Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_894_Библиотеки_им_академика_М_И_Перельмана.pdf
14 Anal Fissure andAnal Stenosis
abc
255
Fig. 14.10 Intra-operative photos of a patient undergoing
house ap anoplasty. (a) The dimensions of the ap are
drawn out. (b) The mobilized ap ready for advancement
Diamond-Shaped Flap
This concept is similar to the house ap.
Choosing the angled design of a rhomboid or the
broad conguration of a house depends on the
shape and size of the target defect.
Rotational “S” Flaps
These advancement aps are more useful for
reconstruction after wide, local skin excision for
Highgrade Squamous Intraepithelial Lesion or
Paget’s disease. Typically, the aps reviewed above
augment anal stenoses better than rotational aps.
References
1. Azarnoff DL, Lee JC, Lee C, Chandler J, Karlin
D. Quality of extemporaneously compounded
nitroglycerin ointment. Dis Colon Rectum.
2007;50:509–16.
2. Barnes TG, Zafarani Z, Abdelrazwq AS.Fissurectomy
combined with high-dose botulinum toxin is a safe
and effective treatment for chronic anal ssure. Dis
Colon Rectum. 2015;58:967–73.
3. Nelson RL, Thomas K, Morgan J, Jones A. Nonsurgical therapy for anal ssures. Cochrane Database
Syst Rev. 2012;2:CD003431.
4. Perry WB, Dykes SL, Buie WD, Rafferty JF.Practice
parameters for the management of anal ssures. Dis
Colon Rectum. 2010;53:1110–5.
5. Hancke E, Rikas E, Suchank K, Völke K.Dermal ap
coverage for chronic anal ssure. Dis Colon Rectum.
2010;53:1563–8.
6. Garcia-Aguilar J, Belmonte C, Wong WD, Lowry
AC, Madoff RD. Open versus closed sphincterotomy for chronic anal ssure. Dis Colon Rectum.
1996;39:440–3.
into the anal canal. Minimizing undermining ensures a
broad-based pedicle and preserves vascularity. (c) The completed bilateral aps. Courtesy of Dr. Daniel L.Feingold
7. Wiley M, Day P, Rieger N, Stephens J, Moore J.Open
versus closed lateral internal sphincterotomy for idiopathic ssure-in-ano: a randomized, controlled trial.
Dis Colon Rectum. 2004;47:847–52.
8. Nelson RL, Chattopadhyay A, Brooks W, Platt
I, Paavana T, Earl S. Operative procedures for
ssure in ano. Cochrane Database Syst Rev.
2011;11:CD002199.
9. Elsebae MM. A study of fecal incontinence in
patients with chronic anal ssure. World J Surg.
2007;31:2052–7.
10. Mentes BB, Ege B, Leventoglu S, Oguz M, Karadag
A. Extent of lateral internal sphincterotomy. Dis
Colon Rectum. 2005;48:365–70.
11. Murad-Regadas SM, Fernandes GO, Regadas FS, etal.
How much of the internal sphincter may be divided
during lateral sphincterotomy for chronic anal ssure
in women? Dis Colon Rectum. 2013;56:645–51.
12. Casillas S, Hull TL, Zutshi M, Trzcinski R, Bast JF,
Xu M.Incontinence after a lateral internal sphincterotomy: are we underestimating it? Dis Colon Rectum.
2005;48:1193–9.
13. Pelta AE, Davis KG, Armstrong DN. Subcutaneous
ssurotomy: a novel procedure for chronic ssurein-ano. A review of 109 cases. Dis Colon Rectum.
2007;50:1662–7.
14. Renzi A, Izzo D, Sarno GD, Talento P, Torelli F,
Izzo G, Martino ND. Clinical, manometric, and
ultrasonographic results of pneumatic balloon dilatation versus lateral internal sphincterotomy for chronic
anal ssure. Dis Colon Rectum. 2008;51:121–7.
15. D’Ugo S, Franceschilli L, Caeddu F, Leccesi L, etal.
Medical and surgical treatment of hemorrhoids and
anal ssure in Crohn’s disease. BMC Gastroenterol.
2013;13:1–7.
16. Lewis RT, Maron DJ.Anorectal Crohn’s disease. Surg
Clin North Am. 2010;90:83–97.
