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using several layers of 2-0 Vicryl suture. All incisions over the thigh
are closed with staples.
Healing is assessed by proctoscopy and a water-soluble contrast
enema approximately 3 months after surgery. In the absence of a
residual or recurrent fistula on the aforementioned studies, an examination under anesthesia is undertaken with anoscopy and probing.
If necessary, additional procedures are performed to obtain complete
healing of the fistula. When the fistula is no longer identified, the
stoma is closed.
Success rates range between 33% and 100% for RVF repair of
all etiologies and between 47% and 92% for RVF repair of obstetric
etiology.
Bulbocavernosus (Martius) Flap
Dr. Heinrich Martius first described a flap consisting of a pedicled,
bulbocavernosus, muscular fat pad graft from either labia majora
based on the perineal branch of the pudendal artery. It has been
used for a long time by gynecologists and urologists for treatment of
uretherovaginal fistulas and later adopted by colorectal surgeons for
the repair of low, complex RVFs.
First, the flap is harvested through a longitudinal incision over
the labia, and the bulbocavernous muscle is mobilized from the
labia with care not to injure the vascular pedicle. Next, the rectum
and vagina are separated through a transperineal incision at the
vaginal introitus, the fistula is divided, and both the rectum and
vagina are closed primarily. A subcutaneous tunnel is created up to
the rectovaginal septum, and the graft is placed into the septum and
secured in place with absorbable sutures, ensuring that the vascular
pedicle is not twisted. The labia and the perineum incisions are then
closed (Fig. 6).
To date of this publication, the largest series published included
23 patients with a reported healing rate of 65% (Pitel et al.). In this
series, 70% of patients had a diversion stoma. Success rates from
smaller series are 65% to 100% (Kniery et al.).
S u g g e S t e d R e a d i n g S
Cannon JA, etal. Rectovaginal fistula. In: Steele SR et al, ed. The ASCRS
Textbook of Colon and Rectal Surgery. New York: Springer; 2016.
Champagne BJ, McGee MF. Rectovaginal fistula, Review. Surg Clin North Am.
2010;90(1):69–82.
Lawes D, Efron J. Rectovaginal and rectourethral fistula. In: Zabar AP,
Wexner S, eds. Coloproctology. London New York: Springer; 2010.
Ommer A, Herold A, Berg E, Fürst A, Schiedeck T, Sailer M. German
S3-Guideline: rectovaginal fistula. Ger Med Sci. 2012;10.
Vogel JD, Johnson EK, Morris AM, et al. Clinical practice guideline for the
management of anorectal abscess, fistula-in-ano, and rectovaginal fistula.
Dis Colon Rectum. 2016;59(12):1117–1133.
Wexner SD, Fleshman JW. Colon and Rectal Surgery—Anorectal Operations.
Master Techniques in General Surgery. Philadelphia: Wolters Kluwer; 2019.
Anal Condyloma
Edward P. Hagen, DO, and Raman Menon, MD
OVERVIEW
Condyloma acuminata, commonly known as anogenital warts, is
one of the most common sexually transmitted diseases in the United
States. It is caused by the highly contagious human papilloma virus
(HPV), which infects squamous epithelia. HPV is a small, nonenveloped, double-stranded DNA virus from Papovaviridae family. The
incubation period ranges from 3 weeks to 8 months. Most infections
are transient and are cleared within 2 years.
There are over 120 distinct HPV subtypes, of which approximately 35 types target the anogenital epithelium and have varying
malignant potential. High-risk (oncogenic) types are 16, 18, 31, 33,
35, 39, 45, 51, 52, 56, 58, 59, 68, 69, and 82. Low-risk (nononcogenic)
types are 6, 11, 40, 42, 43, 44, 54, 61, 72, and 81. Ninety percent of
condyloma harbor HPV types 6 or 11. HPV types 16, 18, 31, 33, and
35 are occasionally identified in condyloma and are often a coinfection with subtypes 6 or 11. Growth patterns range from focally
grouped diminutive warts to large and exophytic carpet-like lesions.
INCIDENCE
An accurate incidence of condyloma acuminata cannot be obtained
because the size of the population at risk is unknown and because
many cases are likely to be undiagnosed or subclinical. It is estimated that there are 500,000 to 1 million new cases of genital warts
annually in the United States. In the United States, 24 million people
are currently infected with HPV. Although condyloma affect both
genders, recent data reveal that women accounted for 67% of the
patient population.
RISK FACTORS
HPV is highly contagious and mostly transmitted through sexual
activity. Unprotected vaginal, anal, and oral intercourse along with
intercourse at a younger age are risk factors for transmission. Transmission from mother to child during delivery can also occur. Risk
factors for development of condyloma include immunosuppression
caused by HIV or transplantation, use of injectable drugs, cigarette
smoking, and diabetes. Recent data have suggested that African
Americans are at increased risk for larger lesions at time of diagnosis,
resulting in more frequent need for surgery.
