 3 days for theVLRM group and the VLUM group (p>0.05). The median follow-up period was 32 months. During the follow-up period, two recurrences were determined 22 and 15 months after operation in the VLRM group. Recurrences were situated in the scar tissue over the midline. INTERPRETATION AND CONCLUSION: Routine application of suction drains is not recommended after V--Y advancement flap closure. Avoidance of the relationship of the postoperative suture line and the midline, if possible, offers a safe method of definitive reconstruction.
OBJECTIVE: To assess two techniques of primary closure after excision of pilonidal sinus. DESIGN: Prospective randomised study. SETTING: University department of surgery, United Arab Emirates. SUBJECTS: 46 patients with chronic pilonidal sinus disease, 24 treated by rhomboid flap transposition, and 22 by deep suturing technique. MAIN OUTCOME: Early mobility and recurrence. RESULTS: All patients in the rhomboid flap transposition group healed their wounds primarily compared with 17 in the primary deep suturing group (77%). (P = 0.02). Five patients wounds broke down as a result of haematoma and infection (23%). The mean hospital stay for the rhomboid flap technique was 6 days compared with 9 days after deep suturing, and the mean follow up for both groups was 18 months, the rhomboid flap group returned to work a mean of nine days earlier than the deep suturing group (23 days). No recurrence has been identified yet in the rhomboid flap group, while 2 recurrences have developed in the deep suturing group (9%). CONCLUSION: Primary closure after excision of pilonidal sinus with a transposed rhomboid flap is successful in the management of pilonidal sinus and is superior to primary closure by deep suturing.
PURPOSE: To investigate the results of wide rhomboid excision with Limberg transposition flap reconstruction to treat pilonidal sinus. METHODS: We analyzed the well-documented records of 238 patients with sacrococcygeal pilonidal sinus who underwent wide excision with a Limberg transposition flap and were followed up for longer than 1 year postoperatively. After the first 40 operations, we modified this flap reconstruction by tailoring the rhomboid excision asymmetrically to place the lower pole of the flap 1-2 cm lateral to the midline. Wound infection rates, hospitalization, time required for free mobilization, and recurrence rates were recorded. RESULTS: Postoperative infection developed in two patients (0.8%), which was easily managed by wound care, antibiotics, removal of skin staples, prolonged drainage, or a combination of these treatments. The mean hospitalization was 2.10 +/- 0.20 days (range 1-3 days), and the mean time required for recovery and return to daily activities was 8.00 +/- 2.50 days (range 4-17 days). There were only three recurrences (1.26%) after a mean follow-up of 29.20 +/- 3.10 months (range 12-38 months). Since we started performing our modification of the technique by lateralization of the inferior apex, no further recurrences have been seen. The recurrence rate differed significantly between the classical Limberg flap group and the modified Limberg flap group ( P = 0.004) CONCLUSION: These results provide further evidence that wide excision with a Limberg transposition flap reconstruction is an effective surgical method for primary or recurrent pilonidal sinus, associated with a low complication rate, short hospitalization and disability, and a low recurrence rate. A modification of the technique was devised to further enhance wound healing and reduce the risk of recurrence.
OBJECTIVE: To evaluate the morbidity and short term results after open compared with closed treatment of chronic pilonidal sinus. DESIGN: Randomised control trial. SUBJECTS: 120 of 164 patients with chronic pilonidal sinus treated between April 1987 and April 1989. INTERVENTIONS: 60 patients were treated by excision and primary suture, and 60 by excision and open packing. MAIN OUTCOME MEASURES: Incidence of early complications (bleeding that needed treatment, wound breakdown, infection, haematoma, or wound pain), number of postoperative visits required, and length of sick leave taken. RESULTS: Those patients who underwent excision and suture had slightly but not significantly fewer early complications (16/60, 27%, compared with 23/60, 38%). Most of the early complications were the result of infection (8, 13% compared with 18, 30%, respectively). They also required fewer followup visits and less sick leave, and their wounds healed more quickly. At one year the numbers of late complications were 19 (32%) and 14 (23%), respectively. CONCLUSION: Excision and primary closure of chronic pilonidal sinus causes less morbidity and is more cost effective than excision and open packing. We plan a three year follow-up to see if these results are maintained.
