The document discusses the management and surgical options for pilonidal sinus (PNS), highlighting that asymptomatic cases do not require treatment while symptomatic cases may necessitate surgical interventions. Various surgical techniques such as open and primary closure have differing recurrence rates and complication risks, with eccentric closure preferred. The take-home message emphasizes the need for individualized surgical choices based on the characteristics of the PNS and the surgeon's familiarity with the techniques.

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