Excision of pilonidal sinus with secondary healing

  • Privatpraxis für Handchirurgie und Handgelenkchirurgie

    Dr. Kirsten Beyermann

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  • Pathophysiology

    For over a hundred years, the etiology and pathogenesis of pilonidal sinus was considered embryonic. This theory, however, has now been abandoned. To this day, the pathogenesis has not yet been fully understood. At present, a multifactorial etiology is presumed. According to this hypothesis, pilonidal sinus develops as a dimple in the anal cleft (rima ani) directly above the coccyx. Mechanical strain, especially when sitting (jeep driver's disease), may result in stretching of hair follicles, which eventually tear. Constant maceration paves the way for the infiltration of pathogens and especially broken hair, which then leads to acute or chronic inflammation. The pasty soft mass burrows into the sides, and in extreme cases to the anus, via a multi-sinusal fistula system.

    One or more of the following are regarded as risk factors in the formation of pilonidal sinus:

    • Excessive hair
    • Deep gluteal fold (obesity)
    • Local irritation
    • Poor personal hygiene
    • Positive family history
  • Herr Prof. Dr. med. Alexander Herold

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 31.12.2013
  • Herr Prof. Dr. med. Alexander Herold

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  • Exposing the fistulizing sinuses

    141-3

    Several fistula orifices are visible in the anal cleft. Probing demonstrates fistulization nearly to the posterior anal verge. The fistulizing sinuses are marked with a dye (toluidine blue) (this ensures complete excision of all secondary sinuses).

  • En-bloc excision

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    Complete oval excision of the entire chronically infected tissue. All tissue marked blue must be safely removed in toto while sparing the sacral fascia and leaving on the sacral fascia as thin a layer of fat as possible.

  • Inspecting the specimen

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    The transected specimen reveals a wide fistulizing sinus with tufts of broken hair.

    Note: 

    • The benefit of excision with healing by granulation is that it requires little technical effort, the biggest downside being the rather long time required for healing.
  • Dressing

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    Petrolatum gauze wound dressing Cover this with crumpled gauze pads. The wound is left to secondary healing.

    Note:

    The hairless scar and the flattening of the anal cleft should eliminate the causes of pilonidal sinus.

  • Herr Prof. Dr. med. Alexander Herold

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  • Intraoperative complications

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  • Postoperative complications and their prevention

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  • Klinikum Ingolstadt

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Guidelines

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  • Literature search

    Literature search under: http://www.pubmed.com