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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 1-5

Lazy S technique for uncomplicated pilonidal sinus


1 WIALS, Highway Hospital, Thane West, Maharashtra, India
2 Department of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, USA

Date of Web Publication17-Sep-2018

Correspondence Address:
Shekhar Suradkar
CMD-Highway Hospital, Thane, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_6_18

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  Abstract 


Background: We present a new Lazy S technique for reconstruction of a defect resulting from excision of the pilonidal sinus. Materials and Methods: In this technique, semilunar incisions, at the opposite ends of the defect facing away from each other are made. Undermining flaps in the subcutaneous tissues is then made, for about 2 cm to facilitate tension-free closure. Results: A total of 42 males were closed by this technique, all under local anesthesia. The in-hospital stay was for 2 days in all patients. One patient (2.1%) developed hematoma and one patient (2.1%) had wound break down which was managed conservatively by secondary intention. Recurrence was seen in 4 (8.3%) patients. Conclusions: Our Lazy-S closure technique is a useful technique for the treatment of pilonidal sinus with favorable.

Keywords: Closure of pilonidal sinus wound, pilonidal sinus, surgical flaps


How to cite this article:
Suradkar S, Suradkar K. Lazy S technique for uncomplicated pilonidal sinus. Indian J Colo-Rectal Surg 2018;1:1-5

How to cite this URL:
Suradkar S, Suradkar K. Lazy S technique for uncomplicated pilonidal sinus. Indian J Colo-Rectal Surg [serial online] 2018 [cited 2018 Oct 21];1:1-5. Available from: http://www.ijcrsonweb.org/text.asp?2018/1/1/1/241300




  Introduction Top


The management of pilonidal sinus has been an enigma for general surgeons worldwide and still remains a controversial topic.

Although the patient usually lives with the disease without any major issues, at times, surgical intervention becomes necessary. Many procedures have been described for the surgical management. All the procedures have some morbidity associated with it. We describe a simple technique for uncomplicated pilonidal disease which is easy to perform, adhering to the principles of pilonidal disease treatment, with less morbidity and aesthetic value.


  Materials and Methods Top


This was a retrospective analysis of a prospectively maintained data. Case records of patients who underwent the Lazy S technique for pilonidal sinus from the year 2007–2012 at our Institute were accessed from our database. Consenting adults with uncomplicated pilonidal disease were included in the study. The inclusion criteria were limited to but not exclusive to following factors – uncomplicated chronic pilonidal disease with 3–5 openings in and near the midline sacrococcygeal area, failure of medical treatment, more than 2 attacks of abscess formation. Patients with acute pilonidal abscess were excluded from the study.

Procedure

The procedure was standardized. The patient was put in a prone jackknife position with a pillow below the pelvis for elevation. The buttocks were separated to expose the operative area using tape. Depilation was done preoperatively using commercially available creams. The operative area was prepped and draped in a sterile surgical fashion. All cases were performed under local anesthesia (LA) using a mixture of bupivacaine and lidocaine (1:100,000). The use of intravenous sedation or anxiolytics was left to the discretion of the anesthetic and the patient. After testing the anesthetized area with a tooth forceps to check the effect of LA, infiltration of the surrounding area with a solution of normal saline (100 ml) and 5 drops of noradrenaline was done. Methylene blue dye was instilled in from the main sinus opening as shown in [Figure 1]. A fistulotomy probe was passed through the midline pit or pits [Figure 2]. Excision of the complete tract was performed over the probe excising the tract, beginning from caudal, end dissecting our way to the cephalad end. Care was taken to stay close to the wall of sinus without going deeper beyond the wall of the tract. The sinus tract was cored out completely including the pits meticulously [Figure 3], [Figure 4], [Figure 5]. The area was then examined thoroughly.
Figure 1: Instillation of injection methylene blue to delineate the tract and the opening of tract

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Figure 2: The tract being probed with excision done over the probe

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Figure 3: Sinus tract being excised

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Figure 4: Excision of tract keeping the midline intact

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Figure 5: Keeping the deeper structures intact while excising the tract

