Pilonidal Disease Excise versus Flap: Technical Tips

Anuradha R. Bhama

Scott R. Steele

Perioperative Considerations

Pilonidal disease is most commonly found in young adults, although it can affect a wide range of ages, with men being more frequently affected than women.
Obesity, sedentary lifestyle, and a deep natal cleft are risk factors for pilonidal disease.
Pilonidal disease is felt to be an acquired disease with a resultant foreign-body reaction to the hair follicle, though there are wide-ranging theories.
Nonoperative options for pilonidal disease have been described to include shaving, waxing, laser, and depilatory agents.
Acute pilonidal abscess should be treated with incision and drainage (I&D).
Excision ± marsupialization and various flaps have been described for chronic and recalcitrant/recurrent disease.

Patient Positioning

Padded operating room (OR) table, arm boards angled toward the head of the bed
Prone
- Allows for access to natal cleft
- Pad all boney prominences
- Kraske roll and/or jackknife position optional (Fig. 17-1)
  
  FIGURE 17-1 ▪ Bed setup for patient positioning. Chest roll (left), Kraske roll, foam padding for knees, and stack of blankets for lower legs to lie upon so that feet are kept floating.
Patient must be strapped/taped to the bed.
Take care when adjusting arms. Arms should be in goal post position toward the head. Carefully rotate the arm into that position while avoiding brachial nerve injury.
If I&D is being done in clinic: prone jackknife table
- Patient kneels on knee rest and flexes at the hip with a pillow supporting the chest. This allows for optimal exposure.

Sterile Instruments/Equipment

Basic procedure tray
- #15 blade scalpel
- Needle drivers and Adson pickups
- Handheld electrocautery and suction
Curettes
Additional equipment
- 10 × 10 drapes placed over the anus to separate from operative field
Sutures
- 2-0 Vicryl
- 3-0 Nylon

Indications for Surgical Treatment

Abscesses require drainage in the clinic, but they can be done in the OR if the patient does not tolerate the procedure without sedation.
When pilonidal disease recurs several times after conservative management measures, surgery is indicated. While there is no “set” number, three or more certainly warrants consideration and we discuss after the first recurrence.
Procedures include lay-open technique, wide local excision with primary closure, wide local excision with marsupialization of the wound and dressing changes, wide local excision of the wound with primary closure, and placement of negative-pressure dressing.
Types of flaps include Limberg flap, Bascom flap, and Karydakis flap.

Positioning and Preparation

Incision and Drainage

The abscess should first be examined—identify the area of maximum fluctuance.
Anesthetize the skin overlying this area. Use 1% lidocaine or 0.25% Marcaine with epinephrine.
Test the skin of the planned incision to ensure the patient cannot feel the area that is about to be incised.
Make an incision overlying the area of maximum fluctuance. This should be off of the midline.
Purulent drainage will be seen and should be irrigated from the abscess cavity.
Saucerize the incision slightly so that the skin edges do not touch.
Pack the wound for hemostasis.
Patient should follow up for wound checks at regular intervals.
Routine antibiotics typically are not necessary.

General Technique for All Cases

Typically done in the OR with patient in prone position with the buttocks taped apart.
Shave the hairs of the natal cleft with clippers.
The skin should be sterilely cleansed.
Identify all of the individual pits using a fistula probe (Fig. 17-2).
If there is a question about any of the possible pits, inject methylene blue (diluted 1:1 with sterile saline) into the main pit using an angiocath. This will highlight the location of the pits (Fig. 17-3).