Cleft Lift Procedure for Pilonidal Disease
Kim C. Lu
Daniel O. Herzig
Pilonidal disease develops within lower midline sinuses in the natal cleft. These sinuses can become occluded and develop abscesses that rupture superiorly and to one side. The exact etiology continues to be debated.
Typically, acute abscesses are drained off midline. A multitude of treatments have been described for treating persistent pilonidal disease. These range from shaving the nearby hair to wide local excisions and even to complex fasciocutaneous flaps such as the Limberg (rhomboid rotational) flap (1).
Acute abscess: Any acute abscess should be urgently drained. After the sepsis were resolved a cleft lift procedure can be done.
Bilateral disease: after all abnormal tissues are removed, reconstruction would require more tissue such as a fasciocutaneous flap, i.e. Limberg (rhomboid rotational) or V-Y flap, or muscular flap such as a rotational gluteal flap.
Typically, the cleft lift procedure is performed on an outpatient basis. Appropriate preoperative risk assessment of cardiac, pulmonary, nutritional, and other factors should be obtained.
No bowel prep is necessary.
The patient should avoid aspirin and all nonsteroidal anti-inflammatory drugs for 1 week prior to surgery.
If general anesthesia were required, it should be induced on a stretcher. After which the patient is placed into the prone-jackknife position. A large pelvic roll and two smaller chest rolls should minimize hyperextension of the neck. Abduction of either shoulder should be less than 90 degrees and both elbows should be well padded. While an assistant pushes both buttocks together, mark the skin where the buttocks touch with permanent marker. These marks will be the most lateral limits of the subsequent dissection (Fig. 35.1A). The buttocks are taped apart and a towel is placed between the legs to absorb excess prep.
The patient is given a dose of broad-spectrum antibiotics such as cefazolin and metronidazole within the hour prior to incision.
Figure 35.2B, shows two midline sinuses, both of which communicate with a left, superior abscess cavity and its opening.
The skin to be excised is marked with an asymmetric ellipse including the off line left-sided abscess cavity (Fig. 35.2A). The side opposite the abscess should be incised about 1 mm to the right of the midline pilonidal sinuses. The lateral side of the ellipse should be just shy of the heavy lines marked prior to taping the buttocks. The superior and inferior extent of the ellipse should be 1–2 cm above and below the pathology.
If the inferior aspect of the ellipse were close to the anus, the incision should curve sharply away from the anus (Fig. 35.2A). This avoids undermining the very thin perianal skin.