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274
External anal sphincter
External opening at penoscrotal junction
External anal sphincter
External opening at penoscrotal junction
16 Hybrid Procedures-Future ofFistula Surgery!
ed and demarcated with diluted methylene blue.
A probe was inserted through the external opening and brought out from the internal opening at
12 o’clock. LIFT procedure was carried out. The
a
Internal anal sphincter
distal tract was curetted and laser-ablated. The
laser ablation of the tract near the penoscrotal
junction was not done due to the proximity to the
urethra (Fig.16.17b).
Internal opening at
12 o’clock position
Dentate line
Magnified view
b
Laser ablation of distal tract
Fig. 16.17 (a) External opening at the penoscrotal junction and internal opening at 12 o’clock position. (b) LIFT done
at 12 o’clock position with laser ablation of distal tract
LIFT
Internal opening at
12 o’clock position
Dentate line
Internal anal sphincter
Magnified view
k
Right external opening
a
16.15 Case Presentations
275
Discussion
The patient had a stula tract extending from
the deep anterior anal space. As the internal opening was easily identied, there was no point in
doing VAAFT. The laser ablation of the distal
tract after curetting helps in faster healing. LIFT
is another technique that is used as a sphinctersaving procedure. LIFT is not routinely done in
our practice. However, as a colorectal surgeon, I
feel that one should be aware of all the modalities
available for the surgical management of a
stula.
openings in the gluteal region, 12cm and 15cm
from the anal verge. An internal opening was
present at the 6 o’clock position at the dentate
line. The patient was anxious as he had been told
that the stula tracts would collapse after a colostomy, but the discharge persisted even after a
year. The patient got an MRI, which revealed a
complex trans-sphincteric stula with intersphincteric, right ischiorectal, and gluteal collections with multiple external openings (St. James
University Hospital classication (grade 4))
(Fig.16.18a).
Undoubtedly the case was challenging. I
Case 4
A 40-year-old gentleman was operated on for stula thrice, but he had a recurrence each time.
Subsequently, a diversion colostomy was done by
a colleague. A few months later, he still had pus
discharge from two openings in the ischiorectal
region. On examination, there were two external
Fig. 16.18 (a) Two
external openings in the
gluteal region. Internal
opening at 6 o’clock
position at the dentate
line. (b) Postoperative
wound
Anal canal
Dentate line
decided on a hybrid procedure, a combination of
VAAFT with laser ablation of the distal stula
tract and proximal stulotomy. The stulous
tracts were demarcated by methylene blue, and
hydrogen peroxide was injected from an external
opening. Bubbles could be seen coming out of a
single internal opening at 6 o’clock. A probe was
Internal anal sphincter
External anal sphincter
Common tract
b
Internal opening at 6 o’cloc
Let external opening
276
16 Hybrid Procedures-Future ofFistula Surgery!
inserted through the external opening at 5
o’clock. It came out of the external opening at 7
o’clock, indicating a communicating horizontal
tract, as shown in the above image. VAAFT scope
was inserted but could not be tilted through the
T-shaped junction. Then the scope was inserted
through the internal opening. Although VAAFT
is an excellent diagnostic tool, it did not add to
the diagnosis already made on MRI. The tract
from 5 o’clock to 7 o’clock was curetted, irrigated, and laser-ablated. Then, through an internal opening, a laser ber was inserted, and the
vertical extension of the tract was ablated. A stulotomy was done starting from the internal
opening up to the anal verge after performing an
excision of the internal opening. Finally, marsupialization was carried out at the stulotomy site.
There was complete healing of the tract in
4weeks. After 9 months, the colostomy reversal
was done. On deep analysis, I was convinced that
the key to success, in this case, was a good stulotomy and laser ablation of the distal tracts. A
larger stulotomy would have resulted in extensive raw areas with prolonged healing time
(Fig.16.18b).
Case 5
One of my colleagues referred a 60-year-old
male patient to me. Two years ago, a surgeon
operated on him for Fournier’s gangrene. He
remained well for 2 years. For the last 2 months,
he had pus discharge from the perianal area, for
which he consulted my colleague.
Two external openings were seen on examination, one at 9 o’clock and the other at 6 o’clock.
They were approximately 6 and 10cm from the
anal verge. On DRE, a single internal opening
was seen at 6 o’clock. The MRI showed a complex trans-sphincteric stula tract extending
superiorly along the right lateral wall of the
sphincter complex involving the external sphincter and then coursing along the right posterior
lateral wall to open at the dentate line. A hybrid
procedure comprising distal coring with proximal stulotomy was planned.
