Sinotomy technique versus surgical excision with primary closure technique in pilonidal sinus disease

Pilonidal disease is a common chronic disorder mainly seen in the sacrococcygeal region, especially in young males. Many surgical treatment modalities have been suggested, but an ideal and widely accepted treatment has yet to be established. Th e aim of this study was to compare quality of life of patients treated with the sinotomy technique with quality of life of patients treated with surgical excision plus primary closure technique by means of quality of life questionnaire. Th e data of patients who had been treated for pilonidal sinus in our clinic from September 2010 to June 2012 were analyzed retrospectively. Forty patients were treated with sinotomy technique and 40 patients were treated with surgical excision plus primary closure technique. Time to return to work and to time to complete wound healing were evaluated. All patients were asked to fi ll the questionnaire after complete healing occurred. Postoperative complications were bleeding in 2.5, infection in 3.75 and fever in 2.5 patients. Th ere were no signifi cant diff erences between the two groups in terms of complete healing (p=0.1) and sport times (p=0.1). Th ere were signifi cant diff erences between the groups in terms of length of hospital stay (p≤0.001), time off work (p≤0.001), times to sitting on toilet and walking without pain (p=0.002 and p≤0.001,respectively). Th e mean postoperative VAS scores were 5.2±3.2 and 2.8±2.2, respectively (p=0.02). Th e technique of sinotomy with good wound and surrounding skin care seems to be an ideal approach with high chance of cure. Th e patients returned to their routine in a short period of time.


INTRODUCTION
Pilonidal sinus (PS) is a common condition aff ecting young and middle-aged adults.It occurs more commonly in males.Th is disease has important economic impacts and is associated with frequent inability to work and discomfort.Men are thought to be at higher risk because of their more hirsute nature.Th e pathogenesis remains uncertainand, there are both congenital and acquired suggestions for the etiology of this condition [1].Risk factors include adiposity, sedentary occupation -life style, local irritation-trauma, insuffi cient body hygiene, excessive hairiness and perspiration [2,3].Many methods of surgical and nonsurgical treatment have been described in the literature [1], including: excision and lyingopen, excision and primary closure of the wound [1], rhombfl ap procedure [4,5].However, midline excision and primary closure remains the most commonly adoptedtechnique worldwide [6].Th e ideal approach for treating pilonidal disease should be simple, infl ict minimal pain, have the best chance for a cure and the least local recurrence rate, avoid admission to the hospital, avoid general anesthesia, and require minimal wound care, inconvenience and time off work for the patient [7,8].Maintaining the quality of life is the main goal for patients with pilonidal disease; it also minimizes the time off work, deviation from normal activity, and costs [9,10]."Return to work period" should be as short as possible because of the economic impacts [11,12].Th e procedure of incision and lying open (sinotomy) involves local excision of the midline sinuses, extending into the central cavity and laying open lateral tracts.Any hairs contained in the sinus are removed and wall of the cavity is scrapped free of granulations [13].We aimed at comparing two techniques: the sinotomy technique with surgical excision and the primary closure technique (the most commonly used techniques in our clinic) in terms of the quality of life by means of a life quality questionnaire.For this purpose,

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we searched for a life quality questionnaire.SF-36 and other questionnaires were general, inadequate, and could not identify problems arising from the treatment of pilonidal disease.For this reason, we designed a questionnaire with 14 items, containing perioperative pain assessment as well as a visual analog scale (VAS).

