RECONSTRUCTION MODALIT IES OF P ILONIDAL

S INUS DEFECTS

A H M ED A L MU MT I N ,

O B J E C T I V E S

• Statement of the problem

• General evaluation if the condition.

• Treatment options

• Some Reconstruction methods

• Take Home messages.

S TAT E M E N T OF T H E P R OBL E M

• Pilonidal disease is a potentially debilitating condition.

• Cause, optimal treatment, still controversial.

• Presentation

• Male:Female

• Age

• Aetiology

E V I D E N C E

E VA LU AT I O N O F T H E D I S E A S E

• History

• Physical examination

T R E AT M E N T / M A N AG E M E N T

• Non-Operative

• Operative

N ON - O P E RAT I V E M A N AG E M E N T

• Trial of gluteal cleft shaving

• Phenol injection and local depilatory cream application

• Fibrin glue

• Antibiotics

• Perioperative prophylaxis

• Postoperative treatment

• Topical use

N ON - O P E V I D E N C E BA S E D

Grade of Recommendation

Gluteal cleft shaving 1 CStrong recommendation based on low-quality evidence

Fibrin Glue 2 CWeak recommendation based on low-quality evidence

Phenol Injection 2 CWeak recommendation based on low-quality evidence

Antibiotics 1 C Strong recommendation based on low-quality evidence

O P E RAT I V E M A N AG E M E N T

• Acute pilonidal disease.

• Chronic pilonidal disease.

• Excise with primary closure.

• Excise, secondary intention.

M I N I M A L S U R G E RY W I T H T R E P H I N E S

• 1358 patients

• Trephines used to debride pits and sinusses and clear debris

• Recurrence at 1, 5 and 10 yrs 6.5, 13.2 and 16.2%

• Mean time to recurrence 2.7 years

Minimal surgery with trephines

VAC

• Alternative method.

• Shortened the length of hospital stay and the need for further surgery

F L A P BA S E D PR O C E D U R E S

• Limberg flap & dufourmental

• Karydakis flap

• Cleft-lift (Bascom)

• V-Y advancement and rotation

• Z-plasty

• Superior gluteal artery perforator flap

L I M BE R G F L A P

• 110 patients, 102 males, 8 females. average age 21, 7 of them recurrent disease and 3 had previous surgeries.

• 107 full healing, one case; epidermolysis and 2 cases, small gaping

• 7 months follow up; one recurrence outside the edge!

• mean length hospital stay 4 days, return to work within 3 weeks.

D U F O U R M E N T E L F L A P

• 310 patients 24 asymptomatic and 55 recurrent disease

• Surgery 40 minutes mean

• No flap necrosis

• Mean hospital stay 1 day (1- 11)

• Mean return to work 7 days (5- 30)

• Minimal pain (visual analogue scale)

• 10.6% wound complications, managed conservatively in all but 2 (0.6%) which was resutured

• Recurrence 7 (2.3%) of patients, all within 25 months. No further recurrence at 5, 10 and 16 yrs

D U F O U R M E N T E L F L A P

D U F O U R M E N T E L F L A P

KA RY DA K I S A N D BA S S C O M ’ S

• Technique for excision

• Karydakis excised up to the sacrum, modified by Bascom.

• Karydakis had less than 1% recurrence with this procedure

• Mean hospital stay is .76 days, Healing 11.1 days, Return to work in 17.7 day

•

– D R. G EOR G E KA RYDA K I S

Karydakis Flap

Z- P L A S T Y

• RCT 72 patients

• Mean follow up for both arms 22 months

• Hospital stay conventional treatment 1.76 (+/-0.75), Z- plasty 2.86 (+/- 0.73 days)

• Wound healing Conventional surgery 41days, Z- plasty 15.4 days

• Return to normal activity 17.5 days for conventional vs 11.9 days for Z- plasty

• One recurrence.

V-Y ADVAN CE ME N T / R O TAT I O N FL APS

• 43 patients

• 16.3% wound complications (managed conservatively), no breakdown

• Mean hospital stay 3 (2- 5) days

• Return to work in mean 17 (13- 25) days

• Recurrence in 1 patient 2.3%

• V-Y advancement

• V-Y Rotation

SU PE R I OR G LU T E AL ART E RY PE RF ORAT OR F L AP

• 15 males were involved.

• Can close defects of any size

• Short surgical time and minimal blood loss.

