Cleft lift technique with tension-free primary closure for repair of pilonidal sinuses: Three years experiences

Cleft lift technique with tension-free primary closure for repair of pilonidal sinuses: Three years experiences

Ayman Soliman, MD; Yasser Abdel Reheem, MD;

Ahmad Awad, MD; Osama El Shiekh, FRCS

Department of General Surgery, Ain Shams University, Cairo, Egypt.

Abstract

Objective: Cleft lift technique was performed in patients with chronic or recurrent pilonidal sinus (PS). It has been reported to provide better results than simple excision  and closure in the midline. The aim of this retrospective study was to evaluate the results after introducing the tension-free flap as asymmetric cleft lift procedure in our hospital on a day care basis.

Patients  and  methods:  Between  June  2008  and July  2011, 236  patients  (199  males,  37 females: median age 30 years; range, 18-46 years) underwent excision ofthe pilonidal sinus with tension-free primary closure in cleft lift technique. Patients were observed and followed up (126 cases (53.3%) of these patients accepted a consultation  in the outpatient clinic w hile 75 cases (31.7%) were interviewed  by phone) for the healing rate and reporting the postoperative criteria over 2 years.

Results: At follow up mean 24 (range 10--27) months after the operation,  169 (72.6%)  of

the wounds were healed while recurrences were present in 32 (13.5%)  of the patients. Further results related to pre-, per- and postoperative conditions are discussed in this paper.

Conclusion:  Cleft  lift procedure results in  a similar looking  wound of the midline and a

shallow cleft. It is very successful in the treatment of difficult recurrent sinuses, where the early results are promising.

Key words: Pilonidal sinuses, recurrences, asymmetric, fl ap, Bascom technique, cleft lift.

Introduction:

Pilonidal sinus disease (PSD) is commonly encountered    in    the    surgical    outpatient clinic.   The   incidence   is   26/100.000   and the  condition  is most  frequent  among  men in their  third  decade  of life. A recent study indicates  that traditional  midline techniques for pilonidal sinus repair give a high wound infection rate, high recurrence rate, poor cosmetic  results and a long time to healing. In a met- analysis comparing results from 74 publications  on  primary  closure  techniques in chronic pilonidal sinus repair the authors conclude that asymmetric or oblique closure techniques (Karydakis-flap, Bascoms procedure, oblique excision etc.) or full­ thickness  plasty techniques  (rhomboid flaps, vy-plasty and z-plasty)  provide better results than the simple closure technique in the natal midline.

In 1973, Dr. George Karydakis, in Greece, excised  the  sinus  with  a  simple  biconvex

'elliptical' excision just crossing the midline

to excise the sinus. It was based 1-2cm from the midline with excision down to the sacrum The asymmetric or cleft lift technique with primary closure is recommended because they are  considered  easier to  perform  providing the same results as the full-thickness  plasty techniques. Both Karydakis and Bascom have described    asymmetric     closure   technique. Karydakis   published   his   experience   with a  simple  and  successful  operation  to  cure pilonidal   sinus  and   presented   the   largest personal   series   in   the   world   where   he describes removal of all deep inflamed tissue and the fixation of the base of a mobilized, asymmetric  thick flap to the sacrococcygeal fascia before skin closure. Bascom describes a thin skin flap mobilization leaving the deep

inflamed  tissue   in  place  and  skin  closure only. Both methods  share  excellent  results; Karydakis reports a less than 1% recurrence rate and Bascom reports a 100% healing rate after minor revisions or a second cleft lift in

9-10% of his patients with refractory PSD.

Due to  its  simplicity  we  introduced  the cleft lift technique  with tension-free primary closure as our single procedure for all symptomatic, chronic pilonidal sinus disease. The aim of this retrospective study was to evaluate the results of our first series of these operations.

Methods:

All  patients  operated  on  with  the  cleft lift procedure from  June 2008 to July  2011 were followed  up in the outpatient clinic. If a patient declined  physical  examination,  he or she was interviewed  by phone  if willing. We were able to contact 201 (85%) ofthe  236 patients who were operated on during this time period. Patients were admitted to the study in Ain Shams University Hospital, Ain Shams Specialized  Hospital (Egypt), Dr. Soliman Fakeeh Hospital and Armed Forces Hospital King Abdulaziz Naval Base Jubail (Saudi Arabia). All of these  patients,  199  (84.3%) men and 37 (15.6%) women, accepted to take part in the study and were included. 126 cases (53.3%)  were seen  in the  outpatient  clinic while 75 cases (31.7%) declined physical examination  and were interviewed by phone within the same timeframe, the rest 35 cases (14.8)  did  not  show  up  after  removal  of stitches for follow up. The mean time period from  operation  to follow  up  was 24 (range

10-27) months Table(l).