BACKGROUND: Personal experience and results about the surgical treatment of pilonidal sinus using the open technique operation are reported. METHODS: Between January 1984 and June 2001, 577 patients (457 males and 120 females) underwent this surgical technique. Eighty-five patients presented recurrences of the under-lying disease previously treated with closed technique in other centres. In order to reduce the risks of recurrence, pilonidal sinus was widely resected in order to remove every fistulous track laterally or towards the anal edge. The surgical wound has to be wide, carefully drained, without vertical walls: the outer part of the wound should be wider than its bottom. The persistence of a hairless scar is a suitable result to avoid relapses. RESULTS: This surgical technique allowed very good RESULTS: Postsurgical morbidity was not observed in these patients; the median time to achieve healing was 8+/-2 weeks. Furthermore, after a 3 year follow-up, only 4 patients (0.69%) relapsed. Recurrent dressings are needed; anyway they neither represent a limit of this technique nor lead to a long term absence from working. The postsurgical period of resting is quite similar to that usually prescribed after other surgical techniques and mainly depends on the patient nature. The treatment with connective tissue repairing drugs may be useful to obtain an effective healing. CONCLUSIONS: In the authors' experience, the open surgical technique may obtain the definitive removal of pilonidal sinus, even if particularly wide, with a safe postsurgical course and a very hight percentage (99.31%) of complete healing without any relapse.
BACKGROUND: Many treatments for symptomatic pilonidal sinus disease have been described. Ambulatory treatment with minimal morbidity and a rapid return to normal activity is desirable. Bascom's operation fulfils these requirements. This paper describes the operative technique and results of treatment. METHODS: Some 218 patients of mean age 27 years were treated as day cases. The mean duration of symptoms was 2.4 years. Sixty-eight per cent of patients had complex disease with more than two midline pits and/or a lateral discharging sinus. One hundred and eighty-three patients (84 per cent) were operated on under local anaesthesia. RESULTS: Ninety-five per cent of patients have been followed up for a mean of 12.1 (range 1-60) months. All except one midline wound healed. Lateral wounds healed after a mean of 4.0 (range 1-15) weeks. Postoperative complications were few, including bleeding in 4 per cent and abscess formation treated by reopening the lateral incision in 6 per cent. Twenty-one patients (10 per cent) have had recurrence and have needed reoperation. CONCLUSION: Bascom's operation is simple and results in considerable financial savings with minimal social disruption and an early return to work. Recurrent disease is no more frequent than after other treatments.
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OBJECTIVE: To evaluate the outcome of each of the three methods used to treat pilonidal sinus disease. STUDY DESIGN: A prospective blind randomised study. MATERIALS AND METHODS: Between April 2000 and February 2003, 83 patients (68 male and 15 female), aged between 19 and 31 years (mean 26.6), scheduled for elective operations for pilonidal sinus disease. Patients were randomly assigned to receive one of three excisional surgical procedures. Group A consisted of 28 patients (22 males and six females) and underwent wide resection of the skin and subcutaneous tissue of the natal cleft, followed by primary closure of the wound in two layers after insertion of suction drain. Group B consisted of 26 patients (22 males and four females) and underwent wide resection of the skin and subcutaneous tissue and their wounds left opened for secondary intention healing. Group C consisted of 29 patients (24 males and five females) and underwent limited excision of the fistulous tract and their wounds were left opened for secondary intention healing. Patients were followed-up for 15 to 48 months post-operatively. Demographic data, operative time, hospital stay, operative blood loss, post-operative pain, wound healing time and patient's satisfaction were recorded. RESULTS: The limited excision group of patients had a highly significant shorter operative time than the closed wound group of patients (p<0.001). They also had the shortest hospital stay, operative blood loss and post-operative pain (p<0.001). The closed wound group of patients showed significantly shortest wound healing time, followed by the limited excision group of patients; the wide excision group of patients showed the longest healing time. Apart from the minimal non-significant elevation of the rate of recurrence in the closed wound group of patients, there was no difference between the three groups. All recurrent cases were obese patients and presented within the first six months after operations. CONCLUSION: Limited excision of a pilonidal sinus represents one of the best therapeutic options. The result of this method is comparable with the more aggressive frequently used excisional method, and it has the advantage of having a shorter convalescence and better patient satisfaction.
