Background
Pilonidal Sinus (PNS) disease is a global problem of young adults with a significant recurrence rate after surgery specially after close surgery. It is more common in hairy adult males than females.1 So far there is no operative procedure which can claim to be recurrence free, every procedure whether open or close has different incidence of recurrence. Karydakis procedure, Limber flap procedure2 though are known to view good results but are also not recurrence free.
Pilonidal sinus is a pathological tract in natal cleft. PNS contains hairs, but if infected also contains debris and pus with granulation tissue. Pilonidal sinus is also found in other areas of the body i.e. hands, feet, umbilicus etc. PNS track may be single or has branches. Latin words, ‘Pilus’ and ‘Nidus’ meaning ‘hair’ and ‘nest’ are responsible for giving the name ‘Pilonidal’ meaning a ‘nest of hair’.3
The reason for high rate of recurrence after PNS surgery is not to understand the causes and factors responsible for recurrence as if these points are not addressed properly the recurrence will ensure. In our method of close surgery the recurrence rate reaching the bottom is due to addressing each and every issue responsible for recurrence properly and effectively. If even one factor responsible for surgery is not delt properly the recurrence will happen. Pilonidal sinus surgery specially closed is not an ordinary simple surgery, it requires dedication, devotion and sincere efforts.
Herbert Mayo for the first time in 1833,4&5 described pilonidal sinus disease. RM Hodges coin the term ‘pilonidal in 1880’.4 Though the pilonidal sinus disease was described in 19th century, but its history goes to few centuries. Sushutra, the father of ancient Indian surgery explained long back that hair can be a root cause for the formation of a sinus.5 He also described the methods of management including Agnikarma and Ksharasutra.6
Various techniques of pilonidal sinus surgery such as Karydakis technique, Limberg flap reconstruction and other flap techniques are all have medium to long learning curve, but Nigam’s procedure has a short learning curve and is a simple and easy technique. Pilonidal sinus is common among young hairy males. It is common among people who sit for long periods, such as taxi drivers. Jeep drivers in World War II used to travel in bumpy terrain for hours or even days in the worst health conditions used to have PNS, which is why it is also called “Jeep driver’s disease”. Surgery of PNS is by open or closed technique. The open technique involves complete removal of the pilonidal sinus and its branches without closing the wound and leaving it to heal by secondary healing. The pain and discomfort of daily dressing is very annoying to the patient and distressing too. On the other hand, the closed technique involves the complete removal of the pilonidal sinus and its branches with closing of the wound by various methods i.e. suturing and flap reconstruction. The healing period of closed technique is very short as compared to open technique so the suffering period is also short for the patient. The recurrence rate is more with closed technique and this compels most of the surgeons to choose open technique.
In our technique, Nigam’s procedure the wound is closed in various layers meticulously to avoid recurrence. In this procedure the healing period after surgery and the hospital stay period are very short. Our technique takes care of all the factors responsible for recurrence which is the main reason for zero recurrence.
Materials and Methods
Patients of acute and chronic pilonidal sinus disease were admitted to various hospitals in Gurgaon, Haryana between January 2001 to September 2024. We have operated 220 patients by our primary closure technique, Nigam’s procedure. The patients of pilonidal cysts and acute pilonidal abscesses were not included in this study. This is the limitation factor of this study. The patients of all age groups were included in this study, advanced age was not considered a contraindication for our procedure. Patients demographics were recorded for age, sex, body weight, body mass index (BMI), duration of disease, and comorbidities such as hypertension, heart disease, diabetes mellitus, obesity, thyroid problem, and lifestyle. A through history of previous surgeries and the type of surgery (closed or open) was also recorded. The pus or discharge swab was taken and tested for antibiotic sensitivity. Appropriate antibiotics were initiated from the morning of the surgery and continued for 3 days. Every patient underwent a routine magnetic resonance imaging (MRI) sonogram for the sinus and its tract. Every patient gave informed consent which explained the type of surgery and its complications. The follow-up of all patients was done from 3 months to 5 years.
Operative Technique
Preoperative preparation: Shaving of the local area was done including the surrounding area of about 20-25 cm. Posture: Patients were positioned in the prone position, and adhesive stretchable tape was applied around the buttocks, securing them apart on the operating table. Anaesthesia: General or spinal anaesthesia was used. Surgery under local anaesthesia was avoided to avoid higher recurrence rate though it reduces the post-operative pain in 48 hours after surgery.7
Steps • The position of sinus opening, and shaved area were checked. • A malleable probe was taken and the tip of the probe was introduced in the sinus opening without pressure and not inserted more than 1 cm to avoid the chances of making a false passage. • Then, 5 ml of undiluted methylene blue dye was taken in a 10 ml syringe. The nozzle of the syringe was directly put in the sinus opening and pressed against the skin with the syringe and then the dye was slowly pushed till it went easily, smoothly without resistance but if resistance was met, it was not pushed with pressure. After waiting for 30 seconds, the dye was pushed again.
