Keywords
pilonidal sinus - rotation flap
Introduction
Sacrococcygeal pilonidal sinus disease (SPSD) is characteristically a blind epithelial
tract generally containing hair. It is believed to be caused by excessive hairiness
and poor hygiene.[1]Other factors affecting the incidence are increased sweating associated with sitting
and buttock friction, obesity, and local trauma. Increased depth, narrowness of the
natal cleft, and the friction movements of the buttocks pave the way for loose hair
to collect and insert into the skin of the natal cleft. The hair is perceived as a
foreign body, and this initiates an inflammatory response that can then lead to a
pocket of infection, leading to an abscess or sinus formation.
The prevalence of SPSD is 4%.[1]
[2] As observed by Akinci et al,[3] SPSD has a predilection for patients having a deeper natal cleft.
Surgical excision of the entire sinus tract is the mainstay treatment option for SPSD.
Several methods have been described for the closure of the postexcision SPSD defect
which include vy-plasty, z-plasty, and w-plasty. However, no consensus exists on a
standard method for closure. In this study, the authors have evaluated their results
of performing a rotation flap for the closure of postexcision SPSD defect. Rotation
flap has been in used in plastic surgery,[4] but its use in SPSD was reported only once.[5] Other publications claiming rotation flap for the treatment of SPSD are in fact
transposition flaps by definition.[6]
Materials and Methods
Fifty-two patients treated for SPSD with excision and closure using rotation flap
from January 2010 to September 2018 were included in this study as per the inclusion
criteria:
-
Primary cases of SPSD with a postexcisional defect of 4 cm or more in its transverse
diameter (width), irrespective of length.
-
Recurrent cases of SPSD treated by any other method at least 6 months prior.
Once the diagnosis was made, on OPD basis, pus was sent from the sinus opening for
bacterial culture and antibiotic sensitivity for selecting the antibiotic during perioperative
period. In case of “no growth,” amoxycillin and clavulanic acid were our drugs of
choice. The patient was admitted in daycare.
Surgical Technique
Patients were placed in prone jack knife position. Methylene blue mixed with hydrogen
peroxide was instilled through the sinus opening to define the extent of the ramifications
of the sinus ([Fig. 1]). The area to be excised was carefully marked and the rotation flap was mapped on
the skin. As with any rotation flap the length of the arc of rotation was around six
times the length of the width of the base of the triangulated defect ([Fig. 2]).
Fig. 1 Sacrococcygeal pilonidal sinus disease (SPSD) with sinus tract marked with methylene
blue and hydrogen peroxide.
Fig. 2 Flap design; for additional advancement a triangle may be excised at the lateral
end of the flap.
This surgery was done under sedation and local anesthesia. A solution for local infiltration
was prepared by mixing 30 cm3 of lignocaine 2% with 20 cm3 of bupivacaine 0.5%. 1 cm3 of adrenaline was added to this solution ([Fig. 3]). Any remnant of the sinus tract, as visualized by the staining with methylene blue,
was also excised. The defect was triangulated.
Fig. 3 Post excision: specimen and defect.
The rotation flap was designed adjacent to the defect and was rotated about a fixed
pivot point to resurface the defect. It is based on random pattern vascularity. Up
to 8 cm defect (length of the base of the triangulated defect) can be closed primarily.
In case if there is tension on suture line, one can do additional advancement by excising
a triangle from the lateral aspect of the base of the pedicle.[7] This has advantage over a back cut which also allows additional advancement but
not at the cost of decreasing the width of the pedicle of the flap, thus endangering
the vascularity ([Fig. 2]).
The flap was rotated to cover the defect ([Fig. 4]) and suturing was done in 2 layers—subcutaneous and subdermal layer with 2–0 polyglyceparone
(absorbable) sutures and skin with staples. A closed drainage system was employed.
The patient was discharged on the same evening.
Fig. 4 Rotation flap completed with drainage tube.
These patients were advised 1 week bed rest.
They were recalled for follow-up after 48 hours to check for any hematoma and removal
of drain. Further follow-up was after 8 days for removal of staples, and subsequently
every month for the first 6 months and thereafter every 6 months ([Fig. 5]).
Fig. 5 Long-term results 1.
Records of the patient follow-ups on the 3rd day, 10th day, 1 month, and 6 month post
surgery were evaluated ([Fig. 5]).
Results
A total of 52 patients were included in this study. Their age ranged from 19 years
to 36 years (mean 29.4 ± 5.5 years). Forty were males and 12 were females. Forty-two
cases were of primary disease and 10 were of recurrent disease.
As evaluated intraoperatively, the transverse defect, post excision, ranged from 4
cm to 10 cm, with the mean 9.4 ± 1.14 cm.
As evaluated on the third day post surgery, 1 patient out of 52 had hematoma formation,
which was treated conservatively, while the rest had shown uneventful healing.
As evaluated on the fifth day post surgery, 1 patient developed a seroma in the perianal
region that required aspiration. However, subsequent healing was uneventful.
At 1 month post surgery follow-up, all 52 patients had no signs of any recurrence
of the disease and a healthy suture line.
At 6 month post surgery follow-up, all 52 patients had no signs of any recurrence.