17. Lee SW, Niec R, Melnitchouk N, Samdani T.Transanal anorectal stricturoplasty using the HeinekeMikulicz principle. Color Dis. 2016;18:101–5.
Pilonidal Disease
EricK.Johnson, AaronWomer, and ScottR.Steele
15
Background
In 1847, Dr. AW Anderson documented a case of
“hair extracted from an ulcer” thus describing the
rst reported case of pilonidal disease [1]. The
term “pilonidal” is derived from the Latin terms
“pilus” (a hair) and “nidus” (nest). The term,
pilonidal disease, was originally described in
1880 by Dr. RM Hodges [2]. For nearly 130years
the diagnoses of pilonidal cyst, sinus, and abscess
have been used or confused interchangeably to
refer to the same disease process, though we
know this categorization is inaccurate. It is perhaps best that we use the broader term of pilonidal disease (PD) to describe this disorder in all
encompassing fashion. The rst pilonidal disease
associated abscess was described in 1854 [3],
though it wasn’t until World War II when surgeons became much more familiar with this disease entity, likely secondary to the large number
of cases seen in members of the military. For a
E. K. Johnson (*)
Colorectal Surgery, Uniformed Services University
of the Health Sciences, Bethesda, MD, USA
Department of Colon and Rectal Surgery, Cleveland
Clinic, Cleveland, OH, USA
A. Womer
Case Western Reserve University School of
Medicine, Cleveland, OH, USA
S. R. Steele
Department of Colon and Rectal Surgery, Cleveland
Clinic, Cleveland, OH, USA
long while, PD was known as “jeep disease” and
was thought to be related to modern military service, which required soldiers to ride in vehicles
for extended periods of time [4].
It is evident from the earliest publications that
the issues confronting those aficted with this
disease have undergone little change over time.
The debate over open vs. closed wound management raged even in the early 1950s. In one VA
study [5], patients who underwent primary
wound closure developed recurrence 40% of the
time and required hospital stays of approximately
17 days, while those managed with open technique stayed for 30 days and had a recurrence
rate of 35%! While lengths of hospital stay and
rates of recurrence have fallen over time, it is
clear that we are still far from perfect in the way
we manage this condition (Table15.1).
Etiology
Theories supporting a congenital vs. acquired etiology abound, though most surgeons today would
agree that PD is an acquired disease. The initiating event seems to be traumatic injury to the skin
and surrounding hair follicles in the natal cleft.
This situation most likely occurs secondary to
trapping of hairs, not necessarily those growing
locally, in the natal cleft. The depth of the natal
cleft creates an unfavorable scenario where friction, warmth, moisture, and perhaps local
© Springer International Publishing AG, part of Springer Nature 2019
D. E. Beck et al. (eds.), Fundamentals of Anorectal Surgery,
https://doi.org/10.1007/978-3-319-65966-4_15
257
258
Table 15.1 Pilonidal disease management and outcomes: literature review
Author Retro or RCT # Patients Type of ap
Can etal.
2009 [6]
Can etal.
2010 [7]
Bessa 2013
[8]
Gendy etal.
2011 [9]
Dudink etal.
2011 [10]
Guner etal.
2013 [11]
Altintoprak
etal. 2014
[12]
Kaya etal.
2012 [13]
Osmanoglu
etal. 2011
[14]
Khan etal.
2013 [15]
Sit etal.
2013 [16]
Arslan etal.
2014 [17]
Saylam etal.
2011 [18]
Ates etal.
2011 [19]
Retro retrospective, RCT randomized control trial, NR not reported
Retrospective 200 Karydakis 8.9% Karydakis,
RCT 145 MLF vs.
Karydakis
RCT 120 Modied
Karydakis & MLF
RCT 73 Cleft lift vs. wide
excision
Retrospective 62 Bascom cleft lift
vs. midline closure
vs. secondary
healing
RCT 122 Limberg ap vs.
Bascom cleft lift
Retrospective 324 Limberg ap NR 3.9% Limberg
Retrospective 94 Modied Limberg
ap
Retrospective 767 Primary closure vs.
marsupialization
vs. Limberg
RCT 120 Limberg vs.
primary closure
Retrospective 401 Karydakis vs.
modied Limberg
vs. Limberg
RCT 295 Limberg vs.
modied Limberg
vs. Karydakis
Retrospective 354 Primary closure vs.
D-ap vs.