1) Incision: An encircling elliptical incision was made around the sinus opening which was carried towards the midline and the two parts of the incision met in the midline. After this, the incision was deepened to try and go beyond the blue-colored tissues. 2) All visible blue tissue was excised. If any blue tissue remained attached, it was removed using a curette. The margins of the wound were then trimmed first with a knife and subsequently with scissors. 3) Meticulous haemostasis was achieved by catching and cauterizing bleeders with small, curved spencer walls artery forceps, or pointed thumb tissue forceps. Proper haemostasis is also one of the fundamentals to avoid recurrence. 4) The wound edges were undermined on both sides in full thickness of the wound. This was done with the help of a knife for 1 to 1.5 cm. 5) A No. 10 or 12 Radivac suction drain was introduced from one side of the incision. The drain was positioned in the lower part of the wound to facilitate drainage by gravity. 6) The wound was then cleaned with a 50:50 mixture of povidone-iodine and hydrogen peroxide. 7) Tension sutures were applied as the deepest first layer of sutures with 1/0 Prolene; 3 or 4 tension sutures were applied. These sutures had to include the full thickness of the wound from the undermined area. 8) The second layer of sutures was applied as interrupted buried mattress sutures with 2/0 Vicryl to close the dead space. 9) The skin was closed using interrupted mattress sutures with 4/0 Prolene. It was ensured that the distance between the sutures did not exceed 0.5 cm to prevent inversion or eversion of the skin. Care was taken to avoid inverting the skin. 10) The drain was fixed with skin with 2/0 silk suture. 11) Dressing Povidone-iodine was soaked, 3 dressing gauze pieces were placed over the suture line. Over it, a few more, dry dressing gauze pieces were kept, and tension sutures were tied over these gauze pieces in simple knots so that they can be opened at the time of dressing and again tied in the same way. Over the tension sutures, one Gamjee was placed and adhesive tape was applied. 12) The patient was asked to lie down on the dressing in the supine position. 13) Skin sutures were usually removed on 8th or 10th postoperative day and tension sutures on the 14th day.
Results
This study included 220 (100%) patients with PNS disease, out of which 198 (90%) were male and 22 (10%) were female. The age of patients varied from 15 to 62 years. The body mass index was recorded, as follows: the normal BMI (138, 62.8%), overweight (60, 27.2%) and obese (22, 10%). Various demographic features of all patients were recorded routinely (Table 1, 2, 3)
The weight of the patients varied from 40 kg to 120 kg. The height of the patients in this study varied from 5’0" to 5’8". The maximum number of patients as per their BMI belonged to the normal BMI (18.5 to 25). Shaving of the surgery site was done in the operation theater before the surgery. All patients were instructed to use epilation cream over the surgical site and peri-surgery area after the removal of sutures, for 3 months. No patient developed a recurrence of PNS after Nigam’s procedure of primary closure after total excision of the PNS tract. No patient was re-operated for any significant complication after surgery (Table 4).
Of all 220 patients one patient developed partial gaping of the wound (skin and superficial subcutaneous tissues) after the removal of sutures. The wound healed gradually with repeated local dressings with 10% povidone-iodine solution-soaked gauze after cleaning the wound with a mixture of hydrogen peroxide and 10% solution of povidone iodine. Patient did not require secondary suturing. The patient had to travel a lot for his job and probably this was the reason for his gaping wound. Wound infection developed in 15 patients (6.8%). These patients were treated with appropriate antibiotics after culture and sensitivity test of discharge and local dressings with 10% povidone iodine solution-soaked gauze. All patients were discharged the next day of the surgery except 3 patients who were discharged after 2 days. All patients were asked about their experience of discomfort and pain after surgery, stay in hospital and other facilities. Most of the patients (95.9%, 211) were highly satisfied with the surgical procedure and did not experience much pain and discomfort. Nine patients (4.1%) were satisfied, but not totally pain-free (Table 5). No patient complained of severe pain, few felt mild discomfort at the surgery site.
