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378
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Fig. 24.1 ( a , b ) The Bascom cleft lift procedure. Compressing the buttocks together will allow marking of the diseased area and deep cleft that
will require excision (Courtesy of Dr. Bascom)
H. Abcarian and G.R. Orangio
remarkably low overall complication rate of 8.5 % and a 1 %
recurrence rate [ 5 ]. The rhomboid or Limberg fl ap has also
been shown to be effective by Urhan in 2002, where he
reported 100 % healing in 102 patients treated with excision
and fl ap closure [ 6 ]. The Bascom cleft lift procedure,
described in 2002, is a technically challenging fl ap that
undermines and obliterates the gluteal cleft in the area of
disease [ 7 ]. The technique emphasizes identifi cation of the
deep cleft through a series of steps to indicate the diseased
(and surrounding) area that needs to be resected to adequately remove the cleft (Fig. 24.1a, b ). The V–Y (fasciocu-
taneous fl ap) advancement fl ap has been utilized since 1993
in patients with complex pilonidal disease [ 8 ]. In 2009, a
series of 43 patients were treated with the V–Y advancement
fl ap with one recurrence and a somewhat higher complication rate including 9.3 % infection, 7 % hematoma, and
16.3 % anesthesia over the fl ap. Unfortunately, over 90 %
were dissatisfi ed with their scar [ 9 ]. The Z-plasty or fl ap has
shown excellent results. In 2006, 144 patients were randomized to two groups comparing excision with open wound
management (i.e., secondary intention) versus excision with
Z-plasty. The Z-plasty had a statistically signifi cant shorter
wound healing, 15.4 days versus 41days ( P < 0.001), com-
pared to conventional management [ 10 ]. In general, the utili-
zation of the gluteus maximus myocutaneous fl ap is reserved
for very recalcitrant pilonidal disease, with the fi rst case
report describing its use in 1984 [ 11 ].
You may fi nd yourself saying “Okay, so what?” First,
pilonidal disease is a common problem seen in a colorectal
surgical practice. Most of the time, these patients are
referred from internal medicine, family practice, dermatologists, and general surgeons for evaluation and treatment, in
part, because of frustration with recurrent disease and also
due to its chronic nature and/or the failure of either conservative and/or prior surgical therapy. Many patients have
been treated with antibiotics, an in-offi ce incision and
drainage, or even pilonidal cystectomy. They are also just as
frustrated because of the intermittent infections or chronic
draining sinus that limits their activity, whether it is purulent or blood and foul odor. The majority of these patients
are in the second decade of life: they are often now in college and have been dealing with pilonidal disease since high
school, and it’s not getting better. You, the true (or deemed)
“colorectal specialist” are then confronted with a disgruntled patient and a benign disease that has become a social
nuisance to them. I have a very long discussion with these
patients (and their parents) about the different surgical
approaches to this disease; many are familiar with these
therapies—through family members, other patients, and in
many cases online research. They usually want to schedule
their surgery during spring or summer break, because they
do not want to interrupt their education or externships for an
operation.
My Approach (Dr. Orangio)
I recommend to these patients re-excision and the utilization
of the VYAF, for several reasons: (1) they have a limited window for surgery and postoperative wound care; (2) they do
not have the “privacy” or “facilities” or “personal” support to
manage an open pilonidal wound that requires packing when
they return to school; (3) they want minimal discomfort and
the shortest recovery time. These patient criteria are the reason to offer this younger patient population and alternative to
pilonidal cystectomy and secondary wound healing. They
must be counseled about the “scarring” that remains postVYAF because it is signifi cant.
24 Complex Pilonidal Disease and Acute and Chronic Perineal Wounds: Point – Counterpoint
379
Fig. 24.2 Recurrent pilonidal disease with extensive midline tunneling and lateral tracts
A Case of Recurring Draining Sinuses
A 26-year-old male with a 10-year history of pilonidal disease presented with a previous incision and drainage of pilonidal abscesses and now with multiple residual draining
pilonidal sinuses. My approach is to place all patients in the
prone jackknife position and use general anesthesia with
intravenous antibiotics (second- or third-generation cephalosporin). The gluteal cleft and gluteal areas are shaved bilaterally and prepped utilizing povidone. On examination, this
patient has complex disease with multiple deep midline and
lateral sinus tracts. I mark the excision site prior to beginning
(Figs. 24.2 and 24.3 ).
