Pilonidal sinus

1. JOURNAL CLUB
Endoscopic Pilonidal
Sinus Treatment:
Long-Term Results of
a Prospective Series
Presented by: Dr. Vishnu S.
Guided by: Dr. Ramachandra J.,
Dr. Sreenidhi G. M.,
Dr. Bhaskar M.,
Dr. Kishan

2. Pilonidal Sinuses: Quick Overview
 Name derived from Latin pilus, hair; and nīdus, nest.
 Most commonly seen in young hirsute males, obese,
sedentary.
 Most common in intergluteal region behind anus.
 Consists of inflammatory sac with tufts of hair contained
within.

3. Risk Factors
 Age: 70% between 20-30 years
 Sex: males > females
 BMI: higher but not significant among obese
 (?) genetic predisposition
 Personal hygiene
 Race
 Body hair
 Deeper natal cleft
 Smoking

4. Historical Background
 Earliest known mention: Ebers Papyrus, ~1550 BC.
 Also mentioned in Sushruta Samhita (शल्यज नाडी व्रणः),
with treatment, viz., setoning (क्षारसूत्रः).
 Name coined by Hodges.
 Increasingly common during WW II, known as “jeep
bottom”.

5. Aetiology
 Congenital theories:
a. Neural crest remnants
b. Phylogenetic remnants of uropygial glands
c. Tail bud involution
d. Epithelial cell rests
 Acquired theories:
a. Bascom’s theory
b. Karydakis’ theory

6. Pathology
 Hallmark: midline pit with/without secondary pits
 Loose hair within sinus tracts
 Usually midline pit is originator, leading to
subcutaneous cavity
 Long-standing sinues have epithelialized tracts
 Majority run cephalad, rest run caudad

7. Clinical Features
Spectrum of conditions:
1. Asymptomatic disease
2. Acute pilonidal sinus
3. Chronic pilonidal sinus
4. Complex pilonidal disease
5. Extra-sacrococcygeal pilonidal disease

8. Staging Systems
 Tezel classification system
 Guner classification system
I. Asymptomatic pits
II. Acute pilonidal sinus
III.Pits within navicular
area with
abscess/drainage
IV. Extensive disease
V. Recurrent disease
I. Single pit in midline, no
lateral extension
II. More than one pit, no
lateral extension
III.Lateral extension in one
direction
IV. Lateral extensions in
bith directions
V. R: recurrent disease

9. Evaluation
 PSD is a clinical diagnosis.
 Superficial ultrasonography.
 Most sensitive is MRI, therefore best modality, however not
indicated unless suspicion of high fistula in ano.
 Intraoperatively, methylene blue dyes,

10. Nonoperative Management
 Phenol injection: 80% phenol injected into sinus for one minute,
multiple sessions
 Fibrin glue after simple curettage of tract
 Radiofrequency ablation

11. Operative Management: Bascom’s
Technique
• Lateral incision given lengthwise
along midline pits.
• Sinus tract entered through incision,
curetted.
• Midline pits connected to incision,
opening cored out.

12. Marsupialization
• Tract opened in midline, all
unhealthy tissue, debris, hair
removed,
• Fibrous tissue in floor preserved,
sutured to skin edge.
• Principle: prevent premature
closure, minimize recurrence.

13. Excision and Primary Closure
• Healing shortened by factor of four.
• Associated with increased
dehiscence and surgical site
infections.
• Improves patient comfort, ensures
flattening of midline, off-midline
scar.

14. Closure Techniques: VY Advancement
• Sinus tracts excised in elliptical
fashion.
• Skin flap elevated laterally in V-
shape, mobilized medially.
• Flap moved to close defect, lateral
end sutured as the limb of ‘Y’.

15. Closure Techniques: Karydakis’
Procedure
• Sinus tracts excised in elliptical
fashion.
• Carried out till presacral fascia.
• One side flap undermined.
• Closure when done flattens natal
cleft.

16. Closure Techniques: Limberg Flap
• Excision done so as to create rhomboid
defect of 60° internal angle.
• Transposition flap raised from adjacent
skin.