After preoperative investigations, he was
taken for surgery. Methylene blue was injected
from the internal opening and seen coming out
from the external opening at 9 o’clock and the
internal opening at 6 o’clock, showing intercommunication between the two tracts (Horseshoe
stula).
Proximal stulotomy followed by marsupialization was done. Both the tracts were cored out
using FiXcision after laser ablation. The patient
recovered well.
Discussion
Fistulotomy at 6 and 9 o’clock would have
resulted in large wounds with prolonged healing
time. The principle behind the procedure was to
create the least raw area. Simple modications
can lead to excellent results if the surgical principles are not compromised.
Case 6
Mr. Q, 45-year man, was referred to me by one
of my colleagues. The patient suddenly developed a painful swelling in the perianal area. The
pain was severe and continuous. He went to my
colleague, who treated him symptomatically.
The pain subsided, and Mr. Q was alright for a
week. After that, he again had pain and pus discharge, for which he was referred to me. He was
apprehensive and wanted me to prescribe medicines without examining him. Somehow, I was
able to convince him for examination. I was surprised to see three external openings; the rst
was at 1 o’clock at the root of the scrotum, the
second at 3 o’clock, and the third at 9 o’clock,
with a single internal opening at the 12 o’clock
position on the dentate line. It was an inverted
Y-shaped tract (Fig.16.19). I explained the case
and advised him for surgery. He was not keen but
eventually agreed. I recommended an MRI, but
he refused.
After getting all the prerequisites, I shifted
him to the operation theatre. Hydrogen peroxide
and methylene blue were injected from an external opening at 1 o’clock. The dye came out from
the internal opening at 12 o’clock at the dentate
line. Fistulotomy with marsupialization was done
at 12 o’clock from the dentate line to the anal
verge after exploring the deep intersphincteric
space. All the intercommunicating tracts got separated after stulotomy. All the tracts were cored
out after laser ablation, and the external openings
References
External opening at penoscrotal junction
Fistula tract
Opening at 9 o’clock position Opening at 3 o’clock position
Magnified view Dentate line
Fig. 16.19 Y-shaped stula tract. Three external openings, one at the penoscrotal junction, the second at 3 o’clock, and
the third at 9 o’clock position with an internal opening at 12 o’clock
277
were widened. The patient was discharged the
next day. When he came for a follow-up, he was
pleased and appreciated my decision.
Discussion
It was an inverted Y-shaped tract, and I combined FiXcision with proximal stulotomy.
FiXcision helped to core the entire tract, and stulotomy helped remove the nidus of infection
and separate the communicating Y-shaped tracts.
The procedure could be completed without creating large wounds.
16.16 Conclusion
After attempting different hybrid procedures, the
most reliable procedure remains distal coring and
proximal stulotomy with laser ablation of the
distal tract. The recurrence rate after this procedure is minimal as the primary source of infection is completely removed. With the advent of
the laser, it has become effortless to manage the
distal tract. I must admit that I have been highly
inspired by Park’s technique, which I follow very
religiously.
Take-Home Message
A paradigm shift from traditional to sphinctersaving methods has emerged as a boon for
patients and surgeons. As a surgeon, I feel that
there is always a fear of failure in whatever procedure one follows. Still, in this evidence- based
era, I advise my colleagues to evaluate the literature, the reported data, and the evidence supporting the procedure before adopting it. The
Cochrane database, randomized trials, and cohort
studies can be excellent guides for using a
technique.
References
1. Pathak DU, Agrawal V, Taneja VK.Submucosal ligation of stula tract (SLOFT) for anorectal stula:
an effective and easy technique. Ambulatory Surg.
2014;20(3):42–3.
2. Gupta K, Mital K, Gupta R, Bakshi T.Distal laser proximal stulotomy-a new sphincter-saving technique a
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3. Parks AG. Pathogenesis and treatment of stula-inano. Br Med J. 1961;1(5224):463.
4. Kasiri MM, Riss S, Stift A, Binder AD, Kogovšek
U, Huth M, Kronberger IE. Optimized stulectomy
using the novel FiXcision® device: a technical feasibility study and evaluation of short-term healing rates.
Tech Coloproctol. 2019;23(6):579–82.
5. FiXcision AMI. https://www.ami.at/en/produkt/
xcision.
6. Giamundo P. Laser treatment for anal stulas: what
are the pitfalls? Tech Coloproctol. 2020;24(7):663–5.