An elliptical incision was performed with en bloc excision of all sinus tracts and scar, leaving a wound that is to the
left of midline and down to the presacral fascia (Fig. 24.4 ).
Although some surgeons prefer to keep the base of the ulcer
in place, I feel this is a chronic wound and should be
removed. The site for the V–Y advancement fl ap (VYAF) is
marked and measured: 12 cm long and 10 cm wide
(Fig. 24.5 ). The fl ap is dissected down to the level of the
gluteal fascia, but not including the gluteal fascia. Then the
medial and lateral portions of the fl ap are then dissected
Fig. 24.3 Excision boundaries for recurrent pilonidal disease
from the gluteal fascia leaving at least a 4–5 cm “vascular
pedicle” (Figs. 24.6 and 24.7 ). It is important here not to
cone in and ensure you are keeping your fl ap of equal and
proper thickness to avoid any devascularized areas.
Remember this will need to move, so adequate dissection
and mobilization without compromising blood supply is
key. With the vascular pedicle isolated, the VYAF can easily
slide past the midline to allow for anchoring to the presacral
fascia and to the contralateral wound margin, which is to the
left of the midline. This will obliterate the infra-gluteal cleft
and move the incision off of the midline to aid in healing
(Figs. 24.8 and 24.9 ). Check the viability of the fl ap again.
Ensure it is healthy at this stage or not under tension that you
can still rather easily do something about. The margins of
the wound and VYAF are approximated with subcuticular
absorbable sutures and a “fl uff” dressing is applied
(Figs. 24.10 , 24.11 , and 24.12 ). I do not use drains, although
some people like to use them to evacuate the fl uid that may
collect early on. The patient remains in the hospital for
24–48 h and is encouraged not to lie on their back and to sit
up straight while sitting and eventually while driving. The
patient is discharged and followed up in 10, 30, and 60 days
postoperatively.
380
H. Abcarian and G.R. Orangio
Fig. 24.4 Defect following excision of recurrent disease
Healing by Secondary Intention (Dr. Abcarian)
Key Concept : Healing by secondary intention has the benefi t
of lower recurrence rates but requires effort and time on both
you and your patient for successful eventual healing .
Surgeons generally desire healing of all wounds in the
earliest possible time. This is the basis of primary closure of
all surgical wounds. The problem with pilonidal cyst closure
by any surgical technique is its relatively high failure rate.
Why do closures after pilonidal cystectomy fail? This conundrum has plagued surgeons throughout the years. In the preantibiotics era, Kleckner surveyed the then American
Proctologic Society® in 1936 and found a recurrence rate of
33 % [ 12 ]. In 1977, Eftaiha and Abcarian reviewed all the
available literature on the subject and reported a recurrence
rate of 34 %. Conversely, excision of pilonidal cyst and
allowing healing by secondary intention had a recurrence
rate of 3 % [ 13 ]. So it seemed that all available surgical tech-
niques of closure and use of antibiotics had made no signifi cant reduction in recurrence rates.
In his 1963 textbook, Gabriel listed several criteria where
he believed a pilonidal cystectomy wound should not be
closed due to high failure rate. These included previous
closures, free discharge of pus, hirsutism, secondary
Fig. 24.5 Measuring out the dimensions for the V–Y advancement
fl a p
openings off the midline, and cysts greater than 7.5 cm
(Fig. 24.13 ) [ 14 ]. Even now, it seems unlikely that wide exci-
sions, undermining skin fl aps and technically complicated
plastic closure (Z-plasty, V–Y advancement fl aps, etc.), will
yield generally lasting results in the presence of the patient-/
disease-related criteria spelled out by Gabriel decades ago.
Other causes of recurrence (and in many cases persistence) following both primary closure and healing by secondary intention of these wounds include (A) inadequate
eradication of all the midline pits, which is the source of pilonidal infection. In the case illustrated in the earlier section of
this chapter by Dr. Orangio, one can clearly see intact midline pits (Fig. 24.2 , which should have been previously eradi-
cated) in addition to midline draining abscess and secondary
opening to the left of and posterior to the prior surgical incision. (B) The lateral (horizontal) tension on the intergluteal
cleft with a longitudinal midline incision and closure that is
essentially unavoidable. This mechanical factor must also
play a role in the failure of fl aps, even despite good mobilization. We can try to overcome this by instructing the patient to
remain less active after a fl ap closure, but certainly absolute
bed rest with the potential for deep vein thrombosis and
life-threatening or lethal pulmonary embolism must be
24 Complex Pilonidal Disease and Acute and Chronic Perineal Wounds: Point – Counterpoint
381
Fig. 24.6 Constructing the V–Y pedicle
condemned. (C) The wide and deep dissection of tissues
required for both excision and construction of fl aps in the
presence of infection that increases the risk of failure secondary to localized sepsis. This unfortunately cannot be overcome by a short course of broad-spectrum antibiotics. In fact,
prolonged use of these antibiotics predisposes to an everincreasing incidence of antibiotic-related complications such
as Clostridium diffi cile colitis. (D) Finally, obesity makes the
management and care of the open wound diffi cult.