Karydakis vs.
Limberg
RCT 269 Karydakis vs.
Limberg
Surgical site
complication rate PTD recurrence rate
30.3% PMC
12.9% MLF, 10.3%
Karydakis
23% Karydakis,
40% MLF
2.6% cleft lift,
26.5% wide
excision
50% Bascom,
73.7% midline
closure, 16.7%
secondary healing
19.67% Limberg,
19.67% Bascom
17% modied
Limberg
NR 11.7% primary, 4.4%
18.3% primary
closure, 1.7%
Limberg
Highest in Limberg,
lowest in modied
Limberg, NR
Highest in
Karydakis, NR
16.5% primary
closure, 29.7%
D-ap, 13.5%
Karydakis, 17.3%
Limberg
11.1% Karydakis,
20.8% Limberg
E. K. Johnson et al.
4.6% Karydakis, 18.4%
PMC
5.8% Karydakis, 9%
MLF
2% Karydakis, 3% MLF
2.5% cleft lift, 20.6%
wide excision
4.8% Bascom, 16.7%
midline closure, 11.8%
secondary wound healing
1.6% Limberg, 0%
Bascom
4.2% modied Limberg
marsupialization, 4.7%
Limberg
8.3% primary closure,
0% Limberg
8% Karydakis, 0.9%
modied Limberg, 4.6%
Limberg
6.3% Limberg, 1.9%
modied Limberg, 11%
Karydakis
7.5% primary closure,
9.9% D-ap, 13.5%
Karydakis, 8.7%
Limberg
3.1% Karydakis, 6.9%
Limberg
hypoxia lead to this local trauma secondary to the
texture of the hair. A granulomatous foreign body
type reaction results. There is even evidence that
PD and hidradenitis suppurativa may be similar
on a histological and immunohistochemical level
[20]. Disease will typically start as a small sinus
that may drain uid or cause irritation, but then
can progress to numerous sinuses with associated
cystic dilation and potential abscess formation. In
cases where disease is ignored and unfavorable
conditions persist, PD can become more widespread. Disease can range from the asymptomatic
single sinus discovered incidentally by a primary
care physician, up to a locally destructive process
associated with signicant disability.
In rare cases PD may involve areas other than
the natal cleft, as is supported by reports of disease occurring in the interdigital areas in hair
dressers [21], as well as in areas such as the
umbilicus that may similarly trap hair and other
debris [22]. The presence of a disease process
that appears similar to PD in these additional
areas lends further support to the theory of etiology proposed above. PD is often said to affect
15 Pilonidal Disease
259
males more commonly than females, however
recent data from the armed forces supports a similar incidence between the sexes at 1.9 and 1.7
per 1000 person-years in males and females
respectively [23]. Many proposed risk factors
have been implicated in the development of PD
including family history of disease, higher body
mass index (BMI> 25), poor personal hygiene
habits, hirsutism, deep natal cleft anatomy, occupations that require prolonged sitting, and excessive sweating [24–26]. Disease is often
encountered in patients who lack many or all of
these risk factors however. A study of prospectively gathered data comparing 587 patients with
PD to 2780 healthy controls showed that hirsute
individuals that sit down for more than 6h/day
and who bathe two or fewer times per week have
a 219-fold increased risk for sacrococcygeal PD
[26]. A family history of PD may not only predispose to disease occurrence, but can also be associated with higher recurrence rates after denitive
surgery and earlier onset of disease [25].
Clinical Presentation/Diagnosis
Patients may present along a wide spectrum with
something as simple as an asymptomatic sinus all
the way up to someone with a large and chronically draining open wound. Common scenarios
include the patient who has an acute pilonidal
abscess requiring drainage, as well as the routine
ofce referral for a discussion of denitive excisional surgery after abscess drainage or persistent
disease causing an impact on the patient’s quality
of life.
Making or conrming the diagnosis of pilonidal disease is straight forward and typically only
requires history taking and a good physical exam.
Aficted individuals will complain of pain over
the sacrococcygeal area that may be accompanied by drainage of clear uid or bleeding. In the
case of abscess, fever and local swelling may also
occur. Examination will reveal “pits” in the midline which is a major clue to this diagnosis. Pits
may occur singly or in multiples. A solitary pit in
a minimally symptomatic individual may be easily overlooked. Induration just lateral to midline
may also be palpated and this can occur unilaterally or bilaterally. Inamed draining sinuses may
also be present. In severe cases, there may be
open wounds ranging widely in size. Acute
abscess is associated with erythema of the
affected skin, uctuance, and local tenderness.