7. Rojanasakul A. LIFT procedure: a simplied
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2009;13(3):237–40. https://doi.org/10.1007/
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8. Ellis CN, Rostas JW, Greiner FG. Long-term outcomes with the use of bioprosthetic plugs for the management of complex anal stulas. Dis Colon Rectum.
2010;53:798–802.
9. Hong KD, Kang S, Kalaskar S, et al. Ligation of
inter-sphincteric stula tract (LIFT) to treat anal
stula: systematic review and meta-analysis. Tech
Coloproctol. 2014;18:685–91.
10. Lehmann J-P, Graf W.Efcacy of LIFT for recurrent
anal stula. Colorectal Dis. 2013;15(5):592–5.
11. Meinero P, Mori L.Video-assisted anal stula treatment (VAAFT): a novel sphincter-saving procedure
for treating complex anal stulas. Tech Coloproctol.
2011;15(4):417–22. https://doi.org/10.1007/
s10151- 011- 0769- 2.
12. Emile SH, Elfeki H, Shalaby M, Sakr A.A systematic
review and meta-analysis of the efcacy and safety
of video-assisted anal stula treatment (VAAFT).
Surg Endosc. 2018;32(4):2084–93. https://doi.
org/10.1007/s00464- 017- 5905- 2.
13. Romaniszyn M, Walega PJ. Are two better than
one? VALIFT: video-assisted ligation of the intersphincteric stula tract—a combination of two
minimally invasive techniques for treatment of
trans-sphincteric perianal stulas. Tech Coloproctol.
2019;23(3):273–6.
14. Weledji EP. Idiopathic anal stula: stulotomy
or stulectomy? Adv Res Gastroentero Hepatol.
2018;11(4):555817.
15. Pfefer, T. J., Choi, B., Vargas, G., McNallyHeintzelman, K. M., & Welch, A. J. (1999).
Mechanisms of laser-induced thermal coagulation of
whole blood invitro. In Rox Anderson R etal Lasers
in surgery: advanced characterization, therapeutics,
and systems IX (Vol. 3590, pp.20-31). SPIE.
16. Hill MR, Shryock EH, Rebell FG. Role of the anal
glands in the pathogenesis of anorectal disease. J Am
Med Assoc. 1943;121(10):742–6.
17. McColl I.The comparative anatomy and pathology of
anal glands. Arris and Gale’s lecture was delivered at
the Royal College of Surgeons of England on Feb 25,
1965. Ann R Coll Surg Engl. 1967;40(1):36.
18. Lunniss PJ, Shefeld JP, Talbot IC, Thomson JP,
Phillips RK. Persistence of idiopathic anal stula may be related to epithelialization. Br J Surg.
1995;82(1):32–3.
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Experimental model of stula-in-ano. Dis Colon
Rectum. 2005;48:353–8. https://doi.org/10.1007/
s10350- 004- 0769- 7.
20. Jun SH, Choi GS. Anocutaneous advancement ap closure of high anal stulas. Br J Surg. 1999;86:490–2. https://doi.
org/10.1046/j.1365- 2168.1999.01077.x.
21. Williams JG, Farrands PA, Williams AB, etal. The
treatment of anal stula: ACPGBI position statement. Colorectal Dis. 2007;9:18–50. https://doi.
org/10.1111/j.1463- 1318.2007.01372.x.
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JJ, Wexner SD.Anal stula plug: initial experience
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24. Mitalas LE, van Onkelen RS, Monkhorst K,
Zimmerman DD, Gosselink MP, Schouten
WR. Identication of epithelialization in high
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DCR.0b013e3182908be6.
Role ofLasers inPilonidal Sinus
“All sinuses heal unless something keeps them open.”
Lord and Miller
17
Key Concepts
• Pilonidal sinus is a cavity or tract in the sacrococcygeal region caused by recurring infection and persistent inammation.
• Pilonidal sinus disease is attributed to the
entry of the hair through a primary opening
called the pit.
• Minimally invasive techniques like endoscopic pilonidal sinus treatment (EPSiT) and
video-assisted laser ablation of the pilonidal
sinus (VALAPS) have gained popularity.
• Pit picking combined with VALAPS gives
good results with a low recurrence.
17.1 Introduction
Pilonidal sinus disease (PSD) is a sacrococcygeal cavity or tract formed by recurrent infection and persistent inammation [1]. In 1847,
A.W. Anderson published a paper on “hair
extracted from an ulcer” [2, 3]. Warren later
documented three instances in 1854, making the
rst case series in “Pilonidal sinus disease” [4].
