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Sacrococcygeal pilonidal sinus (PNS) is a common disease. There are different lines of treatment but the best surgical technique is still controversial. The aim of this study is to show the effectiveness of treatment of sacrococcygeal PNS with excision and primary midline closure as day case surgery. This is the first study on sacrococcygeal PNS to be done in Sulaymania governorate, Iraq. A prospective study was done over a period of 3 years, between 1st Jan 2003 and 31st Dec 2005 in a private general surgical office, in Sulaymania city, Iraq, where 78 cases of chronic symptomatic, uncomplicated, nonrecurrent sacrococcygeal PNS were seen. From these 78 patients 6 patients refused operation and they were excluded from the study. Data collected from the remaining 72 patients were age, gender, presenting complaint and its duration, operative findings, duration of the operation, time of wound healing, any hospitalization if required, time to return to work, postoperative complications, postoperative pain, wound hematoma, wound infection, wound disruption, recurrence of the sinus, cost of the operation, patient satisfaction about the treatment and follow up compliance of the patients. They were treated with excision and primary midline closure technique. From the total no of 72 patients, 7 patients were unable to complete the follow up period and they were excluded from the study, and we continued the study of the outcome data of the remaining 65 patients. Of those 65 patients treated excision and primary midline closure, 1 patient (1.53%) developed wound disruption, 4 patients (6.14%) developed surgical site infection (SSI) and only 3 patients (4.61%) had reccurence of the sinus. It is concluded that excision and primary midline closure technique is simple, convenient, economic and successful treatment as day case surgery for chronic, sympotomatic, uncomplicated and non recurrent sacrococcygeal PNS. Introduction acrococcygeal PNS is a common disease. The true incidence is unknown, but a Norwegian study estimates an incidence of 25 per 1. The peak incidence is among those who are 15–24 years of age and decreases after the age of 25 years; it is rare after 45 years. Three quarters of patients are men. All races can develop the disease, but it seems more common in those with dark, stiff or auburn hair. During the Second World War the condition was common in jeep drivers, which led to it being known as jeep disease. Hodges and authors who came after him believed that the disease was S congenital in origin. But in the last 50 years it has been suggested that the condition is most likely to be acquired and the infection originates within a natal cleft hair follicle and hair is a secondary invader. Sacrococcygeal PNS may be asymptomatic, but symptomatic disease usually presents as pilonidal abscess or chronic pain or discharging sinus. There are many surgical methods for treatment of PNS, like excision and healing by secondary intention (open method). Excision and primary closure (closed method) with the incision can be sited over the midline or displaced laterally and excision with Bas J Surg, 16, September, 2010 111 Day case surgery for sacrococcygeal pilonidal sinus using excision and primary midline closure Nizar Hamawandi reconstructive flap techniques e.g. such rhombid flap and Z plasty flap, but there is no clear consensus as to the optimum treatment, the choice of which will typically be based on the surgeon’s preference and training background. Variations in current practice reflect the literature, which describes a wide spectrum of inpatient outcomes for different open and closed surgical techniques. Up to our knowledge this is the first study on sacrococcygeal PNS to be done in Sulaymania governerate, Iraq. The aim of this study is to show the effectiveness of treatment of sacrococcygeal PNS with excision and primary midline closure as day case surgery. Patients and methods A prospective study was done over a period of 3 years, between 1st Jan 2003 and 31st Dec 2005. During that period, 78 cases of chronic symptomatic, uncomplicated, nonrecurrent sacro coccygeal pilonidal diseases were seen in a private general surgical office, in Sulaymania city, Iraq, and planned for treatment with excision and midline closure technique as day case surgery. From these 78 patients 6 patients refused operation and they were excluded from the study. The remaining 72 patients were studied by taking history and performing physical examination, our preferred technique of treatment (excision and primary midline closure), its possible complications, patients enrollment in the study were explained to the patients and informed consents were obtained. All patients were without coexisting diseases, American society of anesthesiologists (ASA) category 1. The following data were recorded: age, gender, presenting complaint and its duration, operative findings, duration of the operation (was defined as the length of time between the first incision and