PATHOGENESIS, PRESENTATION, AND
DETECTION
HPV invades and infects the basal keratinocytes of the epidermis.
The general appearance of condyloma range from small solitary
flesh-colored plaques to distinct 1- to 2-mm flesh-colored papules
that occur in large clusters (Fig. 1).
The symptoms of infection may vary depending on the number
of lesions and their location. The most common sites of occurrence
are the perianal skin, anal canal, and genital region. Patients with a
small number of warts may be asymptomatic. Other patients, especially those with larger disease burden, may have pruritus, bleeding,
burning, tenderness, discharge, or pain. Larger exophytic masses can
interfere with defecation, intercourse, or vaginal delivery. Lesions
involving the proximal anal canal may also cause stricture.
The lesions are often easily visualized during physical examination of the external anal skin in the office. The extent of
involvement should be documented by physical examination and
anoscopy, sigmoidoscopy, colposcopy, and/or vaginal speculum
examination, as indicated. Application of 5% acetic acid causes the
lesions to turn white and can aid with identification. Other lesions
may also resemble anal condyloma, and the differential diagnosis
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includes benign skin tags, hypertrophic anal papillae, molluscum contagiosum, seborrheic keratoses, hypertrophied sebaceous
glands, condylomata lata (secondary syphilis), dysplastic nevi, and
anal cancer. A biopsy with histopathologic analysis will confirm
the diagnosis.
MANAGEMENT OF ANAL CONDYLOMA
The management of anal condyloma is individualized to the patient
and predicated on the size, number, anatomic distribution, and presentation of the lesions. Spontaneous resolution of condyloma has
been reported, but most patients require intervention. The goal of
treatment is complete destruction of all condyloma, understanding
that the underlying viral infection may persist. The choice of medical management, outpatient office treatment, or treatment in the
operating room, in our opinion, is based on whether it is an initial
outbreak or recurrent disease, the number and distribution of the
lesions, and the presence or absence of intraanal lesions (Figs. 2 and
3). There is no evidence to suggest that one treatment is significantly
superior to another, and patients should be counseled in advance
that recurrence is common and generally occurs within the first few
months after treatment. A summary of common treatments is listed
in Table 1.
We have found that managing the initial presentation in the operating room under conscious sedation allows for excellent results. This
allows for careful inspection of the perianal skin and anal canal and
identification of all lesions with or without the use of counterstaining with acetic acid. Additionally, excision of representative samples
from all quadrants with submission for pathologic examination can
confirm the putative diagnosis and identify potential patients who
may have a high-grade squamous intraepithelial lesion (see further
discussion later). Electrocautery fulguration of the remaining condyloma is the mainstay in addressing small to moderate lesions. Use
of needle-tip cautery is very useful as it can more precisely target the
remaining small condyloma with decreased damage to the surrounding tissue. In this manner, the lesions are fulgurated, first turning
white and then forming an eschar that can be removed with a curette.
What may appear to be a large carpet of numerous condyloma can
be treated in this fashion as the condyloma often have a narrow base,
and islands of normal perianal skin can be identified between them.
This approach has been shown to be safe and without significant risk
of anal stenosis, even with confluent condyloma. One recent small
study suggested that argon plasma treatment may be more effective
at decreasing relapse in HIV-positive patients, however there can be
viable virus in the smoke plumes, which in theory presents a higher
risk of transmission to the exposed treatment team.
On rare occasions, one may encounter carpeting of condyloma
with a wide base and minimal to no intervening normal perianal
skin. In this circumstance, we recommend staging the treatment
of the lesions to minimize anal scarring and stenosis. Such patients
benefit from treatment in the operating room, where only half the
perianal skin is treated and allowed to heal before returning in 3 to 4
weeks to treat the other half.
After clearance of all lesions in the operating room, close office
surveillance is critical. Typically, recurrence is limited to a few
lesions, which are amenable to topical treatment by the physician in
the office or by the patient at home. Trichloroacetic acid (TCA) is a
keratolytic and chemically cauterizes the skin. It can be applied very
precisely in the office with a small cotton-tipped swab with minimal
damage to the surrounding normal skin (see Fig. 2). The most commonly used self-administered topical treatments are imiquimod and
podofilox. The best approach to recurrence may be a combination
of ablative therapy and topical therapy, with reduced recurrence of
condyloma when imiquimod was used as an adjunct to conventional
ablation. Recent data suggest that refractory intraanal condyloma in
particular may benefit from combined therapy with imiquimod and
ablative methods.
FIG. 1 Anal condyloma.
FIG. 2 Treatment of anal condyloma before (A) and after (B) treatment in office with trichloroacetic acid.
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Suspected Anal Condyloma
Office
History and Physical, (Standard) Anoscopy
Operating Room
EUA, Biopsy of suspicious lesions,
Excision or Ablation of all lesions
Office Surveillance
History and Physical, (Standard) Anoscopy
RecurrenceNo Recurrence
Excision under local
FIG. 3 Treatment algorithm for anal condyloma.
