Pilonidal cyst – (sacrococcygeal fistula, pilonidal sinus)
Pilonidal cyst - Causes. Which treatments are applied today? What are their advantages and disadvantages
Pilonidal cyst is a chronic relapsing disease that can be manifested in various parts of the body (intergluteal cleft, navel, etc.). However, it is often found in the sacrococcygeal area. In the old days, it was thought that pilonidal cyst might be a congenital disease, but nowadays the theory behind its development is that it is acquired. A group of hairs gets trapped in a deep and hairy natal cleft in which pressure is applied (e.g., vehicle drivers) leading to abscess formation and chronically to the formation of fistulas.
The disease may manifest as a simple cyst, abscess or can be complicated with many pores. The most common clinical manifestation is a painful inflammatory mass in the sacrococcygeal area with concomitant mild cellulites and often the formation of small cavities or pits. The disease rarely extends to the anus. If an abscess is formed (the cause of which is polymicrobial), drainage is required through eccentric excision and debridement (removal of hairs).
This is a wide excision of the pilonidal cysts with 5 mm borders down to the sacrococcygeal fascia. More specifically, three methods of wide excision of pilonidal cyst are described: Closed, semi-closed and open method.
The closed method involves wide excision of the cyst, and primary closure of the wound with sutures. This technique offers the advantage of faster healing and better aesthetic result; it is accompanied, however, by a higher rate of complications, such as recurrence of the cyst, inflammation, suppuration and wound dehiscence, etc. The semi-closed method involves the primary closure of the wound with partial sutures, so as to facilitate healing and simultaneously to provide adequate drainage of the wound, in order to significantly reduce the risk of suppuration, local accumulation and wound dehiscence. With frequent clothing changes the wound heals by secondary intention. It is more advantageous than the closed method due to the lower recurrence rates or suppuration but its disadvantage is the increased healing time.
In the open method after the excision of the pilonidal cyst the wound is left open and healing by secondary intention is achieved after consecutive clothing changes and the use of topical antiseptics. It clearly has lower chances of suppuration or recurrence, it requires, however, significantly greater healing time and is often accompanied by poor cosmetic outcome. Marsupialization: This procedure involves the insertion of a probe via the main pore, opening and converting the closed cavity into an open pouch, removal of pus and hair and creation of a shallow wound that heals more easily. Marsupialization sutures at the periphery. It has a similar cure rate of pilonidal cyst achieved with wide excision. Methods without excision: They involve careful removal of hair and fibrin from the pores without excision. It requires long-term follow up. Phenol injection into the cyst: Holds a high recurrence rate of the pilonidal cyst and is associated with significant pain. Simple incision of the pilonidal cyst: It involves the incision of the pilonidal cyst solely either through a midline incision that remains open or through a paramedian incision which then is closed. The advantage of the paramedian incision is that it heals more easily, but is not always easy to perform, especially in a complicated disease. Excision of the cyst and closure with reconstructive flap: Necrosis and flap infection are the main problems.
- Karydakis flap: Eccentric elliptical excision (A), removal of the cyst and all the pores up to the sacrococcygeal fascia, mobilization of a flap on one side (B) and closure of the wound, resulting in a shallower natal cleft (C). A closed suction drain is also placed under the flap (recurrence 1%). Hematoma is the main complication.
- Cleft closure (Bascom procedure): This is a closed method with eccentric excision. We close it by creating a skin flap. It includes subcutaneous placement of suction drain.
- Local flaps: They are divided in full thickness z-flap, rhomboid (Limberg) flap, V-Y flap.Recurrence is mainly attributed to infection and incomplete initial technique. Another similar surgical intervention may be performed; however deep wounds that fail to close may require special treatment, such as gluteus maximus myocutaneous flap.The injection of fibrin glue and the use of VAC (Vacuum assisted closure, pressure device for the treatment of post-operative infections) appear to reduce relapses and postoperative hospitalization time, while the use of drains or the administration of antibiotics do not affect the progression of the disease.