Occasionally PD can be mistaken for and anorectal stula if a sinus is present close to the anus. It
is important to examine the natal cleft for pits. If
pits are noted, then pilonidal sinus should be
included in the differential diagnosis in these
individuals.
Disease recurrence is unfortunately a commonly encountered scenario, though examination
of the published literature would for the most part
make one believe otherwise. Early recurrence is
dened as that occurring within 1year of denitive surgery, while any recurrence occurring after
that is considered late. Recurrent PD, especially
early “recurrent” PD is actually persistence of an
open wound that failed to heal after surgery. It is
debatable whether or not to consider this recurrent pilonidal disease or simply a persistent
chronic wound. Incisions placed in the midline
will often demonstrate delayed healing or nonhealing. The reasons behind a non-healing wound
may be different than the etiology of PD, however the techniques we use to treat them are similar. Recurrences present much like primary PD,
and can have association with poor surgical technique, patient non-compliance, or failure to recognize and modify the risk factors that
predisposed to disease in the rst order.
Recurrence may also be an unavoidable result of
the natural history of disease.
Principles ofTreatment
There are several basic principles that should be
considered when treating pilonidal disease such
that the best outcome can be achieved:
1. Control of Sepsis—drain acute abscesses and
avoid any attempt at denitive surgical
management in the setting of active infection.
All PD will be colonized with bacteria, but
this is not the same as active infection. Primary
closure with or without ap reconstruction
will fail in the setting of infection and will
make future management more difcult. Do
not burn bridges.
260
E. K. Johnson et al.
2. Disease Severity and Operative Approach
Should Match—the anatomy or severity of
disease should drive the treatment method that
is selected. If the disease is minor, yet the
patient requests surgery, a pit-picking procedure (as described below) 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
ap reconstruction.
3. Avoid Too Much Excision—the old method of
excising all disease down to the post-sacral
fascia results in an extremely large and complex wound. This technique should be avoided
if at all possible. Excision that is too deep or
aggressive has been shown to correlate with
disease recurrence/treatment failure.
4. Un-Roof All Disease, Debride Granulation
Tissue, Remove Hair—this principle goes with
principle 3 above. Removal or un-roong 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.
5. Use an Off-Midline Excision and Closure
When Possible—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. While it may be impossible
to keep the entire wound out of the midline,
there should be signicant effort to minimize
the amount of wound in the midline.
6. If the Wound is Closed, Tension Must Be
Minimized—because of the inherent difculty with wounds located in the region of the
gluteal cleft, every effort should be taken to
minimize wound morbidity. A “tensionappropriate” closure should be utilized. If this
cannot be achieved initially, then tissue undermining or use of a ap should be considered.
When aps are used, it is important to ensure
a lack of tension at both the excision and
donor site. Tension seems to be better tolerated at the donor site, as is separation of the
operative wound—especially since these sites
are off the midline.
7. Change the Anatomy/Flatten the Natal Cleft—
since it is believed that deep natal cleft anatomy contributes to formation of pilonidal
disease, it seems reasonable that any procedure designed to atten cleft anatomy would
lead to lower recurrence rates. Most ap procedures, and certainly the Bascom cleft lift
procedure, are designed to accomplish this
goal. The cleft lift procedure, in particular,
combines most if not all of the above principles into one operation which has likely contributed to its success. That stated, not all PD
requires these maneuvers.
Treatment
A discussion of all available treatment options
for PD is beyond the scope of this text. As with
many disease processes treated by surgeons, the
presence of numerous options may be helpful but
usually indicates that no single option is perfect.
It is essential that the treatment should be tailored
to the patient’s expectations, anatomy of disease,
and disease severity. Therapeutic options range
from non-operative therapies to large local excisions with local ap reconstruction. The debate
between open wound management and primary
closure remains, and even when closure is performed, local wound care and physical limitations may be required for long periods of time. It
would not be reasonable to expect a single surgeon to be familiar with every available operative
technique. If a surgeon is familiar with three or
four operative techniques ranging in complexity,
this will likely provide acceptable option for the
entire spectrum of disease they may encounter.