In our series of 220 patients, we operated on 15 patients after recurrence of PNS after previous surgery. Most of the patients (5.4%) were operated by open technique by excision of PNS and secondary healing elsewhere. One patient (0.4%) was operated on by excision of PNS & Z-plasty. Two patients (0.9%) were operated on by Karydakis flap technique (Table 6).
Few cases required delayed removal of the drain following the dictum “drain till it drains”. The drain was removed after one week in 16 cases (7.3%) and after 10 days in 2 cases (0.9%). It was observed that the patients with delayed removal of the drain were on blood thinners such as aspirin or/and clopidogrel due to coronary artery disease.
Discussion
The pilonidal sinus is an infective disease which is known for its notoriety of recurrence. There are various theories and discussions about the cause of PNS, whether congenital or acquired. Today, however, it is generally accepted that it is an acquired disease.8,9 The congenital theory of PNS is now rejected due to these facts: Hairs in PNS are dead hairs lying loose with pointed and sharp ends towards the blind end of the sinus, PNS usually occurs between 20 and 29 years of age (82%) and not since birth.10,11 The incidence of PNS is approximately 26 cases per 1,00,000 people.
It is seen at earlier age in women, most frequently at the age of 20-25. The female – to – male ratio varies between 1:3 and 1:5.12 In our study the number of male patients was more and the female male ratio was 1:9, it was 1:8 in the study by Anderson etal.13 It is more commonly seen in those who have dark skin tone, are overweight, have a lot of body hair, and have oily skin.14 In our study also the males (90%) are more in number as compared to females (10%). It occurs 1.2 times more often in men than in women. The age at presentation is 21 years for men and 19 years for women. Our study also shows the maximum incidence of PNS between 20-30 (52.4%) years age group. It is more common in men due to their hairy body. The recovery period in our study of Nigam’s procedure was between 2-3 weeks which is significantly accepted. In some studies, however, the recovery periods are reported to between 13 and 30 days.15 The length of hospital stay for surgery and postoperative period was 1-2 days in our study, the period of hospital stay increases if someone develops complications. Various studies have shown hospital stay 3 days or more depending upon development of complications. Al-Khayat et al studied the postoperative infection rate, which was found to be 12.8%,16 probably cause of overstay in the hospital. In our study, the Nigam’s procedure the infection rate was much lower (6.8%) which was responsible for short hospital stay.
Currently, pilonidal disease is considered an acquired disease.17 Patey et al proposed the hypothesis of pilonidal disease being an acquired disease, suggesting that pilonidal disease results from the suction of hair from surroundings soft tissue and skin, ultimately leading to a foreign body reaction and foreign body granuloma.18 This proposal of pilonidal disease being an acquired, infective, and foreign body reaction was corroborated by King around the same time.19 In aetiopathogenesis of PNS disease, it is commonly accepted that non-living hair provokes a foreign body reaction subcutaneously, leading to an abscess and sinus formation.20
Pilonidal sinus also has a hormonal etiology view as it occurs in young adults (after puberty) and at the same time, hormonal secretion and growth of hairs are also initiated, thus, pointing towards hormonal cause. Currently, there are insufficient data on the presence of hormonal abnormalities in pilonidal sinus disease.21
It is now believed that PNS is caused by penetration of sharp hairs, but it is contrary to the belief of Bascom that it is not the shafts of hairs, instead follicles of hairs seems to be the source.22 Pilonidal sinus is caused by friction of skin with a hard surface in hairy persons leading to burying of hair under the skin and formation of pits23,24 which grow to form a sinus. In hairy young men, plenty of hair is broken down from their roots daily due to friction with clothes and this is more so when driving vehicles for hours at a stretch. The broken hairs are sucked in the furrow over the back, in the midline and settle between the buttocks down to the natal cleft due to gravity and get entrapped here. This entrapment is tighter in obese persons. Electron microscopy has also been used to evaluate hair involved in the pathogenesis of pilonidal disease; Dahl et al confirmed the hook morphology and proposed sharp ends contribute to hair piercing the skin, with hooks preventing retraction.25 Gosselink et al suggest the orientation of the hair scales likely encourages. Hair to be driven deeper into the tissue.26
Pilonidal sinus is common in persons having the following risk factors: Driver’s job, obesity, hairy young men with deep gluteal cleft and family history of PNS.27 Prolonged sitting job, obesity, and driving more than 4-6 hours with less number of baths per week are considered risk factors for PNS.28
Numerous methods have been described as surgical treatment alternatives for sacrococcygeal PNS, including primary oblique excision and closure, marsupialization, secondary healing, V-Y flap, Z-Plasty, Limberg flap, and Karydakis flap techniques.29,30
In the Karydakis flap application, after excision of all sinuses, off-midline closure is performed with the prepared fasciocutaneous flap.31,32 The recurrence rate is under 2%, and the complication rate is about 8%. Smoking and obesity increase wound site infections.33 Karydakis noted that healing of the surgical wound in the depth of the natal cleft was poor and is the main cause of recurrence.34 Karydakis technique’s two goals were to eccentrically excise vulnerable tissue in the midline and to laterally displace the surgical wound out of midline gluteal cleft. His study in 1992 showed very good results and it became an excellent surgery for PNS.35 In our single center study of Nigam’s procedure for PNS, we have noticed that there are other important factors also which increase the incidence of recurrence if neglected, Karydakis had ignored these factors except two. The causes of recurrence of PNS after surgery are: leaving a part of PNS tract during surgery, infection of wound, abscess formation at the surgery site, postoperative hematoma at operation site, tension on suture line, dead space creation during surgery, lack of depilation around the surgery site, and no good hemostasis during surgery.
