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INDICATIONS

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Pilonidal cysts and sinuses should be completely excised or exteriorized (figure 1a and b) . Acutely infected sinuses should be incised and drained, followed later by complete excision after the acute infection subsides. The more limited procedure of exteriorization (marsupialization) is effective when the sinus tract is well defined (figure 1b). Regardless of the various surgical approaches, such lesions may recur.

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PREOPERATIVE PREPARATION

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In complicated sinuses with several tracts present, a dye such as methylene blue may be injected for better identification, although if a careful dissection is carried out in a bloodless field, the surgeon can identify the sinus tracts. It is important that this be done several days before the operation to avoid excessive staining of the operative area, which may occur if the injection is done at the time of operation.

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ANESTHESIA

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Light general anesthesia is satisfactory. The patient’s position requires that special care be taken to maintain an unobstructed airway. Spinal anesthesia should not be used in the presence of infection near the site of lumbar puncture.

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POSITION

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The patient is placed on his or her abdomen with the hips elevated and the table broken in the middle (figure 2).

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OPERATIVE PREPARATION

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Two strips of adhesive tape are anchored snugly and symmetrically about 10 cm from the midline at the level of the sinus and pulled down and fastened beneath the table (figure 3). This spreads the intergluteal fold for better visualization of the operative area. A routine skin preparation follows after the skin is carefully shaved.

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DETAILS OF PROCEDURE

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An ovoid incision is made around the opening of the sinus tract off the midline about 1 cm away from either side (figure 4).Firm pressure and outward pull make the skin taut and control bleeding.

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An Allis forceps is placed at the upper angle of the skin to be removed, and the sinus is cut out en bloc (figure 5). The subcutaneous tissue is excised downward and laterally to the fascia underneath. Great care is exercised to protect this fascia from the incision, as it offers the only defense against deeper spread of infection (figure 6). Small, pointed hemostats should be used to clamp the bleeding vessels in order that the smallest amount of tissue reaction be incurred. Electrocoagulation may be used to control bleeding and to keep the amount of buried suture material to a minimum. Some prefer to avoid burying any suture material by using compression or electrocoagulation to control all the bleeding points. Extreme care should be taken in the dissection of the lower end of the incision, as many small, troublesome vessels are encountered frequently that tend to retract when divided. After ...

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