Non-operative Management
The simplest solution for asymptomatic or minimally symptomatic PD is to avoid invasive intervention. For the occasional individual referred
for the evaluation of asymptomatic midline pits
15 Pilonidal Disease
261
in the natal cleft without concerning physical
exam ndings suggesting infection, no operative
management is required. Operating in this scenario will lead to a situation where the treatment
is worse than the disease. Patients can be counseled on strategies to prevent the development of
symptomatic disease. Risk factor reduction such
as weight loss, avoidance of prolonged sitting at
work, improved hygiene, and weekly clipping of
hair in and adjacent to the natal cleft may diminish the likelihood of a patient developing symptomatic PD.These same nonoperative measures
are also appropriate in the individual with active
symptomatic disease. In the patient presenting
with mild disease, these simple methods of risk
factor modication may lead to improvements in
symptoms and potentially even quiescence. A
1994 study demonstrated that these measures,
combined with limited lateral incision and drainage in the setting of acute abscess, led to fewer
occupied hospital bed days when compared to
excisional procedures [27]. Over 17-years of follow up, only 23 of 101 patients went on to require
excisional therapy.
Due to the success associated with periodic
shaving in and around the natal cleft, some have
recommended laser hair removal as a long-lasting alternative for the conservative management
of PD.Enthusiasm for this method of treatment
aside, robust data to supporting its use do not
exist. Small series of less than 20 patients have
shown some benet to laser epilation in the setting of recurrent PD [28, 29]. The procedure
itself is uncomfortable for the patient and often
requires local anesthetic. Treatments are performed over 3–11 sessions at 6–8week intervals
and are expensive. An investigation of this technique in teenagers with PD, 25/28 of which were
managed initially with surgery, revealed only a
single recurrence over a mean follow up of
2 years [30]. The conclusion of this study was
that use of laser epilation was a safe method for
addressing hair growth associated recurrence.
A randomized comparison of laser hair
removal to traditional methods as an adjunctive
therapy after surgery for PD demonstrated a
lower recurrence rate in the laser treated group
[31]. In this particular trial however, the higher
recurrence in the traditional group appeared to be
related to noncompliance with traditional hair
removal methods after 1 year. There is debate
over the benet of hair removal/shaving in the
setting of PD that has been operatively managed.
A retrospective study of patients previously surgically treated for PD was performed focusing on
those who performed razor hair removal vs. those
who did not [32]. Recurrence was noted to be
higher in the group who shaved (30%) vs. those
who did not shave (19%) (p=0.01), suggesting a
potential negative effect of postoperative razor
epilation. It would be benecial to see future
comparisons between laser hair removal and no
hair removal in the adjunctive setting.
While some form of hair removal may lead to
reduced recurrence rates as well as reduced rates
of excisional therapy, hair removal and other nonoperative methods alone are unlikely to cure disease of more signicant severity. Many surgeons
have noted that the hair found inside of sinus
tracts is clearly noted to be much longer than that
which grows in the region of the natal cleft. Most
surgeons believe that longer hairs fall into the
natal cleft, become trapped, and result in disease.
If this theory is in fact true, local epilation alone
could potentially have only minimal effect.
Methods employing the use of phenol or brin
glue injection to ablate sinus tracts are often considered nonoperative since they do not involve
tissue excision, and have been investigated in
small series by many investigators [33–40].
While the focus is typically on the substance utilized for injection, these procedures employ
curettage of sinus tracts, tissue debridement, and
hair removal, which contribute to their success. Use
of phenol as an ablative agent has been associated
with success rates of 60–95% [33–35]. Fibrin
glue injection combined with a variety of techniques has shown success rates from 90–100%
[36–39]. A recent evaluation of individuals
treated with brin glue revealed that 79% of
patients were satised, 71% were back to normal activities within 2weeks, and 74% required
no further treatment [40]. A video-assisted ablative technique has also been described using a