Sixty patients scheduled for pilonidal sinus surgery were prospectively randomly assigned to receive general anaesthesia or sacrococcygeal local anaesthesia with a newly-described technique. Patients in the general anaesthesia group spent more time in the operating theatre and recovery room than did those in the local anaesthesia group (p < 0.05). Two thirds (67%) of the patients in the local anaesthesia group left hospital on the day of surgery compared to only 17% of patients in the general anaesthesia group (p < 0.05). Visual analogue scale pain scores performed during the 3-day follow-up period favoured the local anaesthetic technique (p < 0.05). Postoperative analgesia requirements were greater in the general anaesthesia group than in the local anaesthesia group (p < 0.05). The majority of patients and surgeons expressed satisfaction with local anaesthesia. Sacrococcygeal local anaesthesia appears to be a successful alternative to general anaesthesia for pilonidal sinus surgery.
Squamous-cell cancer developing in chronic pilonidal sinuses is extremely rare. Thousands of pilonidal cysts and sinuses are operated upon each year, and malignancy is almost never encountered. Only 26 cases of malignancy arising in pilonidal sinuses are reported in the world literature. We report and document a squamous-cell cancer arising in a chronic pilonidal sinus and also review the world literature.
BACKGROUND: There is a high incidence of postoperative complications and late recurrences after operative therapy of a pilonidal sinus. The optimal treatment strategy is still matter of discussion. We studied the long-term results after excision of a pilonidal sinus and primary midline closure compared with the open surgical procedure. MATERIALS AND METHODS: A total of 73 patients (62 male and 11 female, mean age 26.6 years) underwent a total of 79 operations between 1992 and 2001. Thirty patients (38%) were previously operated on because of a pilonidal sinus.Twenty-four were treated in our institution by an open procedure (five after simple abscess incision, 19 after sinus excision) and 52 by primary midline closure. Another three patients received skin flap procedures. RESULTS: Follow-up was possible for 65 patients (82%) for a median of 50 months.Recurrent pilonidal sinus occurred in 22 cases: 18 after primary midline closure (42%) and four after open procedure (21%, P=0.4). We found no relapse following the three skin flap procedures. There was a significantly higher relapse rate in patients operated with recurrent disease (12/25 vs 10/40; P<0.05). CONCLUSIONS: Despite of numerous previously operated patients (38%), there was a high recurrence rate (42%) after excision of a pilonidal sinus and primary midline closure. Alternative operative techniques creating a lateral wound or the various skin flap procedures may be promising alternatives. We are in the process of changing our treatment strategy for patients suffering from a pilonidal sinus.
PURPOSE: Although many methods of surgical and nonsurgical approaches for treatment of pilonidal sinus have been proposed, an optimal treatment modality has not been achieved yet. The aim of this study was to determine advantages, disadvantages, and long-term results of rhomboid excision and Limberg flap procedure. METHOD: One hundred ten patients who had been treated with rhomboid excision and Limberg flap procedure for primary or recurrent pilonidal sinus were invited to the hospital. One hundred two patients responded and were asked about their complaints and satisfaction with treatment. Physical examination was performed on each patient, and their hospital records were reviewed. RESULTS: Three patients developed seroma with negative bacterial cultures, two patients had partial wound dehiscence, and one patient had purulent discharge. Mean length of hospital stay was 3.7 days, and mean time to return to normal activity was seven days. Five patients developed recurrence (4.9 percent) and except for these patients, all of the patients were satisfied with the final result. CONCLUSION: Rhomboid excision and Limberg flap procedure can be performed for managing primary or recurrent pilonidal sinus with a low complication rate, short hospital stay, short time to return to normal activity, and good long-term results.
The operative results of 115 patients with pilonidal sinus are described. The patients were controlled in 1977, 2 to 11 years after surgery. Only small, non-infected pilonidal sinuses should be radically excised followed by primary suture and Redon-drainage. For extended sinuses and for recurrences the best results are obtained when the wound is left open or marsupialisation is applied. Pilonidal sinus-abscesses should be incised. This simple procedure resulted in primary healing in 23% of our patients.
