Wide excision operations

Surgical treatments by this method include wide radical excision of the pilonidal disease containing area, including underlying cavities, tracts and overlying skin and going deep down to the tailbone and sacral bone. This "traditional" operation is usually carried out under general or regional anesthesia and requires hospitalization of one or several days. Healing period may range from several weeks to months and usually entails significant local discomfort, pain and limited daily activity. The wide excision approach is probably based on the old, outdated belief that the condition is an inborn physical deformity existing from birth and it can be cured only by complete and wide removal. This hypothesis was already proven false and neglected in the 1940's, but the same surgical approach continues to be passed from one generation of surgeons to the following until today. Most surgeons in Israel and all over the world still use this operative method.

pilonidal wide excision and primary closure

A similar wide excision is performed in the open method, but the operative wound is not sutured. The remaining open wound necessitates months of local medical care and dressings until healing. Chances of wound infection and recurrent disease are reduced in the open approach.

 

Two forms of operations are common in this category, "closed" and "open": In the closed method the operation concludes with the wound being closed with sutures. Closing the wound shortens the healing period to a few weeks, but increases the risk of postoperative wound infection and the rate of recurrent disease.

pilonidal wide excision and lay open
lay open pilonidal surgery

The adjacent picture demonstrates a pilonidal operative wound left open to secondary

self-closure.

Over the years, the basic wide excision technique underwent various modifications aimed to cope with the limited success and healing difficulties of pilonidal operations. Blame was put, in part, on the presence of the operative suture line, at the bottom of the natal cleft. Accordingly, a technique of asymmetric excision of the pilonidal area was introduced, resulting in the suture line being deviated laterally from the clefts' bottom. Indeed, deviation of the suture line laterally proved to reduce recurrence rate of the disease compared to excisions with midline suture line (Karydakys operation and Bascom mark II operation).

pilonidal asymmetric closure

Others ascribed the high recurrence rate and disturbed wound healing to the high tension applied on surrounding tissues approximated to cover and close the wide operative defect. Complex surgical techniques were therefore developed in which skin and underlying tissues from the buttocks are released and moved medially to cover the wound. Using such tissue flaps in techniques of plastic surgery prevents tension closure, flattens the natal cleft and moves suture line out of the cleft. Recurrence rate is thus reduced to a few percent, but at the price of an extensive and cosmetically deforming surgical procedure, involving the buttocks.

pilonidal rhomboid flap

 

The following drawings illustrate wide excision operations for pilonidal disease using flaps from the buttocks to cover and close the operative defect. These operations may occasionally be indicated for extensive or recurrent pilonidal disease after failed previous treatments. Flap operations are not, usually, the first choice procedure for managing pilonidal disease.

pilonidal z.plasty
pilonidalsinus.org
Layer%25202%2520copy_edited_edited.png