Future treatment may include “therapeutic vaccination” in which
a fusion protein antigen of the virus is used to generate an immune
response targeting infected cells. This minimizes the risk of attacking healthy tissue while enhancing a CD4/CD8 T-cell response. No
vaccine has yet been licensed for therapeutic use at this time, but
ongoing investigations are underway.
GIANT CONDYLOMA ACUMINATA
Giant condyloma acuminata (GCA) is a rare, poorly-defined condyloma variant. No formal size criteria has been established, though
reports in the literature vary from 1.5 to 30 cm in maximum diameter. It was originally described as lacking malignant potential,
however it is now believed that up to 50% of GCA may contain foci
of squamous cell carcinoma. The disease is characterized by large,
slowly progressive, exophytic, ulcerative, cauliflower-shaped tumors
that infiltrate adjacent tissue. It affects men more than women and
Large/MultipleSmall/ Few
Office
Topical: TCA
and/or
anesthesia
Home
Topical: Imiquimod, Podofilox
Operating Room
Exam with excision
and destruction of all
visible lesions
is associated with immunodeficiency, smoking, and multiple sexual
partners.
On clinical examination, one may encounter a palpable tumor
mass with bleeding, pain, fistulae, and clinical pruritus. Most
practitioners recommend operative management with a wide-local
full-thickness excision with 1-cm tumor-free margins. In lesions that
involve the anal sphincter complex, abdominoperineal resection may
be necessary. Adjuvant treatment with chemotherapy and radiation
may also be considered in light of the high risk of recurrence.
ANAL SQUAMOUS INTRAEPITHELIAL
LESION
The incidence of squamous intraepithelial lesions is increasing. It has
been recognized that these HPV-associated anal dysplastic lesions
may be the precursor for anal squamous cell cancer, though the exact
timing of transformation is unclear. Risk factors for progression
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TABLE 1 Common Treatments for Anal Condyloma
Forms of Treatment
Imiquimod (Aldara)
(Patient-applied)
Podofilox
(Condylox)
(Patient-applied)
Synecatechins
(Veregen)
(Patient-applied)
5- Fluorouracil
(Efudex)
(Patient-applied)
Trichloroacetic acid
(Tri-Chlor)
(Physician-applied)
Liquid nitrogen
(Physician-applied)
Mechanism of
Action Treatment Instructions
Induction of pro-in-
flammatory
cytokines
5% cream, applied at bed-
time and washed off in the
morning three times per
week (Monday, Wednesday,
Friday) for up to 16 weeks
Mitosis interruption 0.5% gel, applied twice daily for
3 consecutive days,
followed by 4 days without
treatment; not to exceed 4
weeks
Unknown 15% ointment, applied three
times per day for up to 16
weeks
Mitosis interruption 5% cream applied daily for up
to 10 weeks or 1%
cream applied twice a day for
2–6 weeks
Chemical
cauterization
80%–90% solution applied to
lesions while avoiding uninvolved surrounding skin;
may repeat monthly
Cryoablation Apply with applicator whiten-
ing the surrounding skin;
may repeat monthly
Clearance
Rate
Recurrence
Rate Side Effects/ Pregnancy
40%–80% 10%–20% Irritation, erythema, ulcer-
ation, pain, burning,
edema, induration
Pregnancy: Category C
65%–70% 20%–35% Irritation, erythema, ulcer-
ation, pain, burning,
edema, induration
Pregnancy: Category C
55%–60% 5%–10% Irritation, erythema, ulcer-
ation, pain, burning,
edema, induration
Pregnancy: Category C
50%–75% 25%–50% Irritation, erythema, ulcer-
ation, pain, burning,
edema, induration
Pregnancy: Category X
(contraindicated)
70%–75% 20%–40% Irritation, pain, burning
Pregnancy: Safe to use
70%–75% 30% Irritation, edema, necrosis,
ulceration, pain
Pregnancy: Safe to use
Podophyllin
(Podocon-25)
(Physician-applied)
Electrocautery
(Physician-applied)
Argon laser
(Physician-applied)
Surgical excision
(Physician-applied)
Mitosis interruption 25% extract applied to lesions
once per week to be washed
off by patient 4 hours later
for up to six treatments;
not to exceed 0.5 mL per
application
Electrocauterization Target lesions while minimiz-
ing damage to normal skin;
repeat as needed
Vaporization Target lesions while minimiz-
ing damage to normal skin;
repeat as needed
Removal by tangen-
tial excision
Target lesions while minimiz-
ing damage to normal skin;
repeat as needed
40%–70% 30%–55% Irritation, erythema, ulcer-
ation, pain, burning,
edema, induration;
systemic absorption may
cause fatal side effects
Pregnancy: Category X
(contraindicated)
60%–90%
35% Pain, scarring
Smoke plumes may contain
viable virus and may
pose an infectious risk to
healthcare provider
Pregnancy: Safe to use
80% 30%–50% Pain, scarring
Smoke plumes have been
shown to contain viable
virus and pose an infectious risk to healthcare
provider
Pregnancy: Safe to use
60%–90% 40% Pain, bleeding, scarring
Pregnancy: Safe to use
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include HIV infection, anoreceptive intercourse, transplantation, and
a history of cervical or vulvar neoplasia and lesions with HPV-16.
