Our Primary Closure Operative Technique for Pilonidal Sinus - A Recurrence-Free Procedure

Introduction

Pilonidal sinus (PNS) is an abnormal blind end tract in the upper part of the natal cleft. It opens with a small hole in the skin. It contains hair, debris, and also pus if infected. It is also found in other areas of the body such as the umbilicus and hands and feet. In the natal cleft, it typically runs along the midline between its opening and the anus but may occasionally branch out.

The word ‘pilonidal’ is derived from two Latin words ‘pilus’ means ‘hair’ and ‘nidus’ means ‘nest’. It looks like a ‘nest of hair’¹ that’s why called pilonidal. Pilonidal sinus disease was described by Herbert Mayo for the first time in 1833.^2,3 R.M. Hodges coined the term ‘pilonidal’ in 1880.⁴ The father of ancient Indian surgery, Sushruta, had described that hair can be a root cause for the formation of a sinus.⁵ He also described the methods of management including Agnikarma and Ksharasutra.⁶

Pilonidal sinus is common among young hairy males. It is common among people who sit for long periods, such as taxi drivers. Jeep drivers in World War II used to travel in bumpy terrain for hours or even days in the worst health conditions used to have PNS, which is why it is also called “Jeep driver’s disease”.

The treatment for PNS is only through surgery. The surgery can be done either by open or closed technique. In the open technique, wound is not closed after excision of the PNS tract and is left to heal on its own by secondary healing which takes weeks or even months. In the closed technique, the wound is closed in various layers and the recovery period is much shorter than the open method with less pain and discomfort. Recurrence is more common with closed technique which is why most of the surgeons like open technique over closed technique.

The aim of the current study was to reduce the likelihood of postoperative recurrence, length of hospital stay, and healing time after surgery. Our study also indicates that if the primary closure technique is performed meticulously taking care of all factors responsible for recurrence, which it can reduce the recurrence rate considerably.

Materials And Methods

Patients of pilonidal sinus, acute and chronic, were admitted to various hospitals in Gurgaon, Haryana between January 2001 to December 2022. A total of 180 patients were operated on by our primary closure technique. Cases of pilonidal cysts and acute pilonidal abscesses were not included in this study; one can take it as a limitation factor. The patients of various age groups were included in this study, advanced age was not a contraindication for surgery. Each patient was recorded for age, sex, body weight, body mass index (BMI), duration of disease, and comorbidities such as hypertension, heart disease, diabetes mellitus, obesity, thyroid problem, and lifestyle. History of previous surgeries and the type of surgery (closed or open) was also recorded. Routinely the pus or discharge swab from PNS opening was taken and tested for antibiotic sensitivity. Appropriate antibiotics were initiated from the morning of the surgery and continued for 3 days. All patients underwent a routine magnetic resonance imaging (MRI) sonogram. Informed consent was obtained from all patients. The follow-up of all patients was done from 3 months to 5 years.

Operative technique

Preoperative preparation: Shaving of the local area was done including the surrounding area of about 20-25 cm.

Posture: Patients were positioned in the prone position, and adhesive stretchable tape was applied around the buttocks, securing them apart on the operating table

Anaesthesia: General or spinal anaesthesia was used. Surgery under local anaesthesia was avoided to avoid higher recurrence rate though it reduces the post-operative pain in 48 hours after surgery.⁷

Steps

• The position of sinus opening, and shaved area were checked.
• A malleable probe was taken and the tip of the probe was introduced in the sinus opening without pressure and not inserted more than 1 cm to avoid the chances of making a false passage.
• Then, 5 ml of undiluted methylene blue dye was taken in a 10 ml syringe. The nozzle of the syringe was directly put in the sinus opening and pressed against the skin with the syringe and then the dye was slowly pushed till it went easily, smoothly without resistance but if resistance was met, it was not pushed with pressure. After waiting for 30 seconds, the dye was pushed again.

1. Incision: An encircling elliptical incision was made around the sinus opening which was carried towards the midline and the two parts of the incision met in the midline. After this, the incision was deepened to try and go beyond the blue-colored tissues.
2. All visible blue tissue was excised. If any blue tissue remained attached, it was removed using a curette. The margins of the wound were then trimmed first with a knife and subsequently with scissors.
3. Meticulous haemostasis was achieved by catching and cauterizing bleeders with small, curved spencer walls artery forceps, or pointed thumb tissue forceps. Proper haemostasis is also one of the fundamentals to avoid recurrence.
4. The wound edges were undermined on both sides in full thickness of the wound. This was done with the help of a knife for 1 to 1.5 cm.
5. A No. 10 or 12 Radivac suction drain was introduced from one side of the incision. The drain was positioned in the lower part of the wound to facilitate drainage by gravity.
6. The wound was then cleaned with a 50:50 mixture of pP ovidone-iodine and hydrogen peroxide.
7. Tension sutures were applied as the deepest first layer of sutures with 1/0 Prolene; 3 or 4 tension sutures were applied. These sutures had to include the full thickness of the wound from the undermined area.
8. The second layer of sutures was applied as interrupted buried mattress sutures with 2/0 Vicryl to close the dead space.
9. The skin was closed using interrupted mattress sutures with 4/0 Prolene. It was ensured that Tthe distance between the sutures did not exceed 0.5 cm to prevent inversion or eversion of the skin. Care should bewas taken to avoid inverting the skin.
10. The drain was fixed with skin with 2/0 silk suture.