Laser depilation of the back and trunk was undertaken for all our patients.
Discussion
The surgical treatment of SPSD should intend toward removing all the sinus tracts
as well as the predisposing factors that contribute to the formation of pilonidal
sinus. A major predisposing factor is the deep groove of the natal cleft which needs
to be obliterated[8] ([Figs. 6]and [7]).
Fig. 6 Deep groove in natal cleft in patients with sacrococcygeal pilonidal sinus disease
(SPSD).
Fig. 7 Groove being totally obliterated after surgery.
The treatment described in literature varies from conservative to complicated musculocutaneous
flaps depending on the presentation of the disease and the competence of the surgeon.
Some authors treat patients with abscess and active infection in two stages, the definitive
repair being the second stage.
In an extensive review from 1945 to 2017 by Johnson et al1[9] it has been suggested that primary closure is better than marsupialization or secondary
closure[10] in terms of recurrence. Moreover, if the suture line is off midline, then the results
are better with lower recurrence rate and wound dehiscence.
Recurrence of this disease is mainly due to incomplete elimination of the primary
SPSD or due to persisting predisposing factors which include excessive hairiness,
poor hygiene, and deep natal cleft.[11]
[12]
[13]
We instilled hydrogen peroxide with methylene blue into the sinus opening to delineate
the secondary and tertiary branches. The effervescence created by hydrogen peroxide
facilitates the dye into the branches of the sinus, hence decreasing the chances of
incomplete excision.
For reconstruction following excision, various flaps have been described. The z-plasty
procedure was described by Monro and Macdermott.[14]The disadvantage of this procedure was that part of the suture lining would lie in
the midline which would predispose to recurrence. Another caveat of this procedure
was a 20% incidence of flap tip necrosis.[15]
The w-plasty technique was described by Roth and Moorman in 1977.[16] Again, part of the wound still remained in the midline and recurrence rate was as
high as 8%.
Off-midline closure was described by Karydakis.[17]
[18]In his personal series of more than6,000 cases treated, he reported in 1992, the
rate of recurrence as less than 2% and wound complications as 8%. Similarly, Bascom
has described “cleft lift” procedure to get off midline closure.[19]Though the recurrence rate was low (1–4%), complications like wound dehiscence were
high (8.5–9%).[20]
Similarly, flaps like the rhomboid and fasciocutaneous v-y advancement flap have also
reported a recurrence of 6% and 17%, respectively.[21]
[22]
[23]
[24]
Thus, it is evident that several operative methods are available for the treatment
of SPSD; however, no consensus exists on a gold standard method for treatment.[9]
[25]
[26]
The advantage of rotation flap over other methods, first, is that it has a simple
design. It can be raised by any not-so-experienced surgeon. It is based on random
pattern vascularity and, therefore, is reliable and heals well with almost no risk
of failure.
Second, it gives wide exposure to the floor of the wound to visualize and excise any
residual disease. Moreover, since large defects can be closed effectively, no compromise
is needed on the excision.
Fourthly, it flattens the natal cleft as it brings large amount of subcutaneous gluteal
fat into the natal cleft region, thus greatly reducing a major risk factor in recurrence
of SPSD.
Lastly, off-midline closure is achieved without tension on the suture line with aesthetically
acceptable scar.
In our study, we have observed no recurrence in any of the patients. All our patients
healed well except in two cases (3.85%) that had minor wound complications and they
also healed with conservative measures.
Conclusion
In our experience, single-stage surgical excision of the sinus tract using hydrogen
peroxide and methylene blue for delineation and closure of the excision defect with
rotation flap is a credible treatment option for SPSD.
Fig. 8 Long-term results 2.
Fig. 9 Long-term results 3.
Table 1
Compilation of results of previous studies by other authors to ours for the surgical
management of sacrococcygeal pilonidal sinus disease (SPSD)
|
Operation
|
Author
|
Anesthesia type
|
Length of hospital stay (days)
|
Follow-up (years)
|
Morbidity (%)
|
Recurrence (%)
|
|
Abbreviations: GA, general anesthesia; LA, local anesthesia; SA, spinal anesthesia.
|
|
z-Plasty (transposition)
|
Monroe and MacDormett14
|
GA
|
21
|
–
|
–
|
0
|
|
z-Plasty (transposition)
|
Toubanakis15
|
–
|
–
|
1–10
|
0
|
0
|
|
w-Plasty (transposition)
|
Roth and Moormen16
|
GA
|
5.7
|
–
|
–
|
8
|
|
Asymmetric incision (off-midline)
|
Karydaikys17,18
|
GA
|
3
|
2–20
|
8.5
|
>1
|
|
Asymmetric incision (off-midline)
|
Bascom19
|
–
|
–
|
–
|
8.5–9
|
1–4
|
|
V-y advancement
|
Khatri21
|
|
5
|
0.4–4.5
|
|
|
|
Rhomboid flap
|
Milito23
|
GA/ SA
|
5.3
|
6.2
|
3
|
0
|
|
Elliptical rotation Flap
|
Omer6
|
–
|
1
|
–
|
0.8–4.1
|
0
|
|
Rotational advancement flap
|
Mistry
|
LA/sedation
|
1
|
0.5–5
|
3.8
|
0
|