4 mm rigid hysteroscope with a 5-Fr working
channel [41]. Continuous irrigation is used, hair
removal performed, and the cavity and tract
walls are ablated using radiofrequency energy
262
E. K. Johnson et al.
via a bipolar electrode. Only one recurrence was
reported during 1 year of follow up of 27
patients. A recent systematic review identied 9
studies in which with 497 patients of a mean age
of 25 years underwent Endoscopic Pilonidal
Sinus Treatment (EPSiT). The mean operative
time was 34.7 minutes and all procedures was
performed on an outpatient basis. The mean
Visual analogue score of pain within the rst
week was 1.35. Failure of the technique was
recorded in 40 (8.04%) patients, 20 (4.02%) had
persistence and 20 (4.02%) developed recurrence. The weighted mean failure rate of the
technique was 6.3%, the mean time to complete
healing was 32.9 days, and the mean time to
return to work was 2.9 days [42]. This method
may represent a potential option for minimally
invasive therapy and deserves further investigation. The advantages of these therapies over
excisional methods include a more rapid recovery and less post-procedural pain. One must be
cautious when interpreting the data reported on
these procedures as there is quite a bit of heterogeneity among studies, and the studies investigating minimally invasive therapies seem to
involve patients with lower disease severity.
ment beginning with those that are considered
simple and progressing to the complex.
Basic Procedures
Perhaps the simplest procedure to perform is laying open of the cyst and all associated sinus
tracts, referred to as “unroong” of disease.
Unroong and wide local excision of all involved
tissue, were the treatments utilized most commonly in the early days of surgical PD management. Many surgeons have combined unroong
with marsupialization of the wound. High recurrence rates of 15–35% [5] resulted in the quest
for more effective methods of surgical management. One major key to pilonidal surgery is to
ensure that as much of the surgical wound as possible be kept off the midline, as midline wounds
in the natal cleft are resistant to heal. Simple tract
unroong and curettage is particularly helpful in
the setting of minor disease affecting the perianal
area (often mistaken as an anal stula). The
majority of this wound will lie off the midline
and will quickly heal (Fig.15.1). While we con-
Operative/Excisional Management
There are a large number of interventions available for the operative management of PD.The
literature is full of publications reporting results
from a variety of procedures. Many of the published studies are retrospective reviews examining the results from small series of patients that
have undergone a single type of operative procedure. There are a number of published randomized trials evaluating one surgical method vs.
another with extremely heterogeneous results. If
one procedure is preferred, there is almost certainly evidence available to support its superiority over another. Study results are most likely
heavily inuenced by variations in how patients
are managed postoperatively as well as by differences in surgical technique and skill. Since a
description of every available method is beyond
the scope of this text, we will review some of the
more common methods of operative manage-
Fig. 15.1 Unroong or laying-open technique. (a)
Overlying tissue is excised. (b) Appearance of wound at
completion of the procedure
15 Pilonidal Disease
263
tinue to debate which procedure is superior,
recent data would suggest that the higher the volume of excised specimen, the higher the rate of
surgical site infection (SSI) and hence risk of
recurrence [43]. While many surgeons employ
techniques utilizing open wound management,
some surgeons advocate excision combined with
primary wound closure which can often require
the mobilization of minor skin aps.
Because of a perceived increase in SSI risk
with primary closure, some surgeons have recommended drainage of the wound through a variety of methods with a wide variation in results.
Drainage has been studied, but has not been
shown to result in improved results as far as
patient satisfaction, healing, or infection [44]. A
meta-analysis of the impact of drainage in the
setting of primary closure showed that there were
no statistically signicant differences in outcomes with or without the use of a drain [45]. A
randomized controlled trial comparing the lay
open method to wide excision with primary closure showed that patients healed faster in the
primary closure group with no differences in the
groups noted at 1 year of follow up [46].
Interestingly, this group of investigators made no
effort to keep the surgical wound off the midline.
In 2010 a prospective randomized study was published comparing the lay-open technique to primary closure augmented by the placement of
gentamicin impregnated collagen [47]. The antibiotic impregnated material was placed in the
base of the wound with overlying tissue closure.
The results showed improved healing at 4weeks,
improved postoperative pain, and lower cost in
the primary closure group. Recurrence rates were
no different at 5years.
A four-arm randomized trial comparing primary closure, primary closure with hydrogen
peroxide irrigation, wide local excision, and wide
local excision with hydrogen peroxide irrigation
showed different results [48]. The wide local
excision/peroxide irrigation group showed the
lowest recurrence rate and the fastest time to
healing. The investigators concluded that this
was related to the ability to clearly delineate all
tracts and disease with peroxide irrigation,
thereby allowing them to perform a more precise
and low volume excision. Similarly, another
group performed a retrospective analysis of PD
patients that had undergone surgery and concluded that use of methylene blue injection to
delineate disease was associated with a lower
recurrence rate [49].