Dressing:

Povidone-iodine soaked 3 dressing gauze pieces were placed over the suture line. Over it, a few more, dry dressing gauze pieces were kept, and tension sutures were tied over these gauze pieces in simple knots so that they can be opened at the time of dressing and again tied in the same way. Over the tension sutures, one Gamjee was placed and adhesive tape was applied.

The patient was asked to lie down on the dressing in the supine position.

Skin sutures were usually removed on 8^th or 10^th postoperative day and tension sutures on the 14^th day.

Results:

This study included 180 (100%) patients with pilonidal sinus disease, out of which 164 (91.1%) were male and 16 (8.9%) were female. The age of patients varied from 15 to 62 years. The body mass index was recorded, as follows: the normal BMI (118,65.6%), overweight (50,27.7%) and obese (12,6.7%). Various demographic features of all patients were recorded routinely (Table 1,2,3)

Table 1: Demographic data as per gender

Table 2: Demographic data as per age

Table 3: Demographic data as per weight

The weight of the patients varied from 40 kg to 118 kg. The height of the patients in this study varied from 5’0” to 5’8”. The maximum number of patients as per their BMI belongsed to the normal BMI (18.5 to 25). Shaving of the surgery site was done in the surgery theater before the surgery. All patients were instructed to use epilation cream over the surgery and peri-surgery area after the removal of sutures, for 3 months.

No patient developed a recurrence of PNS after our method of primary closure after total excision of the PNS tract. No patient was re-operated for any significant complication after surgery (Table 4).

Table 4: Post-operative complications after primary closure

One patient had partial gaping of the wound (skin and superficial subcutaneous tissues) after the removal of sutures post operatively. This wound healed gradually with repeated local dressings with 10% povidone-iodine solution-soaked gauze after cleaning with a mixture of hydrogen peroxide and 10% solution of povidone iodine. This did not require secondary suturing. This patient had to travel a lot for his job and probably this was the reason for his gaping wound.

Wound infection developed in 12 patients (6.7%). These patients were treated with appropriate antibiotics after culture and sensitivity test of discharge and local dressings with 10% povidone iodine solution-soaked gauze. All patients were discharged the next day of the surgery except 3 patients who were discharged after 2 days.

All patients were asked about their experience of surgery, stay in hospital and other facilities. Most of the patients (98.3%, 177) were highly satisfied with the surgical procedure and did not experience much pain & discomfort. Three patients (1.7%) were satisfied, but not totally pain-free. (Table 5) No patient complained of severe pain, few felt mild discomfort at the surgery site.

Table 5: Patient feedback on satisfaction

In our series of 180 patients, we operated on 12 patients after recurrence of PNS after previous surgery. Most of the patients (5%) were operated by open technique by excision of PNS and secondary healing elsewhere. One patient (0.55%) was operated on by excision of PNS & Z-plasty. Two patients (1.1%) were operated on by Karydakis flap technique (Table 6).

Table 6: Patients of recurrent pilonidal sinus operated by our primary closure technique

Patients with sedentary jobs were allowed to return to their duties on the 5^th postoperative day and could resume their normal daily activities and travel starting on the 11^th day. One of the main advantages of our procedure is that the patients can sleep on their back in a supine position and can also sleep in any preferred position in bed. The drain was removed on the 3rd day after the surgery. Few cases required delayed removal of the drain following the dictum “drain till it drains”. The drain was removed after one week in 16 cases (8.9%) and after 10 days in 2 cases (1.1%). It was observed that the patients with delayed removal of the drain were on blood thinners such as aspirin or/and clopidogrel due to coronary artery disease.

Discussion

The actual cause of PNS is not known. Earlier it was thought that PNS is a congenital disease. The congenital theory of PNS is now rejected due to these facts: Hairs in pilonidal sinus are dead hairs lying loose with pointed and sharp ends towards the blind end of the sinus, PNS usually occurs between 20 and 29 years of age (82%) and not since birth.^8,9

The incidence of pilonidal sinus is approximately 26 cases per 1,00,000 people. It occurs 1.2 times more often in men than in women. The age at presentation is 21 years for men and 19 years for women. It is more common in men due to their hairy body.