MATERIALS AND METHODS
In our study we retrospectively evaluated 101 cases treated for pilonidal sinus disease from September 2010 to June 2012.Sinotomy technique was performed in 40 patients, and surgical excision as well as primary closure was done in 40 patients, all of them diagnosed with pilonidal disease.Exclusion criteria were previous pilonidal abscess surgery, diabetes mellitus, renal failure, immunosuppression, and age <16 years.All 80 patients fulfi lling the criteria completed the study.We used Irkörücü and Adana Numune' s classifi cation [14] and treatment concept in sacrococcygeal pilonidal disease.Surgical techniques were used in types Ib, IIa, IIb, and some type III patients according to Irkörücü and Adana Numune' s Classifi cation and Treatment Concept (Table 1).Patients' data (demographics and characteristics; age, gender, obesity, hirsute nature, positive family history) were extracted from the medical records.Excision surgery and the primary closure technique were carried out under general anesthesia with endotracheal intubation.Th e sinotomy procedure was performed under local anesthesia, with the patient lying prone.Povidone-iodine antiseptic solution was applied on the shaved skin of the buttocks, and sterile drapes were used to expose the sacrococygeal area.A small quantity of methylene blue was injected into the sinus opening in order to stain the diseased tissue and to identify the sinus extensions.Th e technique of sinotomy was performed as follows: 20 mL of 0.5 bupivacaine with 1:200,000 epinephrine was infi ltrated in the sacrococcygeal area around pilonidal sinus, along with intravenous sedation using 1.5-3 mg of midazolam titrated slowly within fi ve minutes to the desired eff ect.Th e main orifi ce was identifi ed, cannulated with a suitably sized metal probe.Th is was followed by probing the main track and laying it open on the probe.Any cyst wall was dissected out and hair tufts removed.Th e cavity was then curetted to remove infected granulations and debris, followed by washing with hydrogen peroxide and diluted povidone-iodine solution, and fi nally, irrigated copiously with saline.Haemostasis and light packing were performed in the end of the operation.Postoperatively the patients had been observed for 15 minutes then discharged, with prescribed oral analgesics containing paracetamol and codeine.Sinus excision and primary closure was performed as a surgical treatment.All patients were admitted to the hospital the day before the surgery and operated under general anesthesia.Th e patients were placed in the prone jack-knife position on the operating table.Th e natal cleft was shaved just before the surgery.Excision and primary closure was carried out as recommended by Goligher [13].No antibiotics were administered.Th e patients were instructed to return to normal daily activities as soon as they felt comfortable.All patients were checked weekly until the wound had healed and then every three months for one year.Th e patients were scheduled for wound inspection and removal of the sutures on day 7 and day 14 postoperatively.When no leakage from the wound and no dehiscence signs were observed, the last dressing was detached, and this was accepted as a complete healing.In order to evaluate quality of life and patient comfort, all patients were asked to fi ll the questionnaire after complete healing occurred (Supplementary material).Answers were documented and analyzed.Duration of incapacity for work was defi ned as the time from the very day of the surgery to the day on which the patient returned to normal activities including work and leisure activities.Th e V Recurrent pilonidal disease Surgical procedures should be preferred according to the extension of the recurrent disease pain level reported by patients was assessed in the pre-and post-treatment period with a visual analog scale (VAS) score.VAS scores were marked by patients on a horizontal scale, where "0" indicated painless condition and "10" denoted the worst pain.

Statistical Analysis
All data are presented as mean ± standard deviation (SD) unless stated otherwise in the text.Continuous variableswere checked for the normal distribution assumption using the Kolmogorov-Smirnov statistics.Diff erences among the groups were analyzed by the Student' s t-test and the Mann-Whitney U test for continuous variables and the chi-square test for categorical variables, as considered appropriate.Th e probabilities of less than 0.05 were accepted as signifi cant.Data were analyzed using the SSPS 15.0 for Windows software (SPSS® Inc.Chicago IL).

RESULTS
Th ere were 46 men (57.5) and 34 women (42.5) participating in this study.Th eir ages ranged between 16 and 44 years with a mean of 25.7 years.Th e mean BMI of the study population was 27.2 (range 23.6 -41.9), and 41.25 (33/80) of patients were hirsute in nature.As seen in Table 2, no significant diff erences between the two groups were observed in any of the patient characteristics in addition to age and gender.Postoperative complications were bleeding in 2.5, infection in 3.75 and fever in 2.5.Two patients experienced postoperative bleeding that required evaluation in the emergency department.Bleeding was controlled by external packing and application of local pressure and none required surgical haemostasis or blood transfusion.In a one year follow-up period, no patient suff ered from recurrence of the disease.Th e clinical outcomes of both treatment modalities are listed in Table 3. Th ere were signifi cant diff erences between the two groups in terms of quality of life except for complete healing (p=0.1) and sport times (p=0.1).Th e mean postoperative Visual analogue scale scores were 5.2±3.2 and 2.8±2.2,respectively (p=0.02).