The mean age at operation was 30 (range

18-46)   years.    142   patients    (60%)   were overweight (BMI ?: 25) and among these 36 (25.3%) were obese (BMI ?: 30). The average BMI  was  26.6  (range  18.3-34.0).   Patients were questioned about pre- and postoperative conditions   and   physically         examined   for recurrent pilonidal sinus. The mean duration of the disease  before the cleft lift technique operation was 10months(range6-16months).

156 patients  (66%)  of the  included  patients

were primary disease cases whereas 80 (34%)

were recurrent cases after previous PSD operations Figure(l). Sixteen ofthe patients with recurrent disease had been operated on two or more times. These previous operations were drainage of abscesses (83.5%) and wide excisions (16.5%). All patients were operated on in a day care unit. Four of the 236 patients had to stay overnight because of nausea. Operations were performed under local anesthesia supplemented with intravenous analgetic medicaments  in all but one patient who needed general anesthesia because of excesstve pam.

The operation was performed with liberal usage of local anesthesia (and adrenaline), which  was  preferable  to  general  anesthesia in the  prone  position.  This  was  applicable in non- nervous patients if sinus was not too large. We gave plenty of time to insert LA slowly  under IV sedation  with  fine  needle. The flap was created first, usually 2cm wide and  0.5cm  deep  under  the  skin  Figure(2). Then, buttock straps were removed from the edges  of  operating  table  and  the  skin  flap gently pulled across the midline with skin hooks to see if the mark of the outer rim of the 'ellipse' has been made correctly on the skin, and to make adjustments to prevent tension on wound closure. The covering skin flap from the opposite side was undermined. Less may  need to  be excised  from  the  top end where the cleft was shallower than lower down.

The  outer limit of excision  was then  cut with the scalpel, but instead  of going down to the sacrum, the fat was left and only skin and dermis were excised, until the sinus was reached.  We then  prefer  to fully  excise  the sinus track rather than clean it.  The flap was fit gently across the midline on the fat rolled in from the other side over the suction drain tube.  Few fine  PDS  or  vicryl sutures  were used in the fat and did not need to be inserted down to the sacral fascia, unless it was a deep sinus and the fascia was exposed. The 'ellipse ' should be marked out on the operating  table by first marking two points on one side (the most  diseased side), a distance of 1. 5-2 em from the midline and placed far enough apart to allow a gentle curve to be marked out to just

cross the midline a few mms, to include the primary pit in the excision. For small sinuses, use  1.5cm  from  the  midline.  The  distance of maximum  width  of the  'ellipse' is twice the distance the upper and lower points are from the midline (3-4 em). This is measured between the marked lines not between the midline  and  the  outer  edge.  After  probing the tracks to work out their extent, the use of methylene  blue injection into the midline pit will enable all branches to be easily identified in case any are if severed or opened  during the excision Figure(3).

To avoid a 'dog-ear' at the lower end or the

wound tending to 'move'towards the midline, a V excision of skin can be taken off the lower end laterally. This will deviate the lower end a little further from the midline when skin is closed. A fine low-pressure suction drain tube is placed in the fat, brought out lateral to the wound. Allow no suture holes or drain hole to appear in the new midline. Use a subcuticular

3/0 prolene suture loosely knotted as a loop (the wound  lengthens  when the  patient sits, so loose suture needed to prevent a 'cheese­ cutter' effect). We support it with a few interrupted 3/0 prolene sutures. IV antibiotic including metronidazole is given during the procedure. Drain was removed two or three days after the operation when patients came back for a post-operative visit and all sutures out on tenth day.

Patients  are  instructed  for  the  post­ operative care at home to keep the wound dry and to avoid prolonged pressure on the wound for about a week post-operatively. Those that went home with a drain are taught how to empty  the  drain every  day  until  it is ready to be removed. Prophylactic antibiotics are administered   intravenously   (Metronidazole

1.5g and Cefuroxime 1.5g) at the beginning of the operation and continued orally for the first five days after the operation (Metronidazole

0.5g  x 3 and Cephalexin  0.5g  x 3). No pre­

operative   bowel  preparation   is  performed. The patients were told to shower the wound after  defecation   if  necessary.  Paracetamol is     recommended for   postoperative       pain treatment.   All  patients   are  enrolled   in  a

study with telephone and/or office follow-up requested to monitor long-term outcomes. Results:

At  follow  up  24  (10.1%)  patients  were

without  symptoms  or  signs  of  the  disease while recurrence  was found in 9 (4%) of the patients. The recurrences occurred on the average  4  months  after  the  operation  and in 2 of these patients relevant errors in the procedures were discovered: In one patient the nonabsorbable,  intradermal suture was never removed. In another the suture was removed later than scheduled on day 21 instead of on day 10 as planned. For the other 7 recurrences no evident cause was revealed.  Four (45%) of  the  nine  patients  with  recurrences  after the cleft lift procedure had been previously operated for pilonidal abscesses with simple incisions  and  drainage  whereas  7  of  169 (4.1%) in the cured group were previously operated for this condition.  None of the nine recurrences   had   been  previously   operated with more radical, potentially curative techniques as e.g. wide excision.

