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328 The ASCRS Manual of Colon and Rectal Surgery
Gluteal cleft
Midline pits
Anus
Fig. 15.2. Shaving technique.
Two-inch area shaved
around gluteal cleft
(proximity of pits to
anus may limit this)
• Simply cover the wound with a dressing and have the patient
do sitz baths or use a hand-held shower 2–3 times a day.
• The patient should return to the offi ce every week or two until
the wound heals. Any hair that has grown back within 2 in. of
the entire gluteal cleft is shaved at each visit (Fig. 15.2 ).
Initial Presentation: Draining Pilonidal
Chronic Abscess
• Pilonidal disease has been treated in many different ways, but
no treatment has proved completely satisfactory.
Nonsurgical Approach
Shaving
• For the initial treatment of chronic disease (which can be a
chronic sinus that has never been treated or any persistent
disease that has failed to heal despite treatment), shaving alone
has been advocated as the sole alternative treatment for
pilonidal disease.
• Physicians should consider shaving as the initial therapy in all
patients without an acute or chronic abscess and localized
disease. However, no one knows how long one should continue
shaving in order to prevent recurrence. Currently, we recommend
shaving until complete healing has occurred.
15. Pilonidal Disease and Hidradenitis Suppurativa 329
Surgical Approaches
Midline Excision
• The most frequently performed operation for pilonidal disease is
midline excision, with or without primary closure of the wound,
because most chronic or recurrent disease presents while
localized to the midline. In this procedure, only the clearly
abnormal tissue in the midline is excised. It is not necessary to
always excise down to presacral fascia.
• No clear benefi t exists for the use of primary closure after midline
excision. Proponents of primary closure cite the accelerated
healing rate in patients in whom this approach is successful.
However, this comes with the price of a signifi cantly increased
chance of more wound infections.
Unroofi ng and Secondary Healing
• Midline excision without primary closure leaves a large wound,
which is associated with long healing times. If wound closure is
not indicated (i.e., with an associated abscess), a smaller wound
with much shorter healing times can be achieved with unroofi ng
or laying open of the pilonidal sinus (Fig. 15.3a ). Open wounds
require dressing changes and wound care, but unroofi ng is
associated with half the healing time of wide and deep excision.
The recurrence rate is less than 13% with this technique.
Bascom’s Chronic Abscess Curettage
and Midline Pit Excision (Bascom I)
• Bascom bases this procedure on the premise that efforts to help
patients with pilonidal disease should be directed at changing
the gluteal cleft conditions rather than excising a large amount
of normal tissue associated with the diseased areas. In patients
who present initially with a chronic abscess, this procedure has
given excellent results (Fig. 15.3b ).
– He does this by making a generous, vertically oriented
incision through the site of the abscess cavity more than
1 cm off the midline (in some cases more than one chronic
abscess is present) and then curetting it out, without
excising the fi brous abscess wall.
– The connecting tracts to the midline pits are also identifi ed
and the overlying skin undermined so that they drain to
the site of the incision.
330 The ASCRS Manual of Colon and Rectal Surgery
a
Incision (to be
left open)
Gluteal cleft
Undermined area
communicating with pits
Chronic
abscess/
pilonidal sinus
Midline pits (excised)
Anus
b
Open
incision
site
Fig. 15.3. ( a ) Bascom procedure. Lateral incision and debridement of cavity.
( b ) Bascom procedure. Removal of a midline pits with small incisions after lateral
debridement, and closure of midline wounds without closure of the lateral incision.
Gluteal cleft
Closed midline pits
(interrupted 4-0 Prolene)
Anus
– The midline pits are then excised using a small diamond-
shaped incision to circumferentially remove each of them.
According to Bascom, the excised pit should be about the
size of a grain of rice.
15. Pilonidal Disease and Hidradenitis Suppurativa 331
– The undermined fl ap of skin, between the incision and
drainage site and the excised midline pits, is then tacked
down, and the pit excision sites are closed with either
subcuticular or vertical mattress, nonabsorbable suture
(4-0 or 3-0)
– Once this has been accomplished, meticulous shaving
of the gluteal cleft should continue at least once a week
until the wound has healed. Shaving can be done in the
physician’s offi ce, or at home by a family member or
friend who has been given the proper instruction.
• To date, no trials compare Bascom’s procedure with another
approach to chronic abscess.