So what is wrong with leaving the wound open after pilonidal cystectomy? These wounds, irrespective of size, cause
very little pain and disability, and I have found it generally
easy to care for (bathing and packing a coarse 4 × 4 gauze to
separate the edge and keep the wound dry). Changing of the
gauze three to four times daily will debride the open wound
and prevent collection of infected discharge in the cleft. I’ve
found that the best way to dry the wound after bathing is the
use of a hair dryer on the cool setting. The anatomic distance
of these wounds from the anus allows for painless bowel
movements, and patients are uniformly happier than those
having undergone excisional hemorrhoidectomy.
In many cases the correct operation has been done. The
cyst is completely excised without deepening the excision
down to the sacrococcygeal fascia. A small 3 × 4 cm cyst
Fig. 24.7 Completed well-vascularized pedicle. Note the thickness of
the pedicle
excised in total will leave a 4 × 5 cm defect, while carrying
the excision down to the fascia opens up and expands the
wound by 50–100 % of the original size [ 13 ]. In some cases
there are lateral tracts or pockets of disease that may require
additional excision; however, these can often close just fi ne
with secondary intention (Figs. 24.14 , 24.15 , and 24.16 ).
Open wounds begin the “picture frame” shrinkage 2 weeks
postoperatively and will need to be inspected on regular
biweekly basis. The surgeon must take time to shave all edges
of the open wound to prevent growth of hair into the wound
during the healing process (Fig. 24.17 ). Also as the wound
becomes shallower, the dressing gauze must be inserted into
the wound to prevent patchy adherence of the wound edges.
This is easy to instruct the patient because the only painful
area is the skin surrounding the defect and not the depth of the
wound. Small wounds ~3 × 4 cm typically heal in 4–6 weeks,
while larger ones such as 4 × 6 cm may need up to 8–10 weeks
for complete healing. Application of antibiotics, astringents,
or anesthetic ointments is not helpful and may actually contribute to maceration of the wound by adding moisture.
In 1977 Rosenberg recommended reverse taping to pull
the wound edges laterally and fl atten the deep wound in very
obese patients [ 15 ]. Although logically sound, it is diffi cult
382
H. Abcarian and G.R. Orangio
Fig. 24.8 Anchoring sutures in place
for the patient to tolerate the constant pulling sensation and
interference of reverse taping with ambulation and daily
activities. The current use of wound VAC® (LifeCell, New
Jersey) has essentially made this technique obsolete. Yet,
wound VACs are also cumbersome and need nursing or
wound care professionals to change the foam pads at least
every 48–72 h (especially in that location). Despite these
drawbacks, with utilization of portable suction machines,
this has allowed the patient to be able to ambulate and even
return to work (Figs. 24.18 and 24.19 ).
In my opinion, the success rate of fl aps represented in the
literature is simply unbelievable (e.g., 100 % success rate of
Limberg fl aps in 102 patients presented by Urhan) [ 6 ]. In addi-
tion, the reported complication rates of V–Y-plasty are clearly
unacceptable. If followed carefully and long enough, the 9.3 %
infection rate and 7 % hematoma will inevitably grow with the
number of recurrence/persistence of the disease [ 6 ].
My Approach (Dr. Abcarian)
If the purpose of the treatment of pilonidal sinus is an early
return to duty (i.e., front line such as in the armed forces), I
believe the Karydakis technique used on young military personnel offers the least complicated and most satisfactory
procedure with low recurrence rate [ 5 ]. If not, I leave all
Fig. 24.9 Pedicle able to slide past the midline to obliterate the cleft
pilonidal cystectomy wounds open, see the patient every 2
weeks, and shave the wound. Once healed, I recommend
using depilatory cream to prevent hair growth in the vicinity
of the healed wound once a month for an entire year. This
plan has resulted in healing of an overwhelming majority of
recurrent pilonidal cyst patients that have been referred to
me throughout the years. I believe in the wisdom of Gabriel
and his admonition of primary closure in infected, hairy,
recurrent pilonidal with side branching to secondary openings off midline. I would only add obesity to his list.