placement of the dressings), time of wound healing (was defined as full epithelialization over the wound and measured in days), any hospitalization if required, time to return to work, postoperative complications, postoperative pain (was measured by using numerical rating scale, 0:no pain, 10:sever pain), wound hematomas, surgical site infection (SSI), wound disruption, recurrence of the sinus (was defined as a wound that did not heal despite treatment or which healed and then followed by the reappearance of symptoms and sinus), cost of the operation (was measured in Iraqi dinnars, the operation was classified as minor operation according to the list of private hospital operation prices released by Sulaymania health authority), patient satisfaction about the treatment (was measured by using numerical rating scale 0:not satisfied, 10:satisfied) and follow up compliance of the patients was recorded also. The operations were done in a private surgical hospital, all as day case surgery and all cases has been handled by a single surgeon. The patients were instructed to take a bath at home on the day of the operation then admitted to the hospital. At the operating room before induction of anesthesia, prophylactic antibiotics were given, ampiclox 500 mg and metronidaxole 500 mg intravenously and continued postoperaively as ampiclox capsule 500 mg every 6 hours and metronidazole tablets 400 mg every 8 hours for 7-10 days. The operation was done in prone position, a sand bag is put under the pelvis, under general anesthesia and endotracheal intubation. The operative area was shaved on the operating table. The buttocks were retracted with adhesive tape to obtain a better visualization of the operative field. The skin was prepared with full strength 10% povidone iodine solution. The drapings were applied and the anus was excluded from the field of the operation. The extent of the sinus was assessed by Bas J Surg, 16, September, 2010 112 Day case surgery for sacrococcygeal pilonidal sinus using excision and primary midline closure Nizar Hamawandi probing it with a fine probe. A midline elliptical incision of skin and subcutaneous tissue was done, including the opening of the sinuses, and the incision was carried vertically down to the sacrococcygeal fascia. Additional tangentially placed incisions were sometimes needed to excise sinuses extending laterally. Careful attention was needed to ensure that the skin edges are not undermined and also to remove all the sinuses and the tracts and not to miss any branching parts behind. Meticulous hemostasis was done with packing and pressure and diathermy coagulation. The operative field was irrigated with diluted 1% iodine solution. A 12F tube drain was inserted lateral to the midline and brought out at the upper part of the wound. The adhesive plasters were removed. The skin was closed with interrupted mattress 0 proline sutures, taking the sutures deep and passing through the midline of the sacrococcygeal fascia, no subcutaneous sutures were inserted, careful attention was paid to proper edge to edge approximation of the skin margins. The wound was dressed with dry gauze, with pressure application with adhesive plasters across the buttocks. Postopreative analgesia was achieved by giving diclofenac sodium 100 mg IM when the patient recoverd from anesthesia, and on the 1st postoperative day paracetamol tab 500mg tablet 4 times daily was given and continued in the following days according to the patient`s requirement. The patients were discharged home at the same day. The patients were instructed to contact our private clinic or the private hospital whenever new symptoms appeared. The patients were encouraged not to lie on their back for the 1st 24 hour. They were allowed out of bed in the 2nd postoperative day, there is no restrictions to postoperative activities, but to avoid excessive physical strain for the following 3-4 weeks. Normal bowel activity takes place as desired. The 1st postoperative visit to the surgical office was on the 5th postoperative day, where the wound was examined, the gauze dressing was removed together with the tube drain and the wound left exposed and dressed with topical povidone iodine 10% solution. Daily bathing was encouraged. The wound is examined weekly for evidence of wound complications [wound hematoma, wound seroma, SSI (surgical site infection) and wound disruption]. The sutures were removed after 10-14 days. Advices were given for general cleanness and hygiene of the sacral area, avoiding sitting or driving for prolonged periods, frequent bathing and regular removal of the hair by shaving the area every 1-2 week until the patient reaches his late thirties when recurrence is unlikely. All patients were followed up in the private surgical office after 1 month, 3 months, 6 months, 1 year, 2 years and 3 years after the completion of the treatment. During the follow period, the time to return to work, recurrence of the sinus,

DAY CASE SURGERY FOR SACROCOCCYGEAL PILONIDAL SINUS USING EXCISION AND PRIMARY MIDLINE CLOSURE