17. Closure Techniques: Dufourmentel Flap
• Excision done as rhomboid with acute
angle between 60° to 90°.
• Transposition flap raised from adjacent
skin.

18. Closure Techniques: Quaba Flap
• Excision done in circular fashion
• Transposition flap raised from
adjacent skin.

19. Closure Techniques: Webster Flap
 Rhomboid transposition flap for
rhomboids with acute angle between
30° and 60°.
 An M-plasty is added to prevent dog-
ear of the inferior vertex and enhance
flap mobility

20. Closure Techniques: Z-plasty
 Elliptical excision of the sinus tracts is
done and
 Double-transposition triangular flaps
are raised.
 Closed in a “Z” fashion

21. Closure Techniques: Mutaf Flap
 Sinus tracts excised in a triangular
fashion.
 Primary defect is closed with a
quadrangular transposition flap.
 Secondary defect closed with a
triangular transposition flap.

22. Bascom’s Cleft Closure
 Natural line of contact of the
buttock cheeks marked, sinus
tracts excised towards one side
in a triangular fashion.
 Skin flap dissected only up to
the dermis and raised to cover
the defect, so that resultant scar
is off-midline.

23. Endoscopic Pilonidal Sinus Treatment
(EPSiT)

24. Journal Article
• Journal article from: Journal of
Laparoscopic and Robotic Surgeons
• Type of study: prospective series
• Duration: October 2013 through
November 2015
• Sample size: 77 patients (69 males, 8
females)
• Site: Department of Surgery, Casa di
Cura Villa Tiberia, Rome, Italy (Drs.
Giarratano and Toscana). Department of
Surgery, University of Rome Tor
Vergata, Policlinico Tor Vergata, Rome,
Italy (Drs. Shalaby, Buonomo, Petrella,
Sileri).

25. Introduction
 Gold standard: PS excision with primary closure —mainly mid-line closure
or flap-based procedures with variable results with different healing times
and complications.
 In a recent meta-analysis, Enriquez-Navascues et al reported a wide range
of recurrence rates, from 0 to 40%, for different surgical approaches.
 Therefore, new minimally invasive techniques suggested in treatment of PS:
radiosurgery, fibrin glue injection, endoscopy.
 Endoscopy proposed by Meinero et al, who developed special fistuloscope
with the possibility of destroying the sinus cavity and sinus tracts under
direct vision through an operative channel, and by Milone et al, using
hysteroscope.
 However, data in the literature are scant, with short follow-ups.

26. Aim and Objectives of the Study
To analyze the long-term results of a video-assisted minimally
invasive technique viz., endoscopic pilonidal sinus treatment (EPSiT)
for the treatment of sacrococcygeal pilonidal disease.
• To record postoperative complications, wound infection rate,
recurrence rate, time until return to work, and patient satisfaction
score during follow-up or at the last interview.
• To obtain clinical data at 7, 15, and 30 days and at 6, 12, and 24
months after surgery.

27. Materials and Methods: Patient Selection
• From October 2013 through November 2015, 77 patients with
symptomatic chronic or recurrent PS were consecutively enrolled in
the study.
• Patients presenting with acute abscess received antibiotic therapy for
2 weeks before enrollment.
• All patients underwent a day surgery procedure under local anesthesia
and sedation while prone, with buttocks separated by two large
plasters.
• Single dose of antibiotic prophylaxis (cefodizime 1 g) administered
30 minutes before surgery.

28. Surgical Tools
 Performed with a fistuloscope
manufactured by Karl Storz
(Southbridge, Massachusetts, USA)
with 8° angle eyepiece, equipped with
an optical channel 14 cm long with
handle, operative channel, irrigation
channel connected to a 5000-mL bag
containing a solution of glycine +1%
mannitol.
 Other tools: electrode connected to the
electrosurgical knife power unit,
endobrush, tongs, and Volkmann spoon.