There have been several different descriptions
of “pit picking” procedures published. These are
relatively minor procedures in terms of the
amount of tissue excised, the resulting wounds
are small, and they may be best suited for those
with mild to moderate levels of disease. These
procedures are not ideal for the patient with a
large open wound or for those with extensive disease. Regardless of the subtle differences between
the variety of procedures described, all methods
seem to include central pit excision with minimal
surrounding tissue, hair and debris removal, and
excision of the old adjacent abscess cavity or
“cyst” via a lateral incision using an undermining
technique. Pit excision sites are then primarily
closed, and the lateral incision is partially closed
to allow for drainage. The end result is a fairly
cosmetic procedure with minimal pain, early
return to normal activities, and rapid healing
(Fig.15.2) [50]. A circular punch knife of appropriate size may be used for pit excision and is
ideal for this application. There are several modications of this procedure described, but the
basic principles persist in each technique. The
Fig. 15.2 Removal of a midline pit with a small incision
after lateral incision and debridement
264
ab
cd
E. K. Johnson et al.
use of phenol as a sclerosing agent has been combined with pit excision and has resulted in good
outcomes [51].
Complex Procedures
The commonality throughout all “complex” procedures is the mobilization of an adjacent tissue
ap to achieve primary wound closure after excision of some volume of tissue and/or skin. Some
procedures combine wide local excision of a
large volume of diseased tissue with ap reconstruction, while others focus on the preservation
of as much local tissue as possible. These procedures also range from simple to complex. While
there are a number of available options, our attention will focus on the discussion of the Karydakis
ap, the Bascom cleft-lift procedure, and the
rhomboid or Limberg ap procedure and its modications. There are additional ap procedures
such as the z-plasty, V-Y advancement ap, and
other rotational ap techniques that will not be
discussed in this chapter. Keep in mind however
that these aps may be useful in the setting of
recurrent disease after failure of a prior complex
procedure. The use of ap procedures in primary
PD is a topic of debate, with many discouraging
their use outside of the realm of recurrence.
Proponents of their primary use cite that they are
more effective in curing disease, because they
result in a modication of the natal cleft anatomy.
The majority of these techniques result in a attening of the natal cleft, which may in theory prevent disease recurrence.
Karydakis Flap
This procedure is begun by rst excising the
affected tissue in the midline, which will typically leave an elliptical defect. A beveled skin
ap is then created and mobilized across the
midline to facilitate a primary closure that is lateral of the midline (Fig.15.3). A closed suction
drain may or may not be used. The theoretical
advantages of this procedure are the tension free
closure that is out of the midline combined with
some attening of the natal cleft. This ap is
probably the easiest procedure to perform. This
procedure has been shown to be more effective
than simple primary midline closure in terms of
patient satisfaction, recurrence rate, and rate of
postoperative complications [6]. It has also been
reported to be comparable to other more complex ap procedures such as the modied
Limberg ap [7, 8].
Cleft Lift Procedure
The cleft lift procedure was originally described
and popularized by Dr. John Bascom. This is a
simple but intricate procedure that is designed
to “lift” the natal cleft and result in an incision
that is closed off the midline. Wide excision is
Fig. 15.3 Karydakis ap
ac
15 Pilonidal Disease
265
not required, and this may be one reason for the
procedure’s success in theory. The only tissue
excised is the skin overlying the disease on one
side of the cleft. This procedure requires that the
patient be marked prior to incision to establish a
“safe zone”, beyond which no dissection is performed. The authors prefer to perform the marking of the operative area prior to skin preparation.
The patient is placed in the prone position and
the buttocks are squeezed together. The area
where the skin on both sides of the natal cleft
touches is marked with a magic marker. This
establishes the safe zone. The buttocks are then
taped apart exposing the disease. After skin
preparation, the area to be excised is marked
with another marking pen (Fig.15.4a). This proposed incision will be partially elliptical and
should extend from the midline pits out to one
side of the safe zone. The distal portion of this
incision is scimitar shaped in order to facilitate
closure near the anus without causing local
deformity.
b
Fig. 15.4 (a–c) Cleft lift procedure (as described by Bascom)