According to Onder A et al. recurrence rate of 7% to 42% have been reported with this method of primary closure.3,36 Possible reasons among post primary recurrence include scar formation in gluteal cleft and tension.37 In the present study, the flap method led to high postoperative complications, while primary closure resulted in a higher recurrence rate.38
Bascom J reported,39 surgical treatment of pilonidal sinus is often associated with considerable postoperative pain40 and a hospital stay of upto 5 days.41 Our method taught us that every step should be done meticulously and not in a hurry, then only you can achieve good results. Every skin suture should be just approximating the skin and not inverting or everting, if happens particular suture must be removed and reapplied properly. We have operated upon both, primary cases and post recurrence. Even the few cases which were operated 2-3 times prior to our method, we achieved healing without recurrence. All patients were admitted to the hospital for 24 hours (1 day) except 3 patients who were extra sensitive to pain and were kept for 1 more day (total of 2 days). Karydakis reported a hospital length of stay of 3 days,42 Guner et al.43 and Al-Jaberi,44 reported a hospital length of stay of 4 days.
Yoldas T et al., reported that postoperative complication rates were higher in the flap-closure group than in the primary-closure method, but recurrence rates were lower.45 In Nigam’s procedure, both the postoperative complication rate and recurrence rate were very low. Keshava et al. reported that the main treatment goal of the sacrococcygeal PNS disease is the selection of the most appropriate technique that causes the least number of early postoperative complications, shortens the length of hospital stay and results in the least number of long-term recurrences.46 We feel that our technique meets all these requirements.
Various researchers have considered certain factors for selecting the patients for different surgical procedures, these are presence of diabetes or obesity, patients psychological temperament, number of pits and holes along the line of PNS, distance of sinus from anus, any local disease on or near operation area such as dermatitis. In our series, we did not select patients based on BMI and infection at the site of the sinus. We included all patients with obesity, chronic infection, and recurrence too. We feel the success mantra lies in the meticulous procedure and doing every step sincerely.
Common immediate postoperative complications of PNS are wound infection, bleeding, pain, hematoma formation, seroma development, wound gaping and abscess formation. Pain, wound infection, and seroma formation were the main problems encountered by various surgeons doing the Karydakis procedure. Wound infection ranged from 0 to 10.7% in the various studies using Karydakis technique.47 In our series the incidence of wound infection was very low (7.14%), gaping of the suture line after suture removal the was seen in one patient (0.59%). Rate of recurrence was reported less than 1% by Karydakis but in our series, no recurrence has been observed so far during 5 years of follow-up. No patient developed a recurrence of PNS after our method of primary closure after total excision of the PNS tract. No patient was re-operated for any significant complication after surgery.48
Conclusion
The PNS is specially a disease of hairy young males who are persuing their careers and so the loss of time due to discomfort and pain is very important for them. The incidence of PNS is not uncommon. It is not a life-threatening disease, but it causes pain and discomfort and affects the quality of life mandating only surgical treatment. Recurrence of PNS after surgery is the main complication of both, the open and closed methods of surgery. Recurrence is more with the closed method of surgery than the open method. Our method of surgery for PNS is a primary closure method dealing with every factor responsible for recurrence after surgery such as dead space, tension on the suture line, deep natal cleft, hematoma formation, infection, abscess formation, and obesity.
Acknowledgements
We thank Dr. Charvi Chawla for her efforts for conducting literature search and other information required for this research work. We are also thankful to Mr. Vipin Sharma for the preparation of the manuscript.