Treatment: Recurrent Disease and Severe Disease
• Controversy exists over how to treat and follow patients who
heal, but continue to present with multiple recurrent disease
despite attempts at limited surgery and the other conservative
measures discussed above.
• In addition to midline excision, the surgical options often
used today, after initial shaving and hygiene methods have
failed, include rhomboid fl aps, Z-plasty, the Karydakis
procedure, Bascom’s cleft lift procedure, V-Y plasty, gluteus
maximus myocutaneous fl aps, and skin grafting (Table 15.1 ).
• The major disadvantages with fl aps are longer operative times,
greater blood loss, potential fl ap loss, and infection. However,
these fl aps do offer a quicker time to healing than midline
excision, with no increase in infection rate.
Table 15. 1. Complex pilonidal procedure results.
Procedure
Rhomboid fl ap 100 13.5 4.9
Karydakis – 8.5 1
Bascom cleft lift 100 – 0
V-Y plasty 100 8 0
Z-plasty 100 – 0
Myocutaneous fl ap 100 100 0
Skin graft 96.6 – 1.7
% Healing
(mean)
% Complications
(mean)
% Recurrence
(mean)
332 The ASCRS Manual of Colon and Rectal Surgery
Rhomboid Flap
• The rhomboid, or Limberg fl ap, is a cutaneous rotational fl ap
used to fi ll soft tissue defects and is ideally suited for this
purpose with regard to pilonidal disease (Fig. 15.4a –d).
• Despite the overall good results with use of the rhomboid fl ap
for recalcitrant pilonidal disease, this technique necessitates
excision of a large amount of normal tissue and subsequently
a
b
Fig. 15.4. Rhomboid fl ap technique for recurrent pilonidal disease. ( a ) Initial
excision of the sinus cavity. Counter incisions are created as shown. ( b ) Flaps are
raised and maneuvered as shown to close defect. ( c ) Final surgical result. ( d ) Result
at 1 month postoperatively.
15. Pilonidal Disease and Hidradenitis Suppurativa 333
c
d
Fig. 15.4. (continued)
creates a large scar at the fl ap site (Figure 15.4d ). Also, many
patients with chronic abscesses have their abscesses located so
lateral and cephalad to the midline area containing the pits, that
it makes the use of this technique more morbid because of the
size of the fl ap required to cover the excised area.
• With disease localized more or less to the midline, however,
any abscess cavities and all the pits are easily excised. In addition,
this technique works particularly well for fl ap coverage of
chronic wounds (as a result of midline excisions) in the gluteal
cleft that have failed to heal over a prolonged period of time.
334 The ASCRS Manual of Colon and Rectal Surgery
Karydakis Flap
• The two goals of this procedure are (1) to eccentrically excise
“vulnerable” tissue in the midline, or laterally displace it; and
(2) to laterally displace the surgical wound out of the midline
gluteal cleft.
• The large numbers of patients that have received this operation
along with the good reported results make this an attractive
option to consider. However, no one else has ever studied this
or reported their results, nor are there any comparative trials.
Bascom Cleft Lift (Bascom II)
• The key difference between the cleft lift procedure and other
fl ap-based procedures is that the cleft lift procedure excises no
normal subcutaneous tissue.
a
Subcutaneous
tissue
b
Suture line
Tissue
excised from
left side
Skin to be
excised
Gluteal
cleft
Sacrum
Midline
Flap
Gluteal fat approximated
at midline
Sacrum
Fig. 15.5. ( a ) Cleft-lift technique as described by Bascom for nonhealing
midline wounds. ( b ) Final result after fl aps are raised and underlying gluteal fat
is approximated.
15. Pilonidal Disease and Hidradenitis Suppurativa 335
• The goal of the cleft lift procedure is to undermine and
completely obliterate the gluteal cleft in the diseased area.
• This procedure detaches the skin of the gluteal cleft from the
underlying subcutaneous tissue as a fl ap. A portion of this fl ap
containing the diseased skin is then excised from the side of
the buttocks to which the fl ap will be sutured (Fig. 15.5a , b).
• The median follow-up was 20 months (range, 1 month to 15
years) and all patients remained healed. This procedure has
enjoyed spectacular results in Dr. Bascom’s hands, but it awaits
duplication elsewhere.
V-Y Plasty
• It may have applicability in some situations in which other
fl aps have failed, such as the rhomboid fl ap.
