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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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Chapter 17
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 foreignbody 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
Patient in prone position (Kraske or prone jackknife)
Betadine or antiseptic skin cleanser is used to prepare the operative site.
A 10 × 10 drape can be used to exclude the anus from the operative site.
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).
FIGURE 17-2 Identify pits with a fistula probe. A: Pilonidal Disease. B: Passing a
probe to identify the pits.
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).
FIGURE 17-3 Injection of methylene blue. A: Placement of the catheter. B. Injecting
the dye identifies the opening.
Lay-Open Technique with Marsupialized Pilonidal Pits
and Excision of Pilonidal Pits
Identify pits with fistula probe and open the pits with cautery and debride
the edges (Fig. 17-4).
FIGURE 17-4 Lay-open technique. A: Passing the fistula probe. B: After opening the
tract.
Curette the tracts and ensure the granulation tissue is debrided.
Marsupialize the edges of the tract with absorbable suture (Fig. 17-5).
FIGURE 17-5 Marsupialize edges. A: Marsupialization of the tract. B: Final wound.
Infiltrate the wound with local anesthetic.
Place a sterile dressing.
Wide Local Excision
Positioning and preparation are the same as the abovementioned steps.
Identification of pits is the same as the abovementioned steps.
An elliptical incision should be made in the skin to encompass all the pits.
Carry the incision down toward the fascia. The incision does not have to
extend to the fascia, but it needs to be deep enough to excise the base of
the pit. Be careful not to wander laterally during the dissection and stay
close to the pit—this will ensure a smaller wound.
Options are to close the wound or leave it open for twice-daily packing.
If closing the wound:
Close the wound in several layers using Vicryl suture.
Irrigate with sterile saline in between each layer.
For skin closure, use a nonabsorbable monofilament suture in a vertical
mattress manner.
There are several options for dressings:
Can use a small negative-pressure wound therapy system.
Can place a standard sterile dressing to be removed after 48 hours.
Limberg Flap (Rhomboid Flap)
Identify the extent of the resection with probing and injecting methylene
blue. The excision should be a diamond shape (Fig. 17-6).
FIGURE 17-6 Diamond-shaped excision site for Limberg flap.
Mark out the incision for the creation of the flap—the incision should
extend laterally to the right buttock for approximately the same length as
one edge of the diamond excision site (Fig. 17-7).
FIGURE 17-7 Marking of Limberg flap. A: Measuring out the lateral extension. B:
Measuring out the side to ensure it is the same.
The second incision should be parallel to the lateral aspect of the excision
site (Fig. 17-8).
FIGURE 17-8 Marking of Limberg flap.
Figure 17-9 demonstrates the planned rotation of the flap.
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