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After achieving thorough hemostasis, semilunar incisions, at the opposite ends of the defect facing away, were made at both ends as shown in the [Figure 6]. Depending on the size of the midline wound, small parts of the skin near these incisions were excised. The extent of the incision also depended on the length of the midline wound. The total length of the lateral incisions was less than the length of the midline incision as shown in [Figure 7]. As a practice, we always create undermining flaps in the subcutaneous tissues for about 2 cm to facilitate tension-free closure. The end result is as seen in the picture.
Figure 6: Lazy S incision taken

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Figure 7: Flap being created

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The subcutaneous tissue is sutured with 3/O Vicryl sutures with the aid of skin hooks, while the skin is sutured with fine interrupted sutures of 4/O Ethilon as shown in [Figure 8]. As a protocol, a drain is kept in the in the subcutaneous tissue in the postoperative period. At the end of the procedure, a pressure dressing is given, ensuring isolation of the wound from the perineum. Postoperatively, patients were asked to lie in a recumbent or prone position for a minimum of 2 days. Patients were started on a liquid diet in the immediate postoperative period. Postoperative pain was taken care of with oral NSAIDs. Patients were discharged on the 2nd postoperative day (POD). The wound was reassessed on POD 4. The patients were given strict instructions to avoid sitting on buttocks till the wound was completely healed. Till then, usage of donut ring was encouraged. The need to maintain meticulous hygiene and depilate fortnightly around the area of pathology was also stressed upon to the patients. The patients were asked to follow up after a fortnight and thereafter at the end of 2, 4, and 6 months and one year. Thereafter, they were asked to report as and when required. [Figure 9] shows a well healed wound at the end of one year.
Figure 8: The sutured wound

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Figure 9: Scar at the end of 1 year

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  Results Top


A total of 42 patients underwent the procedure of Lazy S technique during the study. All of the patients were males, with their median age being 24 years (range 20–55 years). In all the 42 patients, the procedure could be completed under LA. There were no intraoperative complications during the procedure.

In the immediate postoperative period, 1 patient (2.1%) developed hematoma which was managed with wound exploration, and 1 patient (2.1%) had wound break down which was managed conservatively by secondary intention. Both the procedures were performed under LA.

A follow-up of 6 months was there in all the 42 patients. Four (8.3%) patients had recurrence, 3 in the first 3 months of the procedure and 1 after 1½ of the procedure. While 2 of the 4 cases were again managed using the Lazy S technique the other 2 cases were re-operated with Z plasty technique. In all the four patients, the wound healed without any further complications. There were no wound infections in our series in the postoperative period.


  Discussion Top


The word pilonidal derives from the Latin words pilus ("hair") and nidus ("nest") was first described by Hodges in 1880[1] Its diagnostic characteristic feature is the presence of an epithelial track situated in the skin of the natal cleft, a short distance behind the anus, and generally containing hair.

The treatment options available include fistulotomy with curettage, followed by leaving the wound open to closing the defect with advanced flap repair technique. The various treatment options described in literature include shaving,[2] phenol application,[3] unroofing and curettage,[4] open treatment, repair with partial and primary suture,[5] repair with a local flap,[6],[7],[8],[9],[10],[11] and repair with a local or distant fasciocutaneous and musculocutaneous flap.[12]

The age-old technique of leaving the wound open until granulation tissue occurs or allowing it to heal secondarily with a skin graft is almost given up by many. Although it is associated with low recurrence rates, it is not cost-effective and also requires a longer healing time ranging from 3 to 8 weeks.[13],[14],[15] In a study done by Solla and Rothenberger, reported mean healing time of 4 weeks with a recurrence rate of 6%, for 150 patients who underwent this procedure.[16] Besides, leaving the wound open carries a high risk of infection and also leads to poor scar formation.[17]

Closure of the wound is not only associated with a shorter healing time and less time off work but also cosmetically acceptable to all. Although wide local excision and primary closure is advocated by some, it results in a midline scar and also a high incidence of recurrence.[18],[19]

Off-midline procedures are now considered as the standard of care for the management of Pilonidal Sinus. A meta-analysis including a number of randomized controlled studies published by McCallum et al.[20] have reported a low recurrence rates with off-midline closure techniques. The various off-midline techniques described for defect reconstruction are Rhomboid excision plus Limberg flap, Karyadakis flap, Bascom (cleft lift), V-Y advancement flap, Z-plasty, elliptical rotation flap, perforator flaps, and gluteus maximus muscle-skin flaps. Each of these techniques has its own advantages and disadvantages.

