Classical position for pilonidal sinus
Hair from pilonidal sinus (courtesy of Pankaj Garg, India)
6.4 Differential Diagnosis
Furuncle, carbuncle, anal fistula (Fig. 6.3a, b), hidradenitis suppurativa, specific granuloma, and osteomyelitis of the sacrum should be considered in differential diagnosis (Solla and Rotherberger 1990).
(a, b) Perianal pilonidal sinus mimicking fistula in ano ((a) before and (b) after excision)
Squamous cell carcinoma and basal cell carcinoma have been reported to develop in the long-standing pilonidal sinus.
Apart from routine test, USG may tell about the status of abscess. Simple sinograms do not give much information. On the other hand, methylene blue injection on table will help to delineate the cavity and the side tracts. MRI sinogram is reserved for recurrent and complicated disease.
Asymptomatic patients need lifestyle modifications like weight reduction, regular (fortnight) shaving in the natal cleft area for about 2 in. around, and local hygiene. These patients should be followed and treated if they become symptomatic. Otherwise, there is no role of any kind of treatment. Symptomatic disease should be treated either by conservative or surgical methods, depending on the nature of the disease.
6.6.1 Conservative Treatment
80 % phenol liquid is injected through the tiny openings of the sinus slowly and without pressure until fluid is seen coming through other openings (Stansby and Greatorex 1989). Then the needle is withdrawn and sinus is gently pressed upon to squeeze out debris and hair. The procedure is repeated, and then dressing is applied. The healing occurs in 3–6 weeks in 60–90 % of patients. Cure rate of 92 % was reported with pit excision and phenol injection at day 1, and 7. 10 % of patients developed skin necrosis (Olmez et al. 2013).
Conservative treatment is indicated in those unwilling for surgery, with associated medical comorbidity, mild disease, and if patient cannot take rest for recovery. Disease usually dies after 40 years of age and should be kept in mind while deciding about treatment (Maurice 1964).
6.6.2 Operative Procedures
22.214.171.124 Simple Incision of Abscess
This is done for acute infection to drain the pus and debris (Joshi 1978).
126.96.36.199 Unroofing and Curettage
Unroofing and curettage for pilonidal sinus disease is an easy and effective technique (Fig. 6.4a, b). The vast majority of the patients, including those with abscess as well as those with chronic disease, will heal with this simple procedure, after which even recurrences can be managed successfully with the same procedure. However, healing time is more. Relying on these results, Kepenekci advocated unroofing and curettage as the procedure of choice in the management of pilonidal disease (Kepenekci et al. 2010).
(a, b) Simple unroofing and curettage ((a) before and (b) after surgery) (courtesy of Pankaj Garg, India)
188.8.131.52 Excision With or Without Wound Closure
Excision of sinus and primary wound closure with or without drain is performed when the disease is quiescent (Fig. 6.5a, b). The entire sinus tract is excised, and the wound is closed in layers or left open (saucerization/marsupialization) for secondary healing. Trephining alone may be adequate for simple, superficial, and single sinus.
(a, b) Excision and primary closure of pilonidal sinus
In saucerization, wound is left open to heal by secondary intention in about 6–8 weeks. It is done for sinuses with cellulitis around. It gives broad flat and hairless scar, thereby less risk of friction, hair penetration, and follicle infection. Recurrence rate is from 8 to 21 % (Sondenaa et al. 1996).
In marsupialization, wound edges are sutured to deep tissue, thereby reducing the raw area and healing time with low recurrence rate (4–8 %) (Solla and Rotherberger 1990).
184.108.40.206 Bascom I Technique
This procedure has been recommended in patients with chronic abscess in whom it has shown excellent results without midline scar. The abscess cavity is curetted through a liberal lateral incision. The overlying skin is undermined, and the secondary tracts curetted out to communicate with the main incision. The midline pits are excised with a small-diamond-shaped incision and closed with vertical mattress sutures. The lateral incision is left open to heal by secondary intention. The gluteal cleft is maintained without excising normal tissue (Fig. 6.6) (Jeffery et al. 2009).
Bascom I technique
220.127.116.11 Excision of Sinus with Flap Closure
Flap closure is reserved for recurrent and complex disease with multiple draining sinuses around the midline and when complete excision endangers significant skin loss. The hair follicles are relocated and thereby friction forces avoided. The midline scar is also avoided.
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Bascom II Cleft Lift Technique. The procedure unlike other flap techniques does not excise normal subcutaneous tissue. The skin with thin rim of fat of gluteal cleft is detached from underlying subcutaneous tissue on either side. The unhealthy tissue or tract is excised. Subcutaneous fat is approximated in the midline. The skin flap from normal side is brought across midline and sutured to skin flap of opposite side after excision of diseased skin. This creates primary closure of the midline and obliterating glutted cleft at the same time (Fig. 6.7a–d). No recurrence has been reported by Bascom though duplication of results is awaited (Jeffery et al 2009).
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