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In aetiopathogenesis of PNS disease, it is commonly accepted that non-living hair provokes a foreign body reaction subcutaneously, leading to an abscess and sinus formation.¹⁰ Pilonidal sinus also has a hormonal etiology view as it occurs in young adults (after puberty) and at the same time, hormonal secretion and growth of hairs are also initiated, thus, pointing towards hormonal cause. Pilonidal sinus is caused by friction of skin with a hard surface in hairy persons leading to burying of hair under the skin and formation of pits^11,12 which grow to form a sinus. In hairy young men, plenty of hair is broken down from their roots daily due to friction with clothes and this is more so when driving vehicles for hours at a stretch. The broken hairs are sucked in the furrow over the back, in the midline and settle between the buttocks down to the natal cleft due to gravity and get entrapped here. This entrapment is tighter in obese persons.

Pilonidal sinus is common in persons having the following risk factors: Driver’s job, obesity, hairy young men with deep gluteal cleft and family history of PNS.¹³

Numerous methods have been described as surgical treatment alternatives for sacrococcygeal PNS, including primary oblique excision and closure, marsupialization, secondary healing, V-Y flap, Z-Plasty, Limberg flap, and Karydak flap techniques.14,15 Pilonidal sinus is known to recur after surgery. In search of a method with no or low recurrence, various methods of PNS have evolved. The open method though troublesome for patients but still in use due to the belief that the recurrence rate is less than the closed method. Most closed methods are aimed to reduce the recurrence rate and healing time than open methods. Karykadis noted that healing of the surgical wound in the depth of the natal cleft was poor and is the main cause of recurrence.¹⁶ Karydakis technique’s two goals were to eccentrically excise vulnerable tissue in the midline and to laterally displace the surgical wound out of midline gluteal cleft. His study in 1992 showed very good results and it became an excellent surgery for PNS.¹⁷

The flap technique was described by Karydakis in 1973, and recurrence rates were reported, <1%.¹⁸

The causes of recurrence of PNS after surgery are: leaving a part of PNS tract during surgery, infection of wound, abscess formation at the surgery site, tension on suture line, dead space creation during surgery, lack of depilation around the surgery site, and no good hemostasis during surgery. Prolonged sitting job, obesity, and driving more than 4-6 hours with less number of baths per week are considered risk factors for PNS.¹⁹

In our view, if the tension on the midline suture line is removed, the skin closure is meticulous by avoiding inversion of any part of the incision, and flap-making is avoided, then any type of wound will heal. A simple technique with meticulous dissection and repair will help, and this challenging surgical problem can be corrected successfully even at a small hospital. This procedure has an added advantage of not leaving a shallower natal cleft. The natal cleft becomes normal, so patients don’t experience any abnormal or distorted anatomy.

Our method taught us that every step should be done meticulously and not in a hurry, then only you can achieve good results. We have operated upon both, primary cases and post recurrence. Even the few cases which were operated 2-3 times prior to our method, we achieved healing without recurrence. All patients were admitted to the hospital for 24 hours (1 day) except 3 patients who were extra sensitive to pain and were kept for 1 more day (total of 2 days). Karydakis reported a hospital length of stay of 3 days²⁰, Guner et al.²¹ and Al-Jaberi²², reported a hospital length of stay of 4 days.

Keshava et al. reported that the main treatment goal of the sacrococcygeal PNS disease is the selection of the most appropriate technique that causes the least number of early postoperative complications, shortens the length of hospital stay and results in the least number of long-term recurrences.²³ We feel that our technique meets all these requirements.

In our series, we did not select patients based on BMI and infection at the site of the sinus. We included all patients with obesity, chronic infection, and recurrence too. We feel the success mantra lies in the meticulous procedure and doing every step sincerely.

Pain, wound infection, and seroma formation were the main problems encountered by various surgeons doing the Karydakis procedure. Wound infection ranged from 0 to 10.7% in the various studies using Karydakis technique²⁴. In our series the incidence of wound infection was very low (7.14%), gaping of the suture line after suture removal the was seen in one patient (0.59%). Rate of recurrence was reported less than 1% by Karydakis but in our series, no recurrence has been observed so far during 5 years of follow-up.

Acknowledgments

We thank Dr. Charvi Chawla for her efforts for conducting literature search and other information required for this research work. We are also thankful to Mr. Vipin Sharma for the preparation of the manuscript.

Declaration of patient consent

Informed consent was taken from patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Conclusion

The incidence of PNS is not uncommon. It is not a life threatening disease, but it causes pain and discomfort and affects the quality of life mandating only surgical treatment. Recurrence of PNS after surgery is the main complication of both, the open and closed methods of surgery. Recurrence is more with the closed method of surgery than the open method. Our method of surgery for PNS is a primary closure method dealing with every factor responsible for recurrence after surgery such as dead space, tension on the suture line, deep natal cleft, hematoma formation, infection, abscess formation, and obesity.