What is the efficacy of excision with primary closure for treatment of pilonidal disease?

Updated: Jun 11, 2018
  • Author: M Chance Spalding, DO, PhD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

Excision of a pilonidal sinus [21] entails excision of the midline pits and lateral openings down to the presacral fascia, with removal of minimal surrounding skin. In general, it is unnecessary to remove more than 0.5 cm of skin surrounding the sinus opening. Curetting the wound to remove hair, granulation tissue, and skin debris is essential for promoting adequate wound healing. Although this procedure can be performed with local anesthesia alone, the addition of mild sedation to local anesthesia allows a more complete excision and a more comfortable patient.

Primary wound closure and wound healing by secondary intention are the two principal surgical options for a chronic pilonidal sinus. [22, 6] There remain some differences between these two approaches with regard to wound healing and recurrence. Although primary closure has the potential for earlier wound healing if infection does not occur, it does require that the patient restrict many activities until wound healing is complete.

The incidence of failed primary healing is approximately 16%. This is because a primary closure is rarely completely free of tension and because the wound is considered contaminated despite excision and debridement. Recurrence rates after primary closure may be as high as 38%. Although the technique of excising the pilonidal disease and allowing the patient to heal by secondary intention requires a longer healing time, it is associated with a lower recurrence rate.

In a study that included 242 patients with symptomatic pilonidal disease, Khodakaram et al compared conventional wide excision (n=129) with a modified Lord-Millar (mLM) approach consisting of minimal excision of pilonidal sinuses with primary suture (n=113). [25] The mLM operation was associated with more frequent use of local anesthesia, a lower frequency of hospital admission, fewer postoperative health care visits (2.4 vs 14.6), and a shorter average sick leave (1.0 vs 34.7 days). Estimated 5-year recurrence rates were similar (32 vs 23%). Cost per operated patient and utilization of hospital resources were also lower for the mLM group.


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