The complications after the cleft lift operation  consisted  of five  patients  (2.6%) with hematoma requiring no further treatment, one patient (1.3%) of infection where the wound  healed  9 months  after  revision,  and

24   (10. 7%)   patients   with   residual   open

segments  of their  wounds  after  removal  of the intradermal suture. Fourteen of these wounds healed spontaneously after a mean of

6.3 (range 3-12) months, while seven did not heal and were thus classified as recurrences at follow up. Three patients (33%) of the recurrent pilonidal sinus openings were found caudally in the cicatrice while 2 (22%) were located cranially Table(2).

The   non-absorbable   intradermal   suture was  removed   after  a  mean  of  12.2  days except from one patient where the suture was not removed.  Patients were off work/school for ll.5 (range 3-60) days after the operation. At follow up on the average 12 months after the operation, 112 (47%) patients could not recall to have suffered from any significant pain after the operation while 16 (6.7%) felt pain for a median of 2.6 (range 1-14) days.

Figure (1): Pre-operative picture of patient with chronic, open sinuses (A) & recurrent cases

(B) of pilonidal disease.

Pninl   mnrkt.:d 2cm from midlim:

1

wldlh4cm

' Point marked 1cm from midline

\       but-(IInap  lxcoml"'rtw:- 1n1dlinc of n m!\\  .••haUowt!rcleft

Figure (2):  Cleft lift procedure where Point marked 2cm from midline, width 4cm and 0.5cm deep under the skin.

...•

.....

..._

Figure (3): Cleft lift procedure; (A, B) Recurrent pilonidal sinus. (C, D) Incision mark around the sinus openings & the incision line is a little off the midline. (E) Cut a flap; 2 em wide, 1

em deep & full length of wound (F) Small drain is visible at the upper left of the photograph, Cut beyond and lateral to lower end (dealing with a dog ear).

Table (1): Patients' characteristics and operative findings.

Table (2): Clinical outcomes of clift lift operation for pilonidal disease.

Discussion:

In  spite   of  high   incidence  of  pilonidal disease    affecting   young    population   and the  prolonged  disabling  period   caused   by it, surgeons  have not reached  to the best treatment for this  condition. No matter  what the cause, patients  with pilonidal  disease  can have multiple, recurring bouts of infection and discomfort. Some  undergo  repeat  drainages of abscesses. Some undergo many operations in an attempt to remove the affected area. Too often, these  operations fail to fully  eradicate the disease.

In 1973, Dr. George Karydakis, in Greece,

published his experience with  a simple  and successful operation to  cure  pilonidal  sinus and  later  on  presented   the  largest  personal series in the world.  He excised  the sinus with a  simple  biconvex 'elliptical' excision   only just crossing the midline  to excise  the sinus. It was  based  1-2cm  from  the  midline  with excision  down  to  the  sacrum.   A thick  flap was then created  by undercutting the midline side  of  the  wound.   This  flap  was  advanced across  the midline  to meet  the  other side  of the wound  with two  layers of catgut  sutures

to  the  fat  around  a  drain  tube.  The  wound was then closed with skin sutures. Karydakis believed  and taught  that  hair  insertion is the cause  of pilonidal  sinus  and  attributed his extremely  low   recurrence  rate  of  (1%)  to two facts.  These  are: (a) the whole  wound  is placed away from the midline (recurrences always   occur   in  the  midline)  and  (b)  the resulting new natal cleft is shallower (so hairs do not collect  so readily).

Despite  these  good  results, the  Karydakis operation  has   been    criticised    for   taking too  much  fat,  and  for  placing  sutures   into the   midline    sacral   fascia    (often   causing pain). Most of his patients required general anesthesia and  stayed   in  hospital   a  day  or more.   Dr  Karydakis   was  trying  to  develop ways  to  simplify the  operation for  day surgery. Excision  of the pilonidal sinus and laying the tract open to allow healing by secondary intention  has been described as an option to ensure that the cavity has adequate drainage.  This avoids a wound  infection after primary  closure.   Consider   laying  the  tract open when the primary closure is not free of tension.  Even  after  excision  of the pilonidal

sinus down to healthy presacral fascia, the wound is still considered contaminated.  Both aerobic  and anaerobic  organisms  are found in 50-70% of wounds. The disadvantages  of laying the tract open are the inconvenience to the patient, with frequent  dressing  changes, and close observation of the wound to ensure proper wound healing.

