Pilonidal Sinus Surgery


Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Infectiona overall

1–5 %

 Subcutaneous

1–5 %

 Systemic sepsisa

0.1–1 %

Recurrence of pilonidal sinusa

5–20 %

Chronic discharge

5–20 %

Further surgery

5–20 %

Dehiscence and chronic wound dressings

50–80 %

Rare significant/serious problems

Bleeding/hematoma formationa
 
  Wound (immediate or delayed)

0.1–1 %

Missed pathologya

0.1–1 %

Chronic ulceration with hypergranulationa

0.1–1 %

Less serious complications

Residual pain/discomfort/tenderness
 
 Short term (<4 weeks)

50–80 %

 Longer term (>12 weeks) soiling

0.1–1 %

Scarring

0.1–1 %

Urinary retention/catheterization (males)

1–5 %


aDependent on underlying pathology, anatomy, surgical technique, and preferences





Perspective


See Table 4.1. Complications are usually of a minor nature but may be severe on occasions. Infection and inflammation are usually present as the main indication for surgical drainage. The main complications are infection, pain, and bleeding which are all extensions of the preoperative situation and dehiscence. Recurrence of the pilonidal sinus is very common after incision and drainage, since the underlying problem is often not alleviated.


Major Complications


The main complication is pain, which is often adequately controlled with oral analgesia. Pain with dehiscence (or open management) and chronic dressings is also common. Purulent discharge is not uncommon, but usually settles with repeated dressings. Bleeding is not uncommon, but is rarely great in volume. Infection is usually present before surgery, as is some element of surrounding cellulitis, but on occasions these can worsen. Systemic sepsis is very rare but can occur. Further surgery is usual after simple drainage. Urinary retention and catheterization are not uncommon in males with any form of perineal or groin surgery. Recurrence is not uncommon and often requires further surgery.


Consent and Risk Reduction



Main Points to Explain



  • Discomfort/pain


  • Infection


  • Recurrence


  • Bleeding


  • Delayed healing


  • Chronic dressings


  • Further surgery



Pilonidal Sinus Excision and Laying Open



Description


General anesthesia is usually used, but on occasions local anesthesia may be used. GA affords better examination of the anus and palpation of the pilonidal cyst and is less painful. The prone jackknife or occasionally the lateral decubitus position can be used, depending on the surgeon’s preference. The prone jackknife position offers a better view of the natal cleft for the operating surgeon, and any bleeding usually runs away from the operating surgeon. Anesthetists sometimes object to the prone jackknife position, because of the physiological effects on the circulatory system and respiratory system.

The aim of the procedure is to examine the natal cleft, pilonidal sinus(es), and pilonidal abscess, then excise the pilonidal sinuses and cyst using an elliptical excision, and then pack the cavity with antiseptic gauze, alginate, or occasionally vacuum-assisted dressings. Complete removal of the sinus tracts is the main objective. The other option is marsupialization of the skin edges to the base of the wound.


Anatomical Points


The natal cleft is a narrow moist region, often containing hair, which can develop cutaneous sinuses extending deep into the subcutaneous fat almost to the deep posterior sacral fascia. Hair (usually from the head) enters the sweat glands and forms cystic collections of keratin, sebum, and hair. Multiple sinuses are common, usually close to the midline. Induration and inflammation may distort the anatomy. The pilonidal cyst may be midline or eccentric.


Table 4.2
Pilonidal sinus excision and laying open estimated frequency of complications, risks, and consequences























































Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Infectiona overall

1–5 %

 Subcutaneous

1–5 %

 Systemic sepsisa

0.1–1 %

Recurrence of pilonidal sinusa

5–20 %

Chronic discharge

5–20 %

Further surgery

5–20 %

Chronic wound dressings

80 %

Rare significant/serious problems

Bleeding/hematoma formationa
 

 Wound (immediate or delayed)

0.1–1 %

Missed pathologya

0.1–1 %

Chronic ulceration with hypergranulationa

0.1–1 %

Less serious complications

Residual pain/discomfort/tenderness
 

 Short term (<4 weeks)

50–80 %

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Mar 23, 2017 | Posted by in ABDOMINAL MEDICINE | Comments Off on Pilonidal Sinus Surgery

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