Hidradenitis Suppurativa

Anuradha R. Bhama

Scott R. Steele

Perioperative Considerations

The prevalence of hidradenitis suppurativa (HS) is 0.1%-4% worldwide, with the mean age of onset 20-24 years.
Multiple risk factors are known for HS.
- Cigarette smoking and obesity
- Dietary triggers including dairy products and highly refined simple carbohydrates
The anal region is the second most commonly involved area after the axilla; ˜30%-50% of patients with HS have perianal lesions as a location of their disease (Fig. 13-1).

FIGURE 13-1 ▪ Severe hidradenitis disease in the perianal and groin.
A number of comorbid conditions can be present in patients with HS.
- Acne
- Inflammatory bowel disease
- Spondyloarthropathy
- Genetic keratin disorders
- Squamous cell cancer
Local and small lesions can benefit from medical treatment, but recurrence rates are high.
- Antibiotics
  - Topical (eg, clindamycin)
  - Oral (eg, tetracycline, clindamycin, rifampin)
- Monoclonal antibodies (eg, adalimumab, infliximab)
Indications for surgical treatment
- Widespread disease is an indication for radical surgical excision with possible need for reconstruction with a flap.
- Acute abscess (incision and drainage [I&D])
- Chronic or recurrent HS nonresponsive to medical therapy
- Intolerance of medical treatment

Positioning

Positioning will depend on the location and extent of the disease.
- Either prone jackknife or lithotomy positions can be utilized (Fig. 13-2).
Positioning may need to allow for harvesting of skin grafts or rotation of flaps.
- Changing of positioning for various segments of the operation may be necessary.

FIGURE 13-2 ▪ Lithotomy positioning.

Special Equipment

I&D/lay-open technique
- Fistula probes
- Electrocautery
- Hydrogen peroxide
- Angiocath on 10 mL syringe
Excision and grafting
- Excision
  - #15 or #10 blade and scalpel
  - Electrocautery
  - Forceps
- Grafting
  - Dermatome
    - Air-powered dermatome (Zimmer)
    - Electric-powered dermatome
    - Size of dermatome can be 1, 2, 3, or 4 in wide.
  - Skin mesher
    - Two types
      - With carrier—disposable carrier helps minimize risk of damage to fragile grafts
      - Without carrier
    - Different ratios of meshing (1:1, 1:2, 1:3)
  - Telfa gauze soaked in epinephrine (1:1000 dilution)
  - Negative-pressure dressing (wound Vac)
  - Forceps
  - Suture or staples
- Flaps
  - Standard soft-tissue operating set
  - Drain