R.M Hodges invented the word “Pilonidal disease” in 1880 [5]. The word is a combination of
Pilus and Nidus; Pilus means “hair,” and Nidus
means “nest.” In 1883, O.H.Mayo described the
condition for the rst time [6]. This condition is
often called jeep disease, as many U.S soldiers
riding jeeps were affected by the pilonidal disease during the wars [2]. Over 79,000 soldiers
in the American army had surgery for pilonidal
sinus disease. Two thousand soldiers during the
Vietnamese war were operated on for pilonidal
sinus every year [7].
17.2 Epidemiology
The prevalence of pilonidal sinus is 26 people per
100,000 [8]. In a 2.2:1 ratio, men are more often
infected than women [2]. Each year, an estimated
70,000 Americans are aficted by this disease [9].
According to Kazim Duman etal., pilonidal sinus
is more common in the Turkish community than
in other groups [7]. In studies on pilonidal disease
in south India, P. Rajasekharan etal. found that
most individuals were in the age category of
16–25years, with a male-to-female ratio of 2.98:1
[10]. After the age of 40, PSD is uncommon.
17.3 Location
The most typical location is the natal cleft (94%)
[10]. A study conducted by N. Sion-Vardy
reported some ectopic locations of the pilonidal
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
K. Gupta, Lasers in Proctology, https://doi.org/10.1007/978-981-19-5825-0_17
279
280
PSD
=×ב’‘’ ‘’
2
17 Role ofLasers inPilonidal Sinus
sinus, including the penis, abdomen, scalp, groin,
axilla, and neck [11]. Another location is interdigital, seen in the hands of the barbers as an
occupational hazard [12].
17.4 Risk Factors ofPilonidal
Sinus
According to Hralak et al., pilonidal sinus disease is the second most prevalent condition
among soldiers [13]. It affects white males more
than any other in the young age group [13].
Although there is not much information in the literature to analyze the risk factors, the following
are some of the most prevalent ones [13]:
• Obesity
• Sedentary lifestyles
• Hirsute
• Male gender
• Occupations requiring prolonged sitting like
long-distance drivers
• Deep natal cleft
• Local trauma
• Poor personal hygiene
• Excessive sweating
17.5 Etiology
Many surgeons and clinicians considered pilonidal disease congenital in origin [2]. Harlak etal.
found a family history of pilonidal disease in
roughly 15% of patients [13]. Patey etal. hypothesized in 1946 that pilonidal disease resulted
from the hair sucked from the adjacent soft tissue, causing an inammatory reaction. Hence it
was considered an acquired disease [14].
There are three main theories to support the
acquired origin of pilonidal disease.
17.5.1 Bascom Theory
In 1980, Bascom provided histological evidence
with a series of stages in the disease progression
to support the acquired theory. The skin of the
natal cleft is stretched and lifted away from the
sacrococcygeal fascia while sitting or bending
during physical activity. A negative pressure is
created, and a suction effect is produced due to
gluteal movements that draw hair into the cavity,
causing folliculitis and a small subdermal abscess.
This small subdermal abscess grows over time,
eventually becoming a large abscess cavity [14].
17.5.2 Karydakis Theory
Karydakis described three main factors for the
formation of pilonidal disease
• The invader, loose hair “H.” “H” represents
the number of hair, kind of hair (whether
tough or silky), and shape.
• A force resulting in hair penetration “F”—
depends upon the depth and shape of the natal
cleft.
• Skin vulnerability “V”—depends upon
whether the skin is soft, macerated, excoriated, or has wide pores.
When hair is implanted in the natal cleft, it
bores deeper and deeper into the subcutaneous
tissue like a screw motion effect. The hair always
inserts on its root end, and hence, only loose hair
can get inserted. The hair’s keratin akes allow
the hair follicle to move unidirectional [1, 15]. As
a result, the hair burrows deep in the pit. The
sinus tracts may spread laterally, forming secondary openings with unhealthy granulation tissue.
Based on ndings, a formula was designed for
pilonidal sinus disease
If all the above three factors are present, pilo-
nidal sinus develops [15]. Loose hair has scales
on it. When the hair falls, the friction causes the
hair to enter the depth of the natal cleft in the center. Insertion of one hair allows other hair to enter
the natal cleft. The point of entry of the hair is the
primary sinus, and the point of exit is the secondary sinus [1, 15]. Karydakis suggests that if only
new hair entry could be stopped, many pilonidal
sinuses could be self-cured [15]. According to
Karydakis, folliculitis, although common, does
not lead to pilonidal sinus [15].