Skin  flaps  have  also  been  described  to cover a sacral defect after wide excision. Similarly, this keeps the scar off the midline and flattens the natal cleft. The potential complications  include loss of skin sensation in the flap,  which is observed  in more than

50%  of  patients,  and  necrosis  of  the  flap

edges. Again, primary healing is achieved in

90% of cases. 'Cleft  lift procedure'  was first introduced by Dr. John Bascom in Oregon.

The  cleft  lift  technique   emphasized  the

circulation  of hairs from  a midline  primary pit and through secondary openings. So secondary   openings   a  distance   from   the main   track   and  weren't   included   in  the excision (e.g., by V cuts on one side or both sides  of the  wound to  close  and result in a T-shaped  wound)   Figure(2).   Rather,  they were curetted,  and the openings cleaned  out by pulling gauze through them, to eradicate hair particles. Once the primary pit is dealt with, the secondary pits should heal, because the hairs in them should make their way out. Cleft  lift  technique   with  primary   closure added the following  points; (1) The 'ellipse

'should be marked out on the operating table by first marking two points on one side (the most  diseased  side), a distance  of 1.5-2  em from   the  midline   and  placed  far  enough apart to  allow  a gentle curve to be marked out to just cross the midline  a few mms, to include the  primary  pit in the  excision.  For small  sinuses,  use 1.5cm from  the  midline. (2) The distance  of maximum  width  of the

'ellipse' is twice the distance the upper and

lower points are from the midline  (3-4 em). This is measured  between the  marked  lines not between the midline and the outer edge. (3) After probing the tracks to work out their extent,  the  use of  methylene  blue  injection into the midline pit will enable all branches to be easily identified in case any one is severed

or opened during the excision.  (4) To avoid a 'dog-ear' at the  lower  end  or the  wound tending to  'move' towards the midline, a V excision  of skin can be taken  off the  lower end laterally. This will deviate the lower end a little further from the midline when skin is closed. (5) A fine low-pressure  suction drain tube is placed in the fat, brought out lateral to the wound. Allow no suture holes or drain hole to  appear  in the new  midline.  (6)  Use a subcuticular 3/0 prolene suture loosely knotted as a loop (the wound lengthens when the patient sits, so loose suture needed to prevent  a  'cheese-cutter' effect).  Support  it with  a few  interrupted  3/0  prolene  sutures. (7) The goal of the asymmetric incision is to reduce the depth of the gluteal fold, thereby eliminating the frictional forces between the

2 opposing skin edges. Although the use of an incision that crosses the vertical gluteal fold to excise the pilonidal cavity does eliminate a vertical suture  line within the gluteal fold, healing times may remain considerable. Also, The use of asymmetrical  or oblique elliptical incisions in an attempt to keep incisions out of the natal cleft where wound healing is poor and to prevent unnecessary tension on the closure ofthe wound.

The advocates of excision and primary closure  of  the  wound  using  different techniques   emphasize   on   quicker   healing time, fewer postoperative visits and shorter time off work. Those favoring simple excision or  lay-open  technique,  are  of  the  opinion that if general patient satisfaction, period of hospitalization   and  the  recurrence  rate  are the criteria. Incidences of wound dehiscence following   excision  and  primary  repair  are much more than previously thought. These procedures  also require a long hospital stay and long periods off work.

Our findings suggest that deep tissue damage,  although  obvious,  is  not  the primary  source  of  none  healing,  but  rather is  a  secondary   effect.  Thus,  the   primary source of surgical failures is not week deep midline tissues but rather the shape of the gluteal cleft, which creates the moist, warm, bacteria-friendly  environment. This new paradigm  of  epidermal  origin  of  pilonidal

disease has important implications for initial management of the disease. Armstrong & Barcia, Rickles, and Theodoropoulos et al. all left tissues  in place as we did in this study, with similar success.

Conclusion:

In summary, the goal for treatment of pilonidal disease is 2-fold. The first is excising and healing with a low rate of recurrence. The second  is minimizing  patient inconvenience and  morbidity  after  the  surgical  procedure and avoiding hospitalization with loss of workdays. The suggested modified Bascom technique (Cleft lift with primary closure) is an attractive, safe, easily performed operation with minimal morbidity and can be reliably used as a second-line surgical option for recurrent pilonidal disease.

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