In spite of a number of ingenious operative and non-operative techniques in the management of pilonidal sinus no single technique can be relied upon to prevent recurrence of this benign yet troublesome condition. Once thought to be a congenital condition it is now appreciated that pilonidal sinus most often an acquired condition due to accumulation of tough, bristly hair penetrating the skin, or local hair growing into a skin crevice, pit or abnormal follicle. The most common site is the upper natal cleft but the condition may occur in other sites especially where there is a crevice or irregularity of skin surface with pressure or suction applied to that region. Most surgical procedures have been designed to eradicate the existing sinus and the crevice in which hair tends to accumulate. However, without the presence of hair there can be no pilonidal sinus and, in the past, little attention has been given to preventing the re-accumulation of hair in the troublesome site; hence the risk of recurrence. Management objectives should be directed not only at eradicating the obvious lesion present but also to preventing recurrence of aetiological factors; especially the re-accumulation or re-growth of hair.
PURPOSE: The aim of this study was to demonstrate the advantages of rhombic excision and Limberg flap closure in the treatment of pilonidal sinus disease. METHODS: We treated 24 patients who had chronic pilonidal sinus disease with rhomboid excision and Limberg flap closure. RESULTS: All patients were followed up for a period of 27 months. Mean hospital stay was 4.1 days, and mean time until return to work was 17.5 days. There was no surgical wound infection. Complication rate was 12.5 percent. During the follow-up period, no recurrence was found. CONCLUSION: Because other treatment methods carry a significant failure rate, this technique is an effective alternative in the treatment of pilonidal sinus disease.
PURPOSE: Pilonidal sinus is a common disease and surgical removal and subsequent wound closure is crucial for lasting cure. To evaluate the outcome of different primary closure techniques we performed a pooled analysis of data published in the past 35 years. METHODS: We identified reports on wound infection, early failure, and late recurrence status in relation to treatment modality. Surgical techniques were classified into five groups: simple closure technique in the midline, asymmetric or oblique closure techniques, and full-thickness flap techniques like rhomboid flaps, vy-plasty, and z-plasty. Estimations of the incidences resulted from the quotient of number of responses and the number of patients for each study, and these quotients were summarized over all studies. RESULTS: The MEDLINE search identified 74 publications including 10,090 patients. Pooled data analysis revealed an inhomogeneous effect of the surgical techniques on the infection rate. In contrast, there was a significantly lower early failure rate and late recurrence rate of both the asymmetric-oblique closure techniques and the full-thickness flap techniques when compared with the midline repair technique. No difference was found between the asymmetric repairs and the full-thickness flap techniques. CONCLUSION: Beside the various statistical considerations when using a pooled data analysis combining results from the literature, this overview suggests a significant benefit of asymmetric-oblique closure techniques or flap techniques in comparison with simple closure in the midline. Thus, we recommend an asymmetric closure technique for primary closure of a chronic pilonidal sinus. These asymmetric procedures provide better results than the simple closure in the natal midline. Furthermore, they are not as sophisticated as the full-thickness plasty techniques.
After excision of pilonidal sinus treatment consists either in open procedure or primary closure. We present the results of 45 consecutive patients (male 29, female 16, age 32 +/- 13 years), who underwent surgery between September 2001 and December 2002. Fourteen patients had simple fistula without infection, 18 had fistulas with putride secretion and 13 had abscess. Primary closure with direct suture was performed in 34 patients (76 %: 13 x simple fistula, 13 x fistula with putride secretion, 8 x abscess). Eleven patients were treated by layopen procedure and secondary wound healing. Wound infection occurred in 13 patients (7 x superficial, 6 x deep). Mean time of postoperative treatment was 15 +/- 3 days after closure and primary healing and 66 +/- 15 days after open proce dure or secondary healing. Mean time out of work was 19 +/- 10 respectively 52 +/- 19 days. A recurrence of fistula occurred in eight patients after primary closure (18 %) and none after open procedure. Also in cases of pilonidal sinus with infection, primary wound closure can be carried out even though the rate of recurrences is higher than after open procedure. A successful primary closure significantly reduces time of illness and time out of work.