Z-plasty
• Surgeons experienced with this technique recommend that an
asymmetric closure, such as the Karydakis, be considered
initially before using the rotational fl ap procedures, because
these may be unnecessarily complex.
Myocutaneous Flaps
• Larger areas of disease with large, deep wounds may require
myocutaneous fl aps.
• Most surgeons reserve this technique for the most severe cases,
usually after failure of simpler techniques.
Skin Grafting
• No study looking at skin grafting for pilonidal disease has been
published since 1983 when Guyuron et al. published their retrospective study of 58 patients so treated.
• The authors recommended use of this method for recurrent or
extensive pilonidal disease.
Summary
• The algorithm in Fig. 15.6 delineates an approach to pilonidal
disease based on the evidence presented in this section.
• Conservative treatment ought to form the cornerstone of
therapy – specifi cally, wide, meticulous shaving and hygiene.
336 The ASCRS Manual of Colon and Rectal Surgery
First presentation with
pilonidal disease – no abscess
Two-inch strip shave
Two-inch strip shave–
weekly
Resolution
Two-inch strip shave–
weekly
Resolution
Severe disease –
large surface area
Consider myocutaneous flap,
cleft-lift procedure, or excision
and skin grafting
First abscess
Incision and drainage
Healed wounds with
midline pits and sinuses
Recurrent abscess or
persistent disease
Midline excision
Multiply recurrent
disease
Bascom procedure or
flap/asymmetric closure
Fig. 15.6. Pilonidal disease algorithm.
The best evidence available suggests that shaving should be
done until healing is complete, either in patients treated
primarily this way, or those treated with surgery. When patients
present initially with simple midline pits, sinuses, and various
symptoms, such as pain and occasional drainage, but no acute
abscess, shaving can again be offered as the initial treatment.
• A patient who presents with an acute pilonidal abscess should
have incision and drainage, ideally making the incision lateral
to the midline whenever possible. At the same time, one should
do a 2-in. strip shave circumferentially around the affected area.
• The majority of patients do not recur after conservative
treatment consisting of incision and drainage and shaving.
For these reasons, we do not recommend continued shaving
once healing is complete.
• Patients who present with multiply recurrent pilonidal disease,
meaning disease occurring sometime after healing of prior
episodes (i.e., abscesses, new pits) are more challenging.
– In this case, we prefer to move on to the Bascom chronic
abscess curettage and midline pit excision, or a cutaneous
15. Pilonidal Disease and Hidradenitis Suppurativa 337
fl ap procedure. For the initial management of the chronic
abscess, virtually all cases can be done as an outpatient in
the operating room under local anesthesia with conscious
sedation.
• Neither antibiotics nor drains have been shown to be helpful on a
routine basis. However, when taking on complex fl ap procedures
or skin grafts, antibiotics may be used perioperatively based on
evidence from other arenas of surgery proving their benefi t.
• The evidence presented here also shows that more complications
and recurrences occur with midline excision and primary closure
than with open excision alone. However, time to healing is
greater with open excision.
• Despite the good results reported with the fl aps and asymmetric
closures for pilonidal disease, midline excision or unroofi ng
does seem to work most of the time, and has the advantage of
simplicity.
• Cutaneous rotational fl aps and asymmetric closures may best
be reserved for the patient with a laterally located chronic
abscess, multiply recurrent disease, a large area of involvement,
or a nonhealing wound.
• If the patient presents with a draining sinus, alternately known
as a chronic abscess, the surgeon fi rst needs to note the location
of the sinus relative to the midline. In the case in which all the
disease, sinuses, and pits are located near and in the midline,
then a conservative midline excision is a reasonable fi rst-line
treatment. A Bascom procedure for a chronic abscess/sinus is
also reasonable.
• Many times, however, multiple draining sinuses exist and can
be located far enough away from the midline that a simple
midline excision becomes impractical because of the larger
wound created. In this case, we typically make a choice between
a Bascom I and a rhomboid fl ap.
• As always, shaving should continue with the proper vigilance
until healing is complete.
• For a small, chronic nonhealing wound from a prior operation
for pilonidal disease, a rotational flap is ideal. We prefer
the rhomboid fl ap for this purpose. For extensive recurrence in
the midline with abscesses and multiple nonhealing wounds,
the Bascom II procedure has shown great promise.
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