• Shorter hospital stay, time to mobilisation and return to daily activities

– S UP ER I OR G LUT EA L A RTERY P ER FORATOR F L A P

LU M B A R A D I P O FA S C I A L T U R NOV E R F L A P

• Excision of pilonidal cyst up to lumbosacral fascia

• Undermining of the skin in the intermediate subcutaneous tissue

• Flap developed in 2 (length) to1(base) ratio

• When desired length is obtained, cut up to the lumbar fascia

• Flap then elevated of the erector spine muscles and turned over into soft tissue defect

• Skin sutured over this

LU MBAR AD I POFASC I AL T U RNOVE R F L AP

• 10 patients

• Mean hospital stay of 4 days

• Mean time of work 15 days

• Acceptable cosmesis

• No recurrence

O K ? L E AV E I T O P E N ?

• 18 studies, 12 RCTs open vs closure (10 vs 2) (mid-line/off-midline).

• 6 studies mid-line vs off-midline.

• rapid healing after closure, same infection rate.

• Recurrence was less likely to occur after open healing.

• Earlier return to work with closure.

- P R I M A RY C LOS UR E OR OP EN HEA L I N G BY S EC ON DA RY I N TEN T I ON .

- M I D - L I N E OR OFF - M I D L I N E

“so; Take it Home!”

Off-midline closure should be the standard management when primary closure is the desired surgical option

R E F E R E N C E S

• JB Lynch; AJ Laing; PJ Regan. Vacuum-Assisted Closure Therapy: A New Treatment Option for Recurrent Pilonidal Sinus Disease Report of Three Cases. Dis Colon Rectum 2004; 47: 929–932

• JH Armstrong; PJBarcia. Pilonidal Sinus Disease The Conservative Approach. Arch Surg. 1994;129:914-918

• E Tezel; H Bostanci; Z Anadol. Cleft Lift Procedure for Sacrococcygeal Pilonidal Disease. Dis Colon Rectum 2009; 52: 135- 139

• M Gips; Y Melki; L Salem: Minimal Surgery for Pilonidal Disease Using Trephines: Description of a New Technique and Long-Term Outcomes in 1,358 Patients. Dis Colon & Rect Vol 51: 1656–1663 (2008)

• E Aygen; K Arslan; O Dogru. Crystallized Phenol in Nonoperative Treatment of Previously Operated, Recurrent Pilonidal Disease. Dis Colon Rectum 2010; 53: 932–935

• JN Lund, D.M; S Leveson. Fibrin Glue in the Treatment of Pilonidal Sinus: Results of a Pilot Study. Dis Colon Rectum 2005; 48: 1094– 1096

• R Eryilmaz; I Okan; A Coskun. Surgical Treatment of Complicated Pilonidal Sinus with a Fasciocutaneous V-Y Advancement Flap. Dis Colon Rectum 2009; 52: 2036–2040

• Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006213. doi: 10.1002/14651858.CD006213.pub3. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Al-Khamis A1, McCallum I, King PM, Bruce J.

C O N T I N U E R E F E R E N C E S

• World J Surg. 2013 May;37(5):1115-20. doi: 10.1007/s00268-013-1950-8. Karydakis flap for recurrent pilonidal disease. Iesalnieks I1, Deimel S, Schlitt HJ.

• J Plast Reconstr Aesthet Surg. 2010 Jan;63(1):133-9. doi: 10.1016/j.bjps.2008.07.017. Epub 2008 Nov 14.Superior gluteal artery perforator flap in the reconstruction of pilonidal sinus. Acartürk TO1, Parsak CK, Sakman G, Demircan O.

• N Sungur; U Kocer; A Uysal. V-Y Rotation Advancement Fasciocutaneous Flap for Excisional Defects of Pilonidal Sinus. Plast. Reconstr.Surg. 117: 2448, 2006

• Y Bas; H Canbaz; A Aksoy. Reconstruction of Extensive Pilonidal Sinus Defects With the Use of S-GAP Flaps. Ann Plast Surg 2008;61: 197–200

• A Turan; C Isler,; SC Bas. A New Flap for Reconstruction of Pilonidal Sinus

• Lumbar Adipofascial Turnover Flap. Ann Plast Surg 2007;58: 411–415

• Comparison of Limberg and Dufourmentel flap in surgical treatment of pilonidal sinus disease Ali Tardu1, Adnan Haşlak2, Beyza Özçınar2, Fatih Başak11İstanbul Eğitim ve Araştırma Hastanesi, Genel Cerrahi, İstanbul, Türkiye2Ergani Devlet Hastanesi, Genel Cerrahi, Diyarbakır, Türkiye

T H A N K YO U . .