HFV
17.9 Clinical Presentation oftheDisease
281
17.5.3 Stelzner Theory
Stelzner advocated the pilonidal sinus as a retention dermopathy of an acquired origin, suggesting that the folds of the deep skin, body hair
stiffness, and the rolling action push hair like a
pin into the skin. When hair is rubbed, it moves in
the direction of its root, with the hair scales pointing outwards toward the surface [16].
17.6 Pathophysiology
Activities like sitting and bending cause the
breaking of hair follicles and the formation of
pits. The buttock friction and the shearing forces
allow the hair in the natal cleft to enter the pits by
suction effect. These pits may get lled with
debris, followed by a tract or sinus formation.
The mechanical forces generated during sitting
and bending result in the penetration of hair
deeper into the tissue [1]. This leads to the formation of an acute pilonidal abscess.
Follicular occlusion tetrad is a complex
involving; acne conglobata, dissecting cellulitis
of the scalp, hidradenitis suppurativa, and pilonidal sinus. All these conditions have the same
pathophysiology [17]. Because of follicular
occlusion, several authors consider pilonidal disease part of “follicular occlusion tetrad” [17].
Stelzner et al. (1984) observed a hook-shaped
hair follicle in the pits and hypothesized that hair
migration was unidirectional [17]. Studies further supported the hook morphology by Dahl
etal., who also proposed that sharp ends of the
hair contributed to piercing of the skin [18].
In their study “hair in the sinus,” Friederike
etal. identied short hairpieces with the rootless
sharp cut ends inside pilonidal sinus canals. The
fragments were morphologically like the free
short hair instead of intact hair. Short head hair
penetrates the pilonidal canal more readily than
long hair [19]. Davage, in 1954, observed that the
hair found in the pilonidal cavity originated from
the neighboring overlying tissue, and there were
no follicles within the cyst’s wall [20].
17.7 Histopathology
On histopathology examination, the pilonidal
cyst wall comprises of vascular pyogenic granulation tissue [20]. Stratied squamous epithelium
lines the sinus tract [2]. There are anaerobic and
aerobic bacteria in an infected pilonidal sinus,
making it polymicrobial [21].
17.8 The Direction oftheSinus
Tract
In most cases, the pilonidal sinus tract is cephalad and rarely caudal, corresponding to the direction of hair follicle growth. The presence of sinus
toward the caudal direction is often mistaken as
stula-in-ano.
17.9 Clinical Presentation
oftheDisease
A complete clinical evaluation should be done. It
includes:
• A detailed history
• Physical examination
17.9.1 History
The patients are usually young, with jobs requiring prolonged sitting. The commonest symptoms
are:
• Painful or painless swelling at the base of the
tail bone
• Pus or blood-stained discharge from the
cavity
• Redness of the skin around the area
• Intermittent swelling and spontaneous drain-
age with a foul-smelling discharge
• Formation of one or more holes lateral to the
midline or in the midline
• Hair protruding from the lesion
282
ab
cd
17 Role ofLasers inPilonidal Sinus
17.9.2 Physical Examination
• Single or multiple pits with hair (Fig.17.1d–f).
• Abscesses associated with the pits.
Physical examination may reveal
• Painful swelling posterior to the anal orice in
the sacrococcygeal region (Fig.17.1a) [20].
• Single or multiple openings near the coccyx or
off the midline (Fig.17.1b, c).
• A long sinus tract.
There may be warmth, redness, and tenderness if the pilonidal abscess is present. On palpation, there may be uctuant swelling in the
midline or lateral to the midline at the intergluteal
ef
Fig. 17.1 (a) Swelling posterior to the anal orice in the sacrococcygeal region. (b) Single opening near the coccyx.
(c) Multiple openings near the coccyx or off the midline. (d) Single pit. (e) Multiple pits. (f) Pits with protruding hair
Navicular area
ip of the coccyx
17.10 Navicular Area
283
cleft. In some cases, loose hair can protrude from
the sinus (Fig. 17.1f). A stula-in-ano must be
ruled out if the sinus tract is going caudally.
17.10 Navicular Area
The navicular area lies between the natal cleft’s
lateral edges and their posterior extensions [22]
(Fig.17.2). The posterior border of the anal tri-
Fig. 17.2 Navicular
area
Lateral edge
Anal triangle
angle marks the posterior border of the navicular
cleft. The patient is placed in a jackknife position
to mark the navicular area. The buttocks are
drawn together, and the outer contact lines mark
the natal cleft’s lateral edges. Before releasing
the buttocks, the edges are marked with a pen.
This reveals a ship-like shaped area referred to as
a navicular area [22].
Pits
T
Ischial tuberosity
Anus