The Lazy S technique described by us is also an off-midline procedure. The basic principles of "Lazy S technique" are as follows:

  1. Staying close to the wall of the sinus while dissection
  2. Making of two curvilinear incisions at the caudal and cephalad end in opposite directions.


  3. Moreover, it adheres to the principle of not causing more harm, as it is simple with a very low morbidity.


The infection rate of our technique was 2.1%, which is similar to the other procedures described in the literature. Infection of 12% has been reported with Karydakis flap technique,[21] while with Limberg flap, it ranges between 0.8% and 3%.[9],[22]

The incidence of wound dehiscence following our technique too was low (2.1%) as compared to the reported incidence of 23% following Limbers procedure.[20]

While studies have shown no incidence of hematoma formation following Limberg flap E and Bascom's procedure;[23] in our study, one patient developed hematoma following reconstruction of flap by our technique.

The duration of hospital stay after surgery reflects the cost-effectiveness and the outcome of the technique. Three different studies have shown that the length of hospital stay in patients undergoing surgery with Limberg technique were 2, 4, and 6 days, respectively.[24],[25],[26] In our study, the length of hospital stay was 2 days only.

The reported recurrence rate Karydakis technique is 1%,[27] with Bascom cleft lift technique [28] 1.3%, and by Limberg flap technique 1.5% (range, 0.8%–2.7%).[24]

Thus, our technique of Lazy-S flap procedure is a viable off-midline technique. Although the present study lacks a large number and a long-term follow-up, it has a comparable rate of infection, hematoma formation, wound dehiscence and in-hospital stay with other practiced techniques.


  Conclusion: Top


The Lazy-S flap procedure is a good option for the closure of the wound post pilonidal sinus excision.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hodges RM. Pilonidal sinus. Boston Med Surg J 1880;103:485-586.  Back to cited text no. 1
    
2.
Armstrong JH, Barcia PJ. Pilonidal sinus disease. The conservative approach. Arch Surg 1994;129:914-7.  Back to cited text no. 2
    
3.
Schneider IH, Thaler K, Köckerling F. Treatment of pilonidal sinuses by phenol injections. Int J Colorectal Dis 1994;9:200-2.  Back to cited text no. 3
    
4.
Kepenekci I, Demirkan A, Celasin H, Gecim IE. Unroofing and curettage for the treatment of acute and chronic pilonidal disease. World J Surg 2010;34:153-7.  Back to cited text no. 4
    
5.
da Silva JH. Pilonidal cyst: Cause and treatment. Dis Colon Rectum 2000;43:1146-56.  Back to cited text no. 5
    
6.
Berkem H, Topaloglu S, Ozel H, Avsar FM, Yildiz Y, Yuksel BC, et al. V-Y advancement flap closures for complicated pilonidal sinus disease. Int J Colorectal Dis 2005;20:343-8.  Back to cited text no. 6
    
7.
Bascom JU. Repeat pilonidal operations. Am J Surg 1987;154:118-22.  Back to cited text no. 7
    
8.
Arumugam PJ, Chandrasekaran TV, Morgan AR, Beynon J, Carr ND. The rhomboid flap for pilonidal disease. Colorectal Dis 2003;5:218-21.  Back to cited text no. 8
    
9.
Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, Oguz M, et al. Modified limberg transposition flap for sacrococcygeal pilonidal sinus. Surg Today 2004;34:419-23.  Back to cited text no. 9
    
