Karydakis flap procedure for pilonidal sinus

  • 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 (DD: Open neural tube defect). 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, 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 is a risk factor in the formation of pilonidal sinus:

    • Excessive hair Presumed etiology: The drill effect drives broken hair into the skin, the driving force being the rolling motion of the hair between the buttocks (especially when sitting). Sitting occludes the hair follicles which then become infected. This is notsupported by the fact that: 50% of affected patients are not particularly hairy.
    • Deep gluteal fold (obesity)
    • Local irritation
    • Positive family history
    • Age 15-25 Presumed etiology (according to Bascom): In puberty, sex hormones induce glandular changes in the hair follicles. Microscopy can then detect enlarged hair follicles. The simultaneous increase of the buttocks (fat/muscle) increases the tensile forces on these follicles, especially next to the sacrococcygeal joint (site of the greatest angulation). This results in the formation of the so-called "pits". Sitting elevates the skin above the level of the rima ani. In the event of an impact (unpadded seat, athletics) this causes the base of the follicle to tear, thereby allowing loose hair and/or keratin to be suctioned into the pit by something akin to “negative pressure”. This is notsupported by the fact that: Pilonidal sinus disease is also found in non-adolescents.

    Principle of the Karydakis lateral flap procedure:

    • Flattening the natal cleft
    • Lateralizing the wound away from the natal cleft Studies have demonstrated that midline scarring tends to increase recurrence significantly, prolong healing and increase infection rates.

    Benefits of the technique include:

    • Thick skin flap
    • Simple surgical technique

    Drawback:

    • Large skin defects cannot be closed without tension. Here, a Limberg rotation flap procedure would be more suitable.
  • Chirurgische Praxis

    Dr. Karl Heinz Moser

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  • Indication

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  • Contraindication

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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: 28.03.2013
  • Chirurgische Praxis

    Dr. Karl Heinz Moser

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  • Planning the resection

    122-3

    The technique is demonstrated on a chronic recurrent pilonidal sinus.

    First, define the resection margins. The dotted lines correspond to the highest point of the buttock in question. The ovoid incision should be located eccentric to the midline and cover the entire system of tracts. The central axis of the incision should be about 2cm lateral to the midline.

  • Skin incision

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    Incise the tissue to be removed. Since the chronic infection always predestines this operation to bleeding, we prefer the electrocautery. 

  • En-bloc excision

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    Excise the inflamed tissue together with all the fistula tracts. On the far side of the midline bevel the incision, while bringing it straight down close to the midline. Leave a thin layer of fat on the sacral fascia.

  • Mobilizing the skin flap with fat

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    With electrocautery or scissors mobilize the skin-fat flap from the gluteal fascia close to the midline. This allows adequate mobilization of the flaps without having to incise the fascia, thereby permitting asymmetric closure.

    After diligent hemostasis, place a Redon drain into the wound cavity.

  • Wound closure

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    After loosening/cutting the medical tape adhesive strips on the buttocks, close the wound in layered fashion.

    With strong full-thickness three-point sutures and including the right sacral fascia, join the mobilized skin-fat flap with the contralateral wound margin. This will largely prevent cavity formation.

    Tip: It is best to first place the stitches without tying them.

    Follow this with a subcutaneous suture and close the skin with interrupted sutures.

    And as the final step, instill some local anesthetic through the Redon drain.

    Note: Suture line and later scar are about 1-2cm off the midline. The natal cleft has flattened out somewhat, particularly in its superior region, making it more difficult for hair to penetrate the skin once more.

  • Chirurgische Praxis

    Dr. Karl Heinz Moser

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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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  • References on this topic

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  • Ongoing trials on this topic

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  • Guidelines

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  • Literature search

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