29. Surgical Technique
 Diagnostic step: fistuloscope introduced through external
opening, sinus cavity and fistula tract identified.
 Operative phase: electrode introduced, cavity and tract ablated.
 Granulation tissue destroyed and taken out with Volkmann spoon.
 Hairs removed through tongs inserted through operative channel.
 Patients advised to review in OPD at 1, 2, 4 weeks and routinely
6 monthly upto 24 months.
 Patients monitored for healing, persistence, recurrence, pain,
satisfaction.

30. Follow-up
 Patients encouraged to mobilize immediately, discharge within 3 hours.
 Advice: irrigate sinus with 5 mL saline twice daily through external
opening, keep surrounding area clean, dry, free of hair through epilatory
creams.
 Patients also required to assess pain through VAS, score above 7 represents
severe pain.
 Follow-up at 1, 2 and 4 weeks, at every 6 months until 24 months.
 Healing: complete wound healing with closure of external opening by first
60 postoperative days.
 Persistence: external wound plus secretions.
 Recurrence: 90 days after complete healing

31. Results
 77 patients with 69 males, 8 females; median age range of 23 years.
 No overnight stay/emergency room readmission required for any patients: all discharged
within 3 hours of procedure.
 Mean operating time: 20 minutes plus or minus 6 minutes.
 Mean hospital stay: 7 plus/minus 1 hours.
 At 1 week after surgery, 73 patients (94.8%) reported VAS between 1 and 3, and 4 (5.2%)
reported score between 4 and 6.
 Only 8% required analgesic in first post-op week.
 Mean time to return to work and daily activities was 6 ±3 (range, 2–14) days. Median
healing time was 26 (range, 15– 45) days.
 Overall healing rate: 92%, 8% failures (6 patients): 2 cases of persistence, 4 cases of
recurrence. Of these, 3 underwent successful EPSiT for recurrent disease.

32. Results

33. Discussion
 EPSiT: simple technique.
 Success rate >90%, similar to best reports of open technique, without
prolonged hospitalization, pain, prolonged interruptions of activities.
 Wound healing time much shorter compared to traditional techniques
(26 days vs. 60-90 days).
 Higher patient satisfaction: better aesthetic results due to small scar (5
mm), no sutures, no tension applied.
 Drawback of present study: findings vis-à-vis traditional techniques yet
to be validated in randomized controlled trials.

34. Other Studies (1)
Two hundred and fifty prospective patients
with chronic PD enrolled in a prospective
multicentre study conducted at a secondary and
tertiary colorectal surgery centre.
Primary end-point of study: wound healing,
short-/long-term outcomes such as healing time,
morbidity rate and recurrence rate.
Secondary end-point of this study was quality
of life (QoL).
Complete wound healing rate was 94.8%, and
the mean complete wound healing time was 26.7
10.4 days.

35. Other Studies (2)
27 patients operated on using
EPSiT and followed up in a single
tertiary centre study: time off work,
time to walking without pain, time to
sitting on the toilet without pain,
recurrence, and wound infections
analyzed.
All patients achieved complete
healing, only 1 patient developed
recurrence.

36. Analysis: Is it TRUE?
 Yes, the study is true, for it takes a representative sample size (77
patients).
 Other similar studies (Meneiro et al., 201; Milone et al., 2014)
show similar results and report similarly high levels of patient
satisfaction.

37. Analysis: Is it NEW?
 No, the study is not new, since similar studies have been carried
out earlier (Meneiro et al., 2016; Milone et al., 2014).

38. Analysis: Is it Important?
 Yes, the study is important, for the endoscopic pilonidal sinus
treatment (EPSiT) shows great promise in the areas of wound
healing, prevention of recurrence and cosmesis.

39. Analysis: Should We Change?
 Yes, we should change, for EPSiT may be performed as an
outpatient procedure, with quick recovery, high rates of healing,
low rates of recurrence, and cosmetic satisfaction.
 The learning curve is also not very steep.
 One concern is the cost of the procedure.

40. References
1. Sabiston Textbook of Surgery, 27th Edition
2. Bailey and Love’s Short Practice of Surgery
3. Biofilms, Pilonidal Cysts and Sinuses by Melvin A. Shiffman and
Mervin Low

41. THANK YOU