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  • Q&A with Australian Health Practitioners

    Treatment for pilonidal sinus?

    Related Topic
    My 22 yr old son has been getting infections at the base of his spine near his bottom. We were told this is a pilonidal sinus and would need to be removed. It will need dressing every day for a few months before it is healed but there is a possibility it will not heal at all. Is there any other way to treat this problem.
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  • 28

    Thanks

    Dr Darren Gold

    Colorectal Surgeon (Bowel)

    Dr Gold is a specialist in proctology . This includes haemorrhoids, anal pain, anal fissure, pilonidal sinus, anal fistula, faecal incontinence and constipation. In addition … View Profile

    A pilonidal abscess and sinus is a common condition and usually
    affects relatively young patients in the age range of 15 to 30 years.
    The term comes from the Latin pilo~, meaning hair, and nidus~, meaning
    nest. It is caused by body hair penetrating the skin of the natal
    cleft and causing infection.

    Although a harmless condition, a pilonidal abscess and sinus
    frequently runs a chronic and recurrent course and can be a most
    debilitating condition for a young person to experience. Symptoms
    usually involve recurrent abscess formation with discharge and
    discomfort or even pain on sitting for prolonged periods. The
    discharge is often malodorous and stains clothing, causing severe
    embarrassment. Once established it virtually never heals completely of
    its own accord and surgical intervention is required.

    There is still much debate as to how the hairs get under the skin. The
    acquired theory is that the hairs dig their way into the skin by
    rubbing and pressure and, because of the shape and arrangement of the
    keratin scales (like a fir tree under the microscope), continue to
    move in one direction only — inwards. The congenital theory is that
    epidermal hair cells form too deeply under the skin during embryonic
    formation, and eventually grow up from the deep layer of the skin,
    piercing the skin and letting in bacteria. Either way, bacteria are
    able to enter the subcutaneous tissues and cause infection which
    eventually develops into a pilonidal abscess.

    In the early stages of the infection there may just be some
    superficial cellulitis that will settle with antibiotics. However,
    this may develop into an abscess, identifiable by the severe degree of
    pain and the obvious presence of a fluctuant subcutaneous mass.
    Antibiotics are contraindicated for such abscesses and urgent surgical
    incision and drainage is required. Most pilonidal sinuses will start
    as a pilonidal abscess. When the first abscess has formed and been
    drained, there will be one of two outcomes. Either there is complete
    healing of the abscess or a sinus forms which does not heal and
    discharges either pus or serious fluid continuously.

    Even if the abscess apparently heals, it can lie dormant and
    subsequently form another abscess which is a sign that there are still
    numerous hairs trapped under the skin. The development of a sinus or
    of recurrent abscesses usually indicates that definitive surgery is
    required.

    Surgical Management
    Careful research within the surgical literature identifies the causes
    of recurrent pilonidal problems. In essence, the factors that
    predispose to either wound breakdown or early recurrence are a midline
    wound, a deepened natal cleft (bumcrack) and wound tension. Surgery
    for pilonidal sinus should not only aim to cure the problem but avoid
    the factors that cause the sinus or recurrence in the first place.

    Simple excision with healing by dressings:
    Due to the cumulative recurrence rate and the tendency for multiple
    recurrence, surgery by excision leaving an open wound with healing by
    secondary intention is still the most commonly performed operation for
    all pilonidal disease. This requires wound packing and daily dressings
    either at the general practice surgery or by the local district nurse,
    and it can take about six to twelve weeks to heal. This is a
    time-consuming and frustrating period for both practitioner and
    patient. It can be three months until the patient’s normal duties can
    resume, often resulting in significant loss of income. The recurrence
    rate is very high as by the time healing has occurred more hairs have
    grown into the wound starting the whole process again. This type of
    surgery is outdated and no longer necessary.
    The most commonly performed operations for pilonidal sinus that are
    aimed at achieving primary closure are simple excision with primary
    closure and the Karydakis procedure.

    Simple excision with primary closure:
    The simple excision with primary closure is aimed at removing the
    disease by excising a centrally placed ellipse of tissue and then
    primary closure by approximating the two resulting edges. This
    operation results in a midline scar which is under tension and often
    produces a deepened natal cleft. It is therefore not surprising that
    this operation is associated with high rates of wound breakdown and
    recurrence. Wound breakdown will require packing and dressing to
    achieve full healing due to the size of the wound that is left after
    dehiscence.

    The Karydakis procedure:
    The Karydakis procedure is similar to simple excision with primary
    closure, but aims to remove an eccentrically placed ellipse so that
    the resulting wound is not in the midline and in so doing flattening
    (rather than deepening) the natal cleft. However, in order to achieve
    this, a larger than necessary excision is sometimes required which
    results in significant wound tension. It is therefore prone to wound
    breakdown (albeit less than the simple excision with primary closure),
    leaving the patient with a large open wound that will require repeated
    packing and dressings.
    In order to achieve a tension-free, primarily closed wound, which
    avoids a scar in the midline and at the same time flattens the natal
    cleft, some type of flap procedure is required. The Karyadakis
    procedure is frequently referred to as a flap procedure but this is
    not strictly the case.

    Rhomboid rotation flap
    My preferred operation for pilonidal sinus is the rhomboid rotation
    flap, which excises the diseased tissue and closes the wound in a
    tension-free manner by rotating a similar-sized flap of tissue from
    the neighbouring buttock. It also avoids a midline wound and in the
    process flattens the natal cleft.

    The rhomboid rotation flap operation produces excellent primary
    healing and a very low recurrence rate. Most patients return to work
    with a fully healed wound after two weeks, to normal non-sporting
    activities within four weeks and to contact sport after six weeks.

    Many surgeons are critical of flap procedures due to their complexity
    and the need to involve tissue from the neighbouring buttock, but very
    few complaints are received from patients with a nicely healed wound
    at two weeks. Nevertheless, flap surgery is complicated and highly
    specialised so requires experience and specific training in this type
    of surgery to achieve ideal results.

  • 2

    Thanks

    Dr Jason Wong

    Bariatric (Obesity) Surgeon, General Surgeon, Laparoscopic Surgeon, Upper GI Surgeon (Abdominal)

    Jason Wong is a skilled Laparoscopic and Bariatric Surgeon with expertise in sleeve and gastric bypass surgery, gallbladder, hernia, endoscopic pilonidal, antireflux and emergency general … View Profile

    There is a new treatment available known as Endoscopic Pilonidal Sinus Treatment or EPSiT.

    This treatment does not involve excising all the disease in a radical or less radical fashion, which can sometimes result in a significant wound with high risk of breaking down that can necessitate daily dressings until it has healed.

    Instead, the sinuses that are already present in the natal cleft are used for the surgery and a thin, rigid camera is inserted through these sinuses and all the hairs inside the sinuses are removed. The sinus tracts are debrided and cauterised.

    Data shows that with fewer sinuses, the higher the chance of this approach being effective with 94% healing within 2 months, and patients with recurrence after this treatment can be treated with the same modality again. Less than 10% of patients require pain killers after this method of treatment, and patients go home on the same day and will be back at school or work the following day. The only dressing for this procedure is a sanitary pad in the underwear which can be changed daily without nursing care required.

    Whilst traditional excisional surgery still has a role in the treatment of Pilonidal sinus disease, I believe the less invasive EPSiT approach should be considered in the first in patients with 1 - 3 sinuses.

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