Which operation for pilonidal sinus? Open or closed? Midline or eccentric closure? An algorithm for the operative treatment of symptomatic pilonidal sinus disease is proposed. In addition to intra-operative photos of the operation of Rhomboid excision and Limberg flap.

1. PILONIDAL SINUS:
WHICH OPERATION?
DR. MOHAMAD AL-GAILANI FRCS
CONSULTANT SURGEON
HEAD OF DEPARTMENT OF SURGERY
AL HAMMADI HOSPITAL, NUZHA
RIYADH, KSA

2. PILONIDAL SINUS (PNS)
Pilonidal sinus is a blind tract between the skin and a hair nest
underneath it at the natal cleft
It is common in young age group, in males more than
females
Asymptomatic pilonidal sinus does not require treatment
More than one operation exists for symptomatic PNS
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 2

3. MANAGEMENT
Pilonidal abscess requires incision and drainage
Recurrent symptomatic PNS disease may be
considered for surgical treatment
The choice of procedure depends on the site,
complexity, being recurrent or not and the surgeon’s
experience
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 3

4. TO REMOVE HAIR OR NOT TO?
No evidence to support in asymptomatic cases for
prevention of complications
Following treatment of pilonidal abscess possible
benefit with hair epilation
Razor hair shaving may increase the risk of recurrence
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 4

5. PRIMARY CLOSURE VERSUS OPEN?
Primary closure is for faster healing & return to work
Open method is for less likelihood of recurrence
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 5

6. MIDLINE VERSUS OFF MIDLINE CLOSURE?
Eccentric or off midline closure has a reduced
complication rate, healing time and chance of
recurrence.
Midline simple closure has a higher risk of disruption,
infection and recurrence.
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 6

7. WHAT ARE THE SURGICAL OPTIONS?
Excise and leave open
Marsupialization
Midline simple closure
Karydakis
Rhomboid excision &
Limberg flap
Bascom
Z plasty
V-Y plasty
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 7

8. NEWER SURGICAL OPTIONS?
Laparoscopic video assisted ablation
Phenol ablation
Fibrin glue sealing
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 8

9. RECURRENCE RATE
Overall recurrence rate 5-10%
Closed method 8.7%
Open method 5.3%
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 9

10. SURGICAL SITE INFECTION (SSI)
& ANTIBIOTICS?
Risk Category of SSI: Contaminated Category
Overall surgical site infection rate ranges between 10-
25%
Treatment rather than Prophylaxis
Cephalosporin + Metronidazole for 5 days.
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 10

11. TO DRAIN OR NOT TO?
In primary closure:
Reduces fluid seroma/haematoma collection
No impact on wound infection
No impact on recurrence
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 11

12. PROPOSED PNS SURGERY DECISION
ALGORITHM
PILONIDAL
SINUS
> 4CM
MIDLINE
Z-PLASTY KARYDAKIS
OPENINGS
BASCOM
ECCENTRIC
RHOMBOID +
LIMBERG
< 4CM
OPEN
LENGTH
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 12

13. RHOMBOID EXCISION &
LIMBERG FLAP
• CASE OF A 21 YEAR OLD MALE WITH RECURRENT PILONIDAL SINUS (PNS) DISEASE FOR 3
YEARS
HOW I DO IT?
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 13

14. DR. AL-GAILANI FRCS
NOTE HAIR TUFT FROM CENTRAL PIT WITH AN ECCENTRIC
PNS
14

15. DR. AL-GAILANI FRCS
THE EXTRUDED HAIR FROM THE
PNS
15

16. DR. AL-GAILANI FRCS
ECCENTRIC PNS, LENGH 5 CM
16

17. DR. AL-GAILANI FRCS
PROBE THROUGH THE PNS & SKIN MARKINGS OF THE
PROPOSED RHOMBOID EXCISION AND LIMBERG FLAP
17

18. DR. AL-GAILANI FRCS
INITIAL INCISIONS RHOMBOID EXCISION & LIMBERG FLAP
18

19. DR. AL-GAILANI FRCS
THE EXCISED PNS WITHIN THE RHOMBOID EXCISION
TISSUE
19

20. DR. AL-GAILANI FRCS
THE OPEN WOUND FOLLOWING EXCISION OF PNS PRIOR TO CLOSURE
20

21. DR. AL-GAILANI FRCS
THE COMPLETED OPERATION. NOTE THE READIVAC DRAIN SIZE 10 ON THE
LEFT
21

22. POSTOPERATIVE CARE
Antibiotics for 5 days
Cleanse and re-dress every other day
Keep drain until < 20 ml/24 hours
Remove stitches after 2 weeks
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 22

23. PILONIDAL SINUS SURGICAL TREATMENT
TAKE HOME MESSAGE
 THE FACT THAT THERE IS MORE THAN ONE SURGICAL OPTION FOR
PNS TREATMENT INDICATES THAT NONE ARE PERFECT!
 For < 4 cm PNS, consider Open method
 Open method will need more time to heal, but has a lower recurrence
rate
 Eccentric closure is preferred over Midline
 Choose the appropriate surgical option you are most familial with!
PILONIDAL SINUS: WHICH OPERATION? DR. MOHAMAD AL-GAILANI FRCS 23

24. CONSULTANT BREAST & GENERAL SURGEON
HEAD DEPARTMENT OF SURGERY
IN-CHARGE MEDICAL EDUCATION & TRAINING
AL HAMMADI HOSPITAL, NUZHA
‫الحمادي‬ ‫مستشفى‬,‫النزهة‬
RIYADH, KSA
‫الرياض‬,‫السعودية‬ ‫العربية‬ ‫المملكة‬