Table of Contents  

Al-Ozaibi, Hazim, Al-Mazrouei, AL-Badri, and Al-Ani: Modified Lord–Miller procedure – less is more effective in treating pilonidal sinus

Introduction

Pilonidal disease was first described by Hodges1 in 1880 as an epithelial track situated in the skin of the natal cleft and generally containing hair, hence the name pilonidal, which is taken from the Latin and means literally ‘nest of hairs’.

There is very little evidence for a congenital origin for pilonidal sinus, and the current consensus favours an acquired mechanism resulting from the frictional force generated in the depths of the natal cleft, which tends to drive the hairs subcutaneously where they generate a foreign body reaction.2 It occurs more often in men than in women, is common in people with thick, stiff hairs and usually occurs after puberty (from early adolescence to the mid-30s), favouring the effect of androgens as a risk factor. Other risk factors that might play a role in the cause or delayed healing and recurrence include obesity, a deep natal cleft with poor hygiene, loose natal cleft hairs, family history, infection and local irritation and friction such as sitting and driving for long periods. The condition was termed ‘jeep disease’ after its common occurrence in the United States army in those who had prolonged rides in jeeps during World War 2.

The main concerns in the surgical management of pilonidal sinus disease are wound complications and recurrence. Several techniques have been implemented to address these problems. Most of the procedures performed have a failure rate. Wide excision with secondary wound healing is a frequently performed surgical procedure for pilonidal sinus. This intervention requires general anaesthesia and has a wound healing time of up to several months, with a long interval before the patient can return to work. Wide local excision with either primary closure or reconstructive surgical closure also did not have favourable results or outcomes. Limited excision of the pits and the sinus, preserving intact skin and subcutaneous tissue, can be performed under local anaesthesia in an outpatient setting. Both the healing rate and return to work are faster, and the recurrence rate is low.

Therefore, the aim of any optimal treatment should fulfil the following criteria: quick healing, minimal open wounds that can be easily self-managed by the patient, no hospital admission, carried out under local anaesthesia, early return to work, minimal patient inconvenience and low recurrence.

Method

Data were collected from the records of 44 patients who underwent excision of pilonidal sinus using a modified Lord–Miller procedure6 during the period from September 2011 to May 2013. Pilonidal sinus was classified as simple or complicated. Complicated sinus refers to a sinus with side branches and a lateral opening or one with more than three pits. Cases with infected pilonidal sinus or abscess were excluded from the study.

The procedure was performed mainly under local anaesthesia. The primary pits in the midline were removed by excising a narrow border of skin around the pits, the sinus tract was excised from underneath the skin preserving the intact subcutaneous tissue and a bridge of skin was left between the openings.

During a follow-up period of 12–32 months (median: 17.5 months) details of healing (i.e. no signs of discharge), recurrence and complications were gathered. Patients were seen in the clinic once a week, until completely healed, and again 1 year after surgery. Patients who were not able to attend the clinic 1 year after surgery were followed up by telephone.

Results

After obtaining ethical committee approval, the records of 44 patients with pilonidal sinus, who were operated on using a modified Lord–Miller procedure, were reviewed. A total of 37 (84%) patients were males and 7 (16%) were females. The overall mean age was 23.6 years old (range: 15–39 years old). A total of 23 (52%) were complicated sinus with side branch and 21 (48%) were simple sinus with pits only in the midline.

A total of 21 (48%) patients had a history of previous surgery, 9 (21%) patients had excision and closure (either simple closure or flap) and 12 (27%) had previous incision and drainage of pilonidal abscess. The pits were excised (pit-picking) and the complete tract removed, sparing the skin between the excised pits. Figure 1a shows a complicated sinus before the surgery and Figure 1b one week after operation.

FIGURE 1

(a) Complicated pilonidal sinus before surgery. (b) Complicated pilonidal sinus one week after operation.

8-1-3-fig1a.jpg8-1-3-fig1b.jpg

The amount of skin excised was very limited, as shown in Figure 2.

FIGURE 2

Specimen after excision showing the limited amount of skin excised.

8-1-3-fig2.jpg

A total of 32 (73%) cases were carried out under local anaesthesia and 12 (27%) under general anaesthesia. A total of 37 (84%) cases were carried out as a day case surgery and only 7 (16%) patients required admission (for 24 hours), most of which were requested by the patient over fears of developing pain. Paracetamol was prescribed post-operatively, to be used as needed, and no antibiotics were given. Patients were advised to dress and clean the wound themselves two to three times a day until the wound healed completely and there was no more discharge.

Patients were seen in the clinic once a week, until completely healed, and again 1 year after surgery.

During the follow-up period, patients were observed for the development of complications. There were no significant complications. Three (6.8%) patients developed wound infection, of which one was meticillin-resistant Staphylococcus aureus-positive, and antibiotics were prescribed according to wound culture. One patient had bleeding, which was controlled by packing and pressure dressing. The complete healing time of the wound (i.e. no more discharge) was achieved after 2–7 weeks (mean: 3.6 weeks). The pilonidal sinus was completely cured in 42 (95.5%) of patients. Sinus recurred in only two patients (4.5%). The same procedure was repeated on these individuals and they did not show any signs of recurrence during follow-up.

Discussion

Patients with pilonidal disease can be successfully treated by the pit-picking procedure in more than 80% of selected cases.3 Soll et al.4 performed a selective minimal invasive excision of the sinus after marking the track with methylene blue under local anaesthesia, allowing a fast return to normal activity with a low recurrence rate; the overall recurrence rate was 7% and the median time to return to work was 7 days. A review by Steinemann5 reported a recurrence rate of 7% after minimal invasive sinusectomy.

Lord and Miller described a ‘closed’ technique that included the removal of the midline sinuses and lateral tracts, which produced satisfactory results in 76% of patients.6 It is simple to perform and the complication and recurrence rates are within acceptable limits. Marc-Claude Marti carried out a modification of the Lord–Miller procedure. It had the same concept, but with the addition of excising the whole sinus with the side tract from underneath the skin and leaving a bridge of skin between the sites of the removed pits. The Bascom I procedure, a development of the Lord–Miller procedure, is based on the theory that removing the midline pits will cure the disease by keeping the incision to a minimum.7 The recurrence rate of this procedure is around 10%.8

The Karydakis procedure involved excision and development of a flap with closure away from the midline and flattening the natal cleft. Karydakis reported a recurrence rate of less than 1% and the mean stay in hospital was 3 days.9

Mohamed et al.10 compared the outcome of three surgical modalities to treat pilonidal sinus: (1) wide excision and primary closure; (2) wide excision and wound left open; and (3) limited excision of the fistulous tract and wounds left open for secondary intention healing. The limited excision group of patients had a highly significant shorter operative time. They also had the shortest hospital stay, the lowest operative blood loss and the least post-operative pain. The end result of this method is comparable with the more aggressive frequently used excisional method.

There is uncertainty whether open or closed surgical management is more effective. Healing times were faster after surgical closure compared with open healing. Surgical site infection (SSI) rates did not differ between treatments; recurrence rates were lower in open healing than with primary closure. Comparing surgical midline with off-midline closure, the healing times were faster after off-midline closure. SSI rates and recurrence were higher after midline closure.11 Goodall12 and Verbeck and Bender13 have reported hospital stays of 1.8 days and 15 days, respectively, for excision with primary closure, while Notaras14 and Goodall12 have reported mean hospital stays of 17 days and 18 days, respectively, for excision without closure. Another study showed a high recurrence