DISCUSSION
Various techniques are used currently in the treatment of pilonidal sinus disease [15].Nevertheless, optimal treatment methods for each condition of pilonidal disease have yet to be established.An ideal surgical treatment of pilonidal disease should be simple, necessitate a short hospital stay, and have a low disease recurrence rate.In the literature, diff erent surgical treatment options have been described for managing this condition.Most commonly, marsupialization, primary midline closure and skin fl aps have been used as treatment modalities [16,17].Diff erent rates of morbidity, recurrence and hospitalization times have been reported for each technique [16,18].Larger operations require longer healing times, sometimes several weeks.Surgery has a signifi cant failure rate, with a high incidence of recurrence following the procedure [19,20].Excision of the pilonidal sinus with primary closure has the advantage of rapid healing, but the recurrence rate is also relatively high -up to 38 [1,21].Excision with primary closure obviates a large wound but in the process, the chances of wound infection; wound dehiscence and recurrence are very high [22].Techniques involving closure by Z-plasty, rhomboid or myocutaneous advancement fl aps require long operative time and hospital stay and are fraught with complications like loss of the graft or fl ap [23].Th e usual mean for hospital stay in excision and primary closure techniques reported in previous studies was 4-5 days [24,25].
Incision and lying open (sinotomy) procedure involves local excision of the midline sinuses, extending into the central cavity and laying open lateral tracts.Any hairs contained in the sinus are removed and wall of the cavity is scrapped free of granulations [13].However, it has been reported that the chances of infection are much bigger in the wounds created

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by excision and suturing [26].Incidence rates of wound dehiscence followingexcision and primary repair are much bigger than previously considered [22,23].Th ese procedures also require a long hospital stay and long periods off work [13].
Al Naami reported his experience with the sinotomy technique [27].Th e procedure was carried out under local anesthesia on an outpatient setting, with a complication rate of 3 and a recurrence rate of 2.Yalcin [28] reported that sinotomy has the advantages of simplicity, the possibility to be performed under local anesthesia with excellent recurrence rate of 0 and complication rate of 1.69.In sinotomy, however, as almost no tissue is excised, disfi gurement is minimal and only a narrow short midline scar is left and recurrence, if occurs, could be managed by the same procedure [29].Quality of life is the main goal for patients with pilonidal disease; it also minimizes the time off work, deviation from normal activities, and costs [9,10].In a study evaluating the quality of life, Ertan et al. have reported that the Limberg fl ap technique used in pilonidal sinus surgery is better than primary closure [24].Aydede et al. have reported that the excision and fl ap procedures seem to be successful in large pilonidal sinuses.However, in uncomplicated cases, excision and primary closure yields better results [30].Ideal treatment for pilonidal disease should: be simple, need no hospitalization, minimize both: fi nancial costs for the community, as well as costs for the patient; should not worsen the quality of life, and should be associated with a low complication rate and minimal pain [31,32].

CONCLUSION
Th e method described in this paper was found to be simple, cost-eff ective, and seems ideal with high chances of cure.Th e patients returned to their daily routine within a short period of time.

DECLARATION OF INTERESTS
Th e authors declare no confl ict of interests.

TABLE 1 .
Irkörücü and Adana Numune's classifi cation and treatment concept in sacrococcygeal pilonidal disease III Pits on both side of the natal cleftFlap procedures with wide excision (e.g., modifi ed rhomboid excision and limberg fl ap, dufourmentel rhomboid fl ap, etc.)IV Complex pilonidal disease with multple pits on and side of the natal cleft Wide excision and large fl ap procedures (e.g., rotation fl aps, double rhomboid transposition fl ap, crossed triangular fl aps, negative pressure wound therapy, etc.)

TABLE 2 .
Patient demographics and characteristics

TABLE 3 .
The clinical outcome of both treatment modalities