Effective and minimally painful surgery of pilonidal sinus – asymmetric transposition flap according to Dufourmentel

A pilonidal sinus or sinus pilonidalus (pilus = hair, nidus = nest) is an acute or chronic inflammation in subcutaneous fat tissue, usually in the coccygeal region. The first report was by Mayo in 1833. The disease affects predominantly young men in the 2nd and 3rd decade of life with an incidence of 26 per 100 000 population, with men affected 3x more frequently than women. Pilonidal sinus is viewed as an acquired disease with genetic predisposition. A strong covering of hair, the hair structure, obesity (with increased intertriginous spaces) and increased sweating are factors favoring its development. Familiar predisposition, nonetheless, is part of the multifactorial genesis. Therapy consists of generous excision of the entire undermined abscess tissue. The basis of all surgical approaches is radical and complete excision of the pilonidal sinus or the fistula system. Conservative therapies such as antibiotic administration, cooling or ointment application are only stop-gap measures; healing cannot be expected. Incision in the case of an acute abscess is indicated particularly within two-step surgical management. The discussion on the approach to final removal of the pilonidal sinus fistula system is still controversial. Excision with primarily open wound treatment, excision with primary closure in the midline as well as excision with asymmetric closure using various transposition flaps are available. In Germany primarily open treatment is performed. transposition flap is planned to the right or left at an angle of 60°, usually directed caudally. The ration of flap length to width of the pedicle should not exceed 2 : 1 (Figure 1 and 4). Preoperatively antibiotic prophylaxis with a gyrase inhibitor and thrombosis prophylaxis with low-molecular-weight heparin are initiated. After dyeing the fistular tracts with patent blue the diseased area is excised down to the sacral fascia using a diathermy needle, larger blood vessels are ligated and multiple small vessels are subtly occluded using electrocoagulation. The marked flap area is cut and prepared to the gluteal fascia. In addition to generous excision a sufficiently wide mobilization of the wound edges is important to achieve a tension-free, level closure of the defect by the transposition flap. Even with blood-free surgical fields a suction drainage (8-Redon drainage) is placed in the wound bed to prevent seroma formation, subcutaneous sutures and retention sutures with Prolene 2/0 are placed and finally the transposition flap is fixed without tension. Fine adaptation of the skin is performed with Prolene 4/0 (Figure 2). Duration of surgery is between 30 and 50 minutes, depending on the extent of the lesion. The Redon drainage is removed after 2–3 days. Adapting skin sutures are removed on the 12th day, retention sutures around the 15th postoperative day. Patients remain in the clinic overnight for observation. Full burdening is recommended only after 4–6 weeks. Antiphlogistics are administered if needed for 2–3 days. Here fistula-carrying tissue is excised in an ovular fashion down to the sacral fascia and wound healing is by secondary intention with subsequent granulation. This approach corresponds to the recommendations in the last Guidelines of the German Society of Coloproctology [1]. This therapy also has disadvantages for the patient. In the first days or weeks pain is to be expected. Dressing changes by third persons and inpatient therapy often over several days are necessary. Healing duration in open wound treatment lies between 30 and 90 days. Consistent and time-consuming dressing and tamponade changes are required. The associated prolonged sick leave must therefore be taken into consideration. After conclusion of secondary wound healing often a thick, hard, sometimes painful scar remains (no subcutaneous fatty tissue, periosteal irritation). As an alternative to the open method a rhomboid transposition flap in the Dufourmentel technique [2] with primary defect closure and thus shortened reconvalescence is presented in the following.