In patients who are at higher risk for malignant transformation,
one may consider performing anal cytology akin to the cervical Pap
smear. The terminology used in describing cytologic findings is
similar to that of the cervical Pap: atypical squamous cells of undetermined significance (ASC-US) and low-grade (LSIL) or high-grade
squamous intraepithelial lesion (HSIL). The finding of HSIL or LSIL
from either anal cytology or on biopsy of a condylomatous lesion
requires further investigation and workup.
There is controversy on the optimal management and surveillance
strategy of patients with HSIL or LSIL. The two general approaches
to managing these patients are high-resolution anoscopy (HRA) or
expectant management (EM). HRA involves careful inspection of the
anal canal with a high-resolution microscope after application of acetic acid (with Lugol’s solution counterstaining) to identify other putative dysplastic regions for biopsy or ablation. EM involves frequent
office examinations with operative excision of any visible lesions. In
a recently published single-institution, retrospective, cohort series,
Crawshaw et al. analyzed the outcomes for 424 patients with biopsy-proven LSIL or HSIL who underwent either HRA (220 patients)
or EM (204 patients). Only 3 patients progressed to anal squamous
cell cancer (1 in the HRA group and 2 in the EM group), with all 3
patients being noncompliant with either treatment or follow-up. Our
practice has been to follow the EM pathway for these patients.
HUMAN PAPILLOMAVIRUS VACCINE
Human papillomavirus (HPV) vaccination is an effective method
to prevent HPV infection. Three different vaccines are available in
United States: a quadrivalent vaccine (HPV4, Gardasil) targeting
HPV 6, 11, 16, and 18; a 9-valent vaccine (HPV9, Gardasil 9) targeting HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58; and a bivalent vaccine
(HPV2, Cervarix) targeting HPV 16 and 18.
In 2019, the United States Advisory Committee on Immunization
Practices (ACIP) combined the recommendations for administering
the HPV vaccine series (HPV9, HPV4, or HPV2) to males and
females. Their current recommendations are that the vaccine is given
routinely at 11 to 12 years of age or until 26 years of age if not started
previously. These vaccines can be administered as young as 9 years
of age. Catch-up vaccination is also recommended for females 13 to
26 years of age who have not been previously vaccinated, and in 2019
they added males to this recommendation.
No data exist regarding the long-term efficacy of administration of the HPV vaccine in the setting of active or previous HPV
infection. Some practitioners advocate vaccinating in this setting
as it may confer protection against the other HPV strains to which
the patient may not have been exposed. Our practice has been to
refer high-risk patients to an infectious disease specialist for further
discussion.
S u g g e S t e d R e a d i n g S
Crawshaw BP, Russ AJ, Stein SL, etal. High-resolution anoscopy or expectant
management for anal intraepithelial neoplasia for the prevention of anal
cancer: Is there really a difference? Dis Colon Rectum. 2015;58:53–59.
Husein-ElAhmed H. Could the human papillomavirus vaccine prevent recur-
rence of ano-genital warts?: a systematic review and meta-analysis. Int J
STD AIDS. 2020;31:606–612.
Klaristenfeld D, Israelit S, Beart RW, etal. Surgical excision of extensive anal
condylomata not associated with risk of anal stenosis. Int J Colorectal Dis.
2008;23:853–856.
Meites E, Szilagyi PG, Chesson HW, etal. Human papillomavirus vaccination
for adults: updated recommendations of the Advisory Committee on
Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68:698–
702.
Palefsky JM, Giuliano AR, Goldstone S, etal. HPV vaccine against anal HPV
infection and anal intraepithelial neoplasia. N Engl J Med. 2011;365:1576–
1585.
Werner RN, Westfechtel L, Dressler C, et al. Anogenital warts and other
HPV-associated anogenital lesions in the HIV-positive patient: a
systematic review and meta-analysis of the efficacy and safety of
interventions assessed in controlled clinical trials. Sex Transm Infect.
2017;93:543–550.
Management of
Pilonidal Disease
Rebecca L. Gunter, MD, MS, Eric K. Johnson, MD, and
Scott R. Steele, MD
INTRODUCTION
Pilonidal disease represents a spectrum of disorders ranging from a
simple asymptomatic sinus in the skin up to a large, complex open
wound with multiple draining sinuses and infection. It is for this
reason that the old nomenclature of pilonidal cyst or pilonidal sinus
should likely be replaced by the more appropriate term pilonidal dis-
ease (PD). The term pilonidal is derived from the roots “pilus” (hair)
and “nidus” (nest). PD is believed to be an acquired disease related
to trapping of hairs in the natal cleft that leads to local trauma and
inflammation. It is common, and although it can affect anyone, it
is typically seen in hirsute individuals who have deep natal clefts.