Point: Counterpoint
Key Concept : There are many ways to approach the same
disease process . You need to have a sound rationale behind
what you do and never stop listening to ( and learning from )
other people ’ s opinions and experiences .
Dr. Abcarian and Dr. Orangio
1 . Dr . Abcarian it appears that you essentially only utilize
“ healing by secondary intention ” of pilonidal cystectomy
wounds ?
Abcarian: That is correct.
24 Complex Pilonidal Disease and Acute and Chronic Perineal Wounds: Point – Counterpoint
383
Fig. 24.10 Deep and subcuticular sutures in place on the fl a p
2 . I ( Dr . Orangio ) feel that for a subpopulation of patients
with pilonidal disease who have failed “ healing by sec-
ondary intention ” or have recurrent pilonidal disease , the
utilization of fasciocutaneous fl aps should be included in
the surgeon ’ s armamentarium of options . The literature is
quite supportive of this approach . Why do you disagree ?
Abcarian: I have taken care of too many failed fasciocutaneous fl aps in my 40 years of practice, and these are
literally nightmares.
3 . Would you agree with me that recurrent pilonidal disease
is secondary to inadequate primary excision ?
Abcarian: In some cases yes, in others it is inadequate
postoperative wound care by the patient and the surgeon.
4 . Why do you think that some patients have prolonged heal-
ing or even “ nonhealing ?” Do you feel this is because of
poor compliance by the patient or not enough postoperative care by the primary surgeon ?
Abcarian: Both. Some patients simply refuse instructions for home care (i.e., showering, shaving, and packing). Then there are surgeons who give a fi rst postoperative
appointment for 6 weeks after surgery.
5 . How do you manage the patient with a “ nonhealing ”
wound , and at what point do you consider the process of
healing with secondary intention a failure ?
Fig. 24.11 Pedicle sutured in place leaving only the lateral defect
Abcarian: As long as the wound keeps getting
smaller, the edges are shaved, and there is no patchy
healing, I continue to examine and treat the wounds
every 2 weeks.
6 . You mention Gabriel ’ s textbook of 1963 discusses rea-
sons for not utilizing a primary closure and tries to postulate that for those reasons fasciocutaneous fl aps
should not be used . Do you believe this is a valid
criticism ?
Abcarian: Hirsutism, recurrence after primary closure,
cysts longer than 7.5 cm, side branching, and worse yet
active discharge of pus—all should discourage anyone
from a plastic closure of pilonidal wounds using fl aps,
whatever kind of fl aps.
7 . In one section you seem to advocate the use of negative
pressure wound dressing ( VAC ), could you explain to me
why you would support this method over the utilization of
any fasciocutaneous fl aps ?
Abcarian: Some deep wounds in obese patients are
diffi cult to pack at home. It is possible though to place a
VAC for3–4 weeks, allow the wound to shrink, and then
care for it without need for VAC therapy. If VAC treatment fails, the patient is no worse off. One cannot say the
same for failed fasciocutaneous fl aps.
384
H. Abcarian and G.R. Orangio
Fig. 24.12 Completed pedicle
8 . Under what circumstances would you agree with myocu-
taneous fl aps in pilonidal disease ? There is some literature that does support its utilization in pilonidal disease .
Abcarian: Surgeons are creatures of habit. I do what
has worked for me in 40 years of practice, which has
included caring for many, many failed fl aps of all kinds.
9 . Any closing comments about pilonidal wound
management ?
Abcarian: One is hard pressed to fi nd an awful lot of
downside with the excision of pilonidal cyst and allowing
the wound to heal by secondary intention—except for the
time it takes to heal. Having had a personal disastrous
postoperative course with primary closure and the need
for two additional operations to get this “simple” problem
to heal taught me a valuable lesson. “Do not do onto
others….”
Thank you Dr . Abcarian
Management of the Perineal Wound
Key Concept : Perineal wound complications after abdominoperineal resection ( APR ) for low rectal cancer ( LRC ),
anal canal cancer ( ACC ), and proctocolectomy ( PC ) for
Fig. 24.13 Extensive pilonidal disease in a patient with multiple risk
factors for recurrence
infl ammatory bowel disease ( IBD ), especially Crohn ’ s ’
Disease ( CD ), are a major cause of postoperative morbidity
and mortality . Yet the disease process will often dictate your
approach . Therefore , you need to have a stepwise approach
that may utilize a multidisciplinary team to ensure adequate
healing and avoid this complication , when possible .