10.
Karydakis GE. New approach to the problem of pilonidal sinus. Lancet 1973;2:1414-5.  Back to cited text no. 10
    
11.
Bessa SS. Results of the lateral advancing flap operation (modified karydakis procedure) for the management of pilonidal sinus disease. Dis Colon Rectum 2007;50:1935-40.  Back to cited text no. 11
    
12.
Stroosma OC. Gluteal fasciaplasty as a method of primary closure in the treatment of pilonidal sinus. Arch Chir Neerl 1978;30:61-4.  Back to cited text no. 12
    
13.
Eryilmaz R, Sahin M, Okan I, Alimoglu O, Somay A. Umbilical pilonidal sinus disease: Predisposing factors and treatment. World J Surg 2005;29:1158-60.  Back to cited text no. 13
    
14.
Søndenaa K, Andersen E, Nesvik I, Søreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis 1995;10:39-42.  Back to cited text no. 14
    
15.
Borges G, Maciel Júnior JA, Carelli EF, Alvarenga M, De Castro R, Bonilha L, et al. Pilonidal cyst on the vault. Case report. Arq Neuropsiquiatr 1999;57:273-6.  Back to cited text no. 15
    
16.
Solla JA, Rothenberger DA. Chronic pilonidal disease. An assessment of 150 cases. Dis Colon Rectum 1990;33:758-61.  Back to cited text no. 16
    
17.
Dahmann S, Lebo PB, Meyer-Marcotty MV. Comparison of treatments for an infected pilonidal sinus: Differences in scar quality and outcome between secondary wound healing and limberg flap in a prospective study. Handchir Mikrochir Plast Chir 2016;48:111-9.  Back to cited text no. 17
    
18.
Søndenaa K, Diab R, Nesvik I, Gullaksen FP, Kristiansen RM, Saebø A, et al. Influence of failure of primary wound healing on subsequent recurrence of pilonidal sinus. Combined prospective study and randomised controlled trial. Eur J Surg 2002;168:614-8.  Back to cited text no. 18
    
19.
Muzi MG, Milito G, Cadeddu F, Nigro C, Andreoli F, Amabile D, et al. Randomized comparison of limberg flap versus modified primary closure for the treatment of pilonidal disease. Am J Surg 2010;200:9-14.  Back to cited text no. 19
    
20.
McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for pilonidal sinus: Systematic review and meta-analysis. BMJ 2008;336:868-71.  Back to cited text no. 20
    
21.
Petersen S, Aumann G, Kramer A, Doll D, Sailer M, Hellmich G, et al. Short-term results of karydakis flap for pilonidal sinus disease. Tech Coloproctol 2007;11:235-40.  Back to cited text no. 21
    
22.
Lapid O, Rosenberg L, Cohen A. Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg 2001;54:570-2.  Back to cited text no. 22
    
23.
Guner A, Boz A, Ozkan OF, Ileli O, Kece C, Reis E. Limberg flap versus bascom cleft lift techniques for sacrococcygeal pilonidal sinus: Prospective, randomized trial. World J Surg 2013;37:2074-80.  Back to cited text no. 23
    
24.
Cihan A, Mentes BB, Tatlicioglu E, Ozmen S, Leventoglu S, Ucan BH, et al. Modified limberg flap reconstruction compares favourably with primary repair for pilonidal sinus surgery. ANZ J Surg 2004;74:238-42.  Back to cited text no. 24
    
25.
Daphan C, Tekelioglu MH, Sayilgan C. Limberg flap repair for pilonidal sinus disease. Dis Colon Rectum 2004;47:233-7.  Back to cited text no. 25
    
26.
Tekin A. A simple modification with the limberg flap for chronic pilonidal disease. Surgery 2005;138:951-3.  Back to cited text no. 26
    
27.
Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z J Surg 1992;62:385-9.  Back to cited text no. 27
    
28.
Tezel E, Bostanci H, Anadol AZ, Kurukahvecioglu O. Cleft lift procedure for sacrococcygeal pilonidal disease. Dis Colon Rectum 2009;52:135-9.  Back to cited text no. 28
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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