Elevated body mass index, poor hygiene, prolonged sitting, and
excessive sweating may be additional risk factors. Hair type may be
a predictor, with some authors hypothesizing that recently cut short
pieces of hair more easily insinuate themselves into the gluteal cleft,
and others hypothesizing that hair with barbed ends may more easily
become trapped in the gluteal cleft and incite PD.
The typical individual presents with drainage or pain in the area of
the gluteal cleft. Patients will often have acute abscesses that require
immediate drainage. Definitive surgical management in the face of
active infection must be discouraged. Simple abscess drainage may be
all that is required or may act as a bridge to definitive surgery. Management with oral antibiotics will fail in the setting of acute abscess,
but it may be successful in the inflammatory phase before abscess formation. Diagnosis is based largely on history and physical examination and requires no laboratory or radiographic testing. The presence
of midline pits in the sacrococcygeal region coupled with drainage,
abscess formation, or an open wound all suggest PD, whereas alternative diagnoses of hidradenitis suppurativa, Crohn’s disease, anal
fistula, and in rare cases neoplasm should also be considered.
TREATMENT
Treatment options range from simple shaving without surgery to
wide local excision and complex flap reconstruction. There are many
described methods of treatment. It is the belief of the authors that a
surgeon should be familiar with three to four methods of surgical
management that address the entire spectrum of disease severity
and then work to develop expertise in each of them. It is the disease
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severity in fact that should drive the method selected for surgical
treatment. Although any method could potentially be used in any
situation, it would seem inappropriate to do a complex flap procedure such as a rhomboid flap in the setting of very minor disease.
Less-extensive methods will lead to optimal outcomes with lower
risk in the setting of mild disease.
Nonoperative Treatment
In selected cases of minor disease, nonoperative treatment consisting of shaving and hygiene measures can be quite successful. Older
retrospective studies have shown that patients have more favorable
outcomes if shaving is used and surgery is avoided. It should be
noted that these data are older and were compiled during the era
when wide excision with healing by secondary intention was more
common. Laser hair removal has been shown to reduce recurrence
of PD in cohort studies, but there are no randomized controlled trials to date to support its use. It may also be reasonable to encourage
laser hair removal in the setting of minor disease such as primary
treatment. The risk is low, but the cost to the patient may be quite
high, and this should be considered. Weight loss and avoidance of
prolonged sitting may also help minimize symptomatic PD.
Operative Management
We will focus on several procedures. These techniques can be
grouped into basic or simple procedures, intermediate procedures,
complex flap procedures, and endoscopic procedures. The literature regarding the success of one procedure over another is mixed
and consists mostly of small retrospective cases series, with some
randomized controlled trials comparing two or three methods. It
is possible to find data supporting the use of any procedure over
another; therefore it is critical that a surgeon is familiar with their
personal outcomes as they relate to procedural approach. Aftercare
by the patient and provider is likely as important as the procedural
technique in success. It is imperative that patients keep the operative
area clean, perform excellent wound care, and avoid strenuous activity until healing has taken place. Poor wound management and poor
decision making will lead to failure.
Principles of Treatment
Several basic principles should be considered when treating pilonidal
disease so that optimal outcomes can be achieved, as discussed in the
following sections.
Control Sepsis
All acute abscesses must be drained, and any attempt at definitive
surgical management in the setting of active infection should be
avoided. All PD will be colonized with bacteria, but this is very
different from active infection. Primary closure with or without
flap reconstruction will fail in the setting of infection and will make
future management more difficult.
Do the Least Amount of Work Possible
As stated previously, the anatomy or severity of disease should drive
treatment method selection. If the disease is minor, yet the patient
requests surgery, a pit-picking procedure (description to follow)
plus or minus a small amount of additional excision may be all that
is needed. Complex and recurrent disease typically requires a wide
excision and flap reconstruction.
Avoid Too Much Excision
The old adage advising excision of all disease down to the post-sacral
fascia results in an extremely large and complex wound. This technique should be avoided whenever possible. Excision that is too deep
or aggressive has been shown to correlate with disease recurrence/
treatment failure.
Unroof All Disease, Debride Granulation Tissue, and
Remove Hair
This principle goes part and parcel with the principle of avoiding too
much excision. Removal or unroofing of skin overlying active disease
may be essential, but do not be tempted to dissect any deeper. It is
important, however, to account for all disease. Any hair or debris should
be removed, and granulation tissue should be curetted or cauterized. It
may be helpful to inject sinuses with methylene blue to ensure that no
extensions are missed. Probes may also be used. If the wound is to be
closed, adequate irrigation of the wound with saline is encouraged.
Use Off-Midline Excision and Closure
It is essential to attempt to perform an off-midline excision and closure. Wounds located in the midline of the gluteal cleft just do not
seem to heal as well as those located elsewhere. Although it may be
impossible to keep the entire wound out of the midline, there should
be significant effort to minimize the amount of wound in the midline.
Minimize Tension if the Wound Is Closed
Because of the inherent difficulty with wounds located in the region
of the gluteal cleft, every effort should be taken to minimize wound
morbidity. A “tension-appropriate” closure should be utilized. If this
cannot be achieved initially, then tissue undermining or use of a flap
should be considered. When flaps are used, it is important to ensure
a lack of tension at both the excision site and the donor site. Tension
and separation of the operative wound seem to be better tolerated at
the donor site because these sites are off the midline.
Change the Anatomy/Flatten the Natal Cleft
It is believed that deep natal cleft anatomy contributes to formation
of pilonidal disease; therefore it seems reasonable that any procedure
designed to flatten cleft anatomy would lead to lower recurrence
rates. Most flap procedures, and certainly the Bascom cleft lift procedure, are designed to do this. The cleft lift procedure in particular
combines most if not all of the aforementioned principles into one
operation, which has likely contributed to its success. That stated, not
all PD requires this to be done.
Never Underestimate the Impact of Postoperative Care
Postoperative management has a significant impact on the ultimate
outcome, especially in cases of off-midline closure. Limitations in
physical activity, work restrictions, and limitations of weight bearing
on the buttock will help minimize wound dehiscence. There are no
true prescribed evidence-based recommendations to follow, but clear
written instructions should be provided to patients that can easily be
followed. These recommendations should be covered in the preoperative discussion as they will sometimes affect a patient’s decision to
undergo a surgical procedure.
Basic/Simple Procedures
Abscess Drainage
An individual presenting with an acute pilonidal abscess requires
only definitive incision and drainage at first. Typically, the abscess
“points” to one side of the natal cleft, and this is easily visualized or
is palpable. Our recommendation is to incise the abscess cavity just
off midline under local anesthetic. It is important to ensure that all
loculations are broken up and that all purulence is drained. Initial
packing is often employed for hemostasis, but we have not found
continued packing to be necessary. Once or twice daily showering
with soapy water aids in keeping the wound clean. These wounds
will typically close in 1 to 2 weeks, but they can sometimes result in
a chronic wound.
Non-Excisional Procedures
Patients with relatively minor disease who wish to avoid an excisional procedure may be candidates for alternate therapies, such as
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the injection of phenol or fibrin glue. This procedure begins with
removal of hair and debris from the tracts or pits. After administration of local anesthetic, the tracts are injected with phenol to create
epithelial destruction and inflammation to encourage tract closure.
Alternatively, fibrin glue may be injected to close the tracts. These
can be combined with endoscopic techniques to delineate all tracts
and thoroughly debride them (discussed later).
Pit-Picking/Simple Bascom Procedure
In cases of mild chronic disease in which the primary complaint is
related to midline pits or in cases in which there is a small wound
off-midline, this procedure may be considered ideal. It is simple and
results in a healed wound rather quickly—usually in 1 to 3 weeks.
In most cases, PD shows an affinity for one side of the natal cleft. In
cases in which disease is localized purely to the midline in the form
of pits, a pit-picking procedure alone is appropriate. In this technique, the central pits are excised using a punch knife of appropriate
size (just slightly larger than the pit itself). The knife is inserted to full
depth, hair and debris are removed, and the wound is closed primarily. The authors prefer 3-0 Vicryl suture, but any absorbable or permanent suture may be used. This is repeated until all pits are excised.
It is not unusual to encounter a bit of bleeding after pit excision, and
this can be controlled with needle-tip electrocautery.
In cases in which there is induration off the midline, a true simple
Bascom procedure can be performed. Pits are excised as described
earlier, and a 2- to 3-cm incision is created just lateral to the indurated area off the midline. A skin and subcutaneous flap is created
by dissecting toward the midline pits, ultimately connecting the two
areas of dissection. Indurated tissue is excised, the wound is irrigated,
and then it is partially closed at the superior and inferior portions
leaving the central portion open. A small amount of packing is
placed in the open portion of the wound and is removed the next
day. Continued packing may be used or omitted per surgeon and
patient preference. This technique minimizes excision in the midline
and keeps the larger wound in a lateral position, which expedites and
simplifies healing (Fig. 1).
Excision With or Without Primary Wound Closure
Many consider the gold standard of surgical management to be
simple excision with healing by secondary intention. It is certainly
still commonly performed, though many patients prefer to avoid an
open wound. Using the principles outlined earlier, the disease should
be unroofed ensuring that all hair, debris, and granulation tissue is
removed, curetted, or cauterized. Every attempt should be made to
minimize the tissue excised and to keep the majority of the wound
off the midline. If possible, a simple primary closure can be performed, though the authors’ experience is that this often fails. Alternatively, the wound may be left open to heal by secondary intention,
and the skin edges may be marsupialized.
This procedure rarely results in a complex wound if patients
are appropriately selected. If careful and meticulous wound care is
employed postoperatively, the rate of success is reasonably high with
this technique—again in appropriately selected individuals. Patients
with extensive and destructive disease should not be managed this
way as management results in a large and complex wound that rarely
heals. Complete healing in the best of cases takes weeks to months.
Some have reported the use of negative pressure dressings in this
setting, but management of these devices in this location is often
challenging. This option may be appropriate with larger wounds if
resources are available.
Intermediate Procedures
These procedures involve the excision or unroofing of disease in
the midline (or just off the midline) followed by subcutaneous flap
mobilization and tension-appropriate closure with or without the use
of a closed-suction drain. They are designed to alter the cleft anatomy while minimizing the amount of excision. They also employ an
off-midline closure. Patients with mild to moderate disease are ideal
for these techniques. Those with extensive or destructive disease are
not likely suitable for this type of management. Disease that is very
close to or abuts the anal verge may also present a challenge if considering this type of management.
FIG. 1 Two cases treated with the simple Bascom approach (lateral excision and midline pit excision or pit picking). (A) Patient in the
early stages of healing. (B) Patient near completely healed. (Courtesy Eric Johnson, MD.)
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Karydakis Flap
Initially, the affected tissue in the midline is excised, which results in
an elliptical defect in the natal cleft. A skin flap with a beveled edge
is then created and mobilized such that it will reach across midline to
facilitate a tension-appropriate primary closure. The wound is closed
in layers to obliterate as much dead space as possible. Superficial
wounds do not require drainage, but deeper wounds may require
employment of a closed-suction drain. Development of seroma
places the repair at risk. If a drain is used, the authors leave it in place
for a minimum of 3 days and require that the output be 20 mL or less
per day for 2 consecutive days. This is a simple procedure to perform
and results in some flattening of the natal cleft as well as a closure off
the midline (Fig. 2).
Cleft Lift Procedure
This is a simple yet creative procedure originally popularized by the
late Dr. John Bascom. It employs all the aforementioned principles
and is suitable for most patients who are encountered. Preoperative
marking of the patient in the prone position in the operating room
is essential to correct performance of this procedure. This is the preferred procedure of the authors for patients with mild to moderate
PD. Before a chlorhexidine prep is performed, the “safe-zone” is
marked with indelible marker by pressing the gluteal tissue together
in the midline. The mark is drawn where the tissue from each side
touches in the midline. The buttocks are then taped apart revealing
a “wishbone”-shaped mark. This establishes a “safe zone” beyond
which no further dissection should be performed. This also ensures a
tension-appropriate closure. An additional elliptical/scimitar-shaped
mark is placed over the area with more significant disease after skin
preparation. This marks the skin that will be excised. The inferior
portion of this mark is scimitar-shaped to ensure appropriate closure
near the anal verge. After instillation of epinephrine containing local
anesthetic, the skin of the diseased area outlined by the elliptical
mark is excised. Take care not to excise much if any subcutaneous fat.
This will invariably expose some sinus tracts, hair, and granulation,
which should all be removed, curetted, or cauterized. A skin/subcutaneous flap, about the thickness of a mastectomy flap, is created by
dissecting toward the opposite side safe-zone boundary. Use of skin
hooks facilitates this dissection. When the flap is raised inferiorly
(near the scimitar), the dissection should be slightly deeper, providing additional thickness to this portion of the flap. Scar tissue in the
midline is then released by dividing it into small squares. The flap is
mobilized across the midline, and the wound is closed in layers, taking care to obliterate as much dead space as possible. In the majority
of cases, a closed-suction drain will not be necessary, though when
used it should be managed as described earlier. This procedure
results in flattening of the natal cleft with an off-midline closure and
is easy to perform (Fig. 3).
Complex Procedures
These procedures consist of a wide excision of severely diseased
tissue followed by mobilization of a lipocutaneous flap from an
adjacent donor site that is utilized for closure of the complex wound.
They will almost always require closed-suction drainage. These procedures are ideal for patients who present with complex, destructive,
and recurrent disease. The advantage of these techniques is that they
bring thick and healthy tissue into the midline to fill and close large
defects. They also flatten the natal cleft, potentially leading to lower
recurrence rates. Disadvantages include the time and skill required
to perform the procedures as well as the complexity of wounds that
result from flap failure. Fortunately, complete loss or dehiscence of
a flap is a relatively rare complication if patients are appropriately
selected.
Rhomboid Flap
This is a more complex procedure that is quite useful in the setting
of complicated PD. The patient is again positioned in the prone position, and a chlorhexidine skin prep is performed. We do administer
intravenous antibiotics to cover skin flora. A diamond-shaped area
of skin is excised, encompassing all disease. This is typically carried
down to the post-sacral fascia, though a more conservative excision
may be performed based on the amount of disease present. It is
helpful to orient the original diamond- or rhombus-shaped excision
just slightly counterclockwise. This ensures that the inferior tip of the
rhombus is not located adjacent to the anus, which is the most likely
area of postoperative wound separation. This technique is referred
to as a modified rhomboid or Limberg flap. The flap is then mobilized
from the donor site, typically the right buttock. The thickness of the
flap should be identical to the thickness of the tissue excised from the
midline. The flap should be handled gently throughout the case. It is
created by incising laterally from the right lateral tip of the rhombus
onto the right buttock and then inferiorly (Fig. 4). One must ensure
preservation of a thick and wide pedicle to ensure adequate blood
FIG. 2 Karydakis flap procedure. (A) Midline pits are excised. (B) Skin flap from one side is raised. (C) Skin flap is secured down to the underlying
tissue so that the wound is moved off the midline (D).
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supply. It is also wise to mobilize some of the tissue above the flap
on the right buttock to minimize tension at the donor site closure
portion of the repair.
After adequate flap harvest, it is rotated in a counterclockwise
direction to cover the midline. The closed-suction drain should be
placed, typically from the right side superiorly, and the flap is then
secured to the mid-portion of the wound with a 2-0 absorbable
suture. This will often require the help of an assistant. At this point,
it is not unusual to feel just a bit unsure of one’s ability to close this
large wound. Do not worry; it will close. The wound is then closed in
layers with absorbable suture. The authors close the skin with a 4-0
monofilament absorbable suture and then cover the wound with surgical skin glue. The drain is managed as referenced earlier (see Fig. 4).
It is imperative to ensure that the patient does not engage in
strenuous activity for 4 to 6 weeks after this procedure. This wound is
always closed under some tension and is at risk for dehiscence during
this period. It is not unusual to develop one or two small areas of
wound separation that may drain in the first 1 to 2 weeks after surgery. This is not a serious complication, but it will require some minor
wound care for 2 to 4 weeks. These areas almost always close. If they
fail to close by 12 weeks postoperatively, we do not hesitate to return
the patient to the operating room for minor debridement and primary
closure of these areas, which has been uniformly successful (Fig. 5).
Special Situations
In some patients, the extent of disease extends far enough up onto the
lower back that it may be impossible to harvest a flap large enough to
C
FIG. 3 Bascom cleft lift procedure. (A) The “safe zone”
is marked by pressing the gluteal tissue together in the midline
and marking where the skin of each side touches the midline.
(B) Scimitar-shaped area of diseased skin is excised, curving away
from the anal verge and favoring one side of the safe zone. (C) Skin
flap from the opposite side of the safe zone is raised. (D) Skin flap is
secured to the underlying tissue, moving the wound off the midline.
(E) Completely healed wound. (Courtesy Eric Johnson, MD.)
close the entire wound. We have encountered this several times and
have a standard approach that we take in this setting. The key is to
excise the portion of the wound involving the natal cleft and nothing
more. The portion of the wound above the cleft can be debrided
and treated like any open wound. It will heal because it is not in the
low midline, as long as one has source control in the natal cleft. The
rhomboid flap can be created in the standard fashion, rotated into
place, and left with a free edge superiorly (Fig. 6). A negative pressure
wound dressing is an excellent adjunct in this setting and will assist
with rapid healing.
Although we will not go into an extensive description, the V-Y
flap technique is useful in the setting of failed flap repairs. This
method allows mobilization of a large amount of tissue into the
midline to close large defects. This is the only setting in which we
use this technique, as the rhomboid flap is extremely effective as a
primary complex technique. When performing these complex flap
repairs, patient selection is imperative. It is unwise to embark on
an attempt in a patient who is a tobacco user or an uncontrolled
diabetic. Those with collagen vascular disorders or documented
problems with wound healing should be approached with caution.
In terms of procedural timing, we will attempt definitive surgery
after abscess drainage when there is no visual evidence of ongoing
acute inflammation or infection. If a definitive procedure fails, we
wait as long as possible before a salvage procedure—no sooner than
12 weeks (early and rare) and typically between 6 and 12 months.
It is important to allow a “failed” procedure time to heal, as they
often will.
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C
B
FIG. 4 Rhomboid flap procedure. (A) Area of excision and
rhomboid flap are marked. (B) Rhomboid flap is rotated into place.
(C) Rhomboid flap secured at the completion of the case. (Courtesy
Eric Johnson, MD.)
FIG. 5 Patients treated with a rhomboid flap may develop small areas
of wound separation during the healing process. These occur commonly
and tend to drain for a short time before healing. (Courtesy Eric Johnson,
MD.)
FIG. 6 Patient who was treated with a rhomboidflap buthad disease that
extended for a fair distance cephalad. The cephalad portion of the disease
was debrided/unroofed and left open. The wound was treated with a negative pressure device and healed without incident. (Courtesy Eric Johnson,
MD.)
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