Disease Process
Low Rectal Cancer and Anal Canal Cancer
Key Concept : These typically are large defects that often are
not amenable to re - approximation and may require a multidisciplinary approach for closure .
In the era of multimodality therapy for anal canal cancer
(ACC) and neoadjuvant therapy for low rectal cancer (LRC),
the incidence of perineal wound complications has increased
dramatically [ 16 – 18 ]. Both patient populations are given
“sensitizing” doses of chemotherapy along with over
5,000 cGy of radiation for over 6 weeks and then subjected
to APR. It should not be surprising to us that wound complications may result. In this cohort, primary closure of perineal
wounds leads to postoperative wound complication in
10–40 % and up to as high as 80 % in patients who have
failed primary chemoradiation for ACC and gone onto a
24 Complex Pilonidal Disease and Acute and Chronic Perineal Wounds: Point – Counterpoint
385
Fig. 24.16 Wound after near-complete closure with secondary intention (Courtesy of W. Brian Sweeney, MD)
Fig. 24.14 Recurrent pilonidal disease (Courtesy of W. Brian
Sweeney, MD)
Fig. 24.15 Resulting wound after excision (Courtesy of W. Brian
Sweeney, MD)
salvage APR [ 19 , 20 ]. In either patient population, with
extensive perineal disease or with vaginal/or vulvar involvement, they will require wider en bloc resections or even
Fig. 24.17 The shaved wound after excision of the pilonidal disease
pelvic exenteration (Fig.
24.20 ). This population usually
cannot have primary closure of the perineal wound.
The conduct of the APR is consistent for LRC and failed
or recurrent ACC; the patient is in the modifi ed perineal
lithotomy position using adjustable stirrups. The abdominal
portion (whether with laparotomy or laparoscopically) is
conducted with meticulous dissection including high ligation
of the major vessels (inferior mesenteric artery/vein), wide
pelvic dissection of the rectum, and total mesorectal excision
(TME). If able, I will use an omental interposition fl ap to fi ll
the pelvis. The perineal portion can either be performed synchronously (my preference) or following repositioning in the
prone position (Fig. 24.21 ). In either case, this involves wide
386
H. Abcarian and G.R. Orangio
Fig. 24.18 Nonhealing pilonidal wound. Seton placed initially due to
recurrent subcutaneous abscesses (Courtesy of Eric K. Johnson, MD)
Fig. 24.20 Abdominal perineal resection (APR) for cancer (Courtesy
of Justin A. Maykel, MD)
Fig. 24.19 Negative pressure suction device in place in the apical portion of the wound following nonhealing with fl ap closure. This wound
healed without further incident (Courtesy of Eric K. Johnson, MD)
excision of the pelvic fl oor, detachment of the levator muscles from their bony attachments, and loose approximation
of skin and subcutaneous tissue using interrupted absorbable
sutures [ 17 , 21 , 22 ]. In select cases, a multidisciplinary
approach (especially plastic surgery) will be required to aid
in the construction of fl aps for fi nal pelvic fl oor reconstruction (Fig. 24.22 ). Drains, if needed, can be placed from the
transabdominal or transperineal approach. With this method,
the technical goal is to attempt primary closure of the perineal wound with undue tension and the least amount of
morbidity.
I n fl ammatory Bowel Disease (IBD)
Key Concept : The extent of the infl ammation ( especially with
CD ) will determine your extent of resection . Preserve muscle
Fig. 24.21 Resulting perineal defect demonstrating the posterior vaginectomy (Courtesy of Justin A. Maykel, MD)
and surrounding tissue , when possible , to aid in achieving a
well - vascularized , tension - free closure .
Patients with either ulcerative colitis (UC) or Crohn’s
Disease (CD) who require proctocolectomy (PC) and end
ileostomy have been a technical challenge and conundrum
to surgeons for decades. The management of the perineal
wound has been especially problematic for both the surgeon
and the patient alike. The options have been (1) to leave the
wound open and pack, with or without closure of the peritoneum; (2) close the perineal wound and place a transabdominal drain, again with or without closure of the peritoneum;
and (3) perform an intersphincteric proctectomy to help preserve some of the surrounding muscle and tissue to aid in
wound healing [ 23 – 28 ]. One of the most signifi cant techni-
cal advancements has been the endoanal proctectomy [
30 ]. In 1977, Abcarian discussed that in patients with CD
29 ,
and the “watering can” anus composed of several fi stulas,
24 Complex Pilonidal Disease and Acute and Chronic Perineal Wounds: Point – Counterpoint
387
Fig. 24.22 Fournier’s gangrene (Courtesy of W. Brian Sweeney, MD)
the extent of the APR was determined by the extent of the
perianal disease and the overall activity of the disease [ 23 ,
24 ]. Abcarian advocated the endoanal proctectomy, with
“coring out” of the fi stula tracts to reduce the size of the
excision. The recommendation of performing a two-stage
procedure, whereby a total colectomy with ostomy is initially performed, and following a period to allow the perineal disease to “quiet down” return for the completion
proctectomy, has shown confl icting results [ 25 , 28 ]. On one
hand, the overall healing of perineal wounds in patients with
CD at 1 year is approximately 30 %. Contrast this in UC
patients at 1 year, where it is ~89 %, and you can see how
CD can be so challenging [ 24 , 28 ]. The authors agree that in
patients with CD who require a proctectomy, you should
fi rst determine the extent of active disease. If there is negligible disease with no active infection, an endoanal proctectomy and closure of the wound (with or without closure of
the skin) is an acceptable approach. If there is active disease
with active infection including draining fi stulas, a more conservative approach to the perineal wound is appropriate.
This may involve packing or placement of a negative pressure vacuum device.
We also agree that in patients with large superfi cial
wounds resulting from excision of extensive bilateral hidradenitis suppurativa or post-wide debridement for synergistic
bacterial infections (i.e., Fournier’s gangrene, Fig. 24.22 ),
these seldom result in nonhealing wounds. In both instances,
the anal sphincters remain intact, and there is essentially no
midline wound with constant lateral traction forces to contribute to nonhealing. In this case, grafting may be required
due to the extent of debridement of the subcutaneous tissue
and skin; however, there is typically no large perineal defect.
This is in contrast with the post-APR (LRC/ACC) midline
wound, which is often closed without any support from
deeper tissues to anchor the closure.
Management of the Nonhealing Chronic Perineal Wounds
Key Concept : Proper preoperative counseling regarding the
possibility of chronic wound issues and early involvement of
the wound care team are helpful in the management of these
nonhealing perineal wounds .
No matter the underlying disease that could be discussed
regarding the complications of “failed” perineal wound—
whether it is a wound infection, delayed healing >6 months,
reoperation, dehiscence, abscess, ulcer, chronic sinus, or
perineal hernia—they are all problems colorectal surgeons
will face over their careers. Uniting them all, the management of any one of these complications is challenging and
frustrating to everyone involved. The acute complications of
infection, reoperation, dehiscence, or abscess formation are
problems we have all dealt with likely several times and may
require a multidisciplinary approach to their management.
During the preoperative consultation regarding an abdominal
or pelvic operation, the patient should understand not only
about the potential for ostomy but also about the possibility
of perineal wound complications. We often highlight that
early involvement of the wound ostomy nursing (WON)
team is invaluable to assist a patient in a life with an ostomy;
however, we should also be utilizing their same early involvement for the management of the nonhealing perineal wound.
When approaching these wounds, my recommendation is
you should take into consideration the following: disease
process, work-up, and nonoperative therapy and operative
therapy.
Disease Process
Key Concept : Search for an underlying cause related to the
patient ’ s disease process to help guide your approach to fi guring out why the wound won ’ t heal .
When confronted with the chronic open perineal wound
(COPW), it is important to perform a few basic investigations. Post-APR for cancer, you should review their most
recent CT or PET scan to ensure there is no recurrent disease.
If negative, an examination under anesthesia with multiple
biopsies to rule out recurrent cancer, in addition to cultures
to assess the types of bacteria that have colonized the wound,
should be performed. With the emergence of certain strains
of virulent bacteria (i.e., VRE, MRSA), you may need to
institute a prolonged course of directed antibiotic therapy
prior to reconstruction. In patients with CD, you should also
perform an examination under anesthesia and/or endoscopy
to assess the underlying disease activity, and rule out presence of an abscess or fi stula (from colon, small bowel, bladder, or vagina) to the perineum that could be causing
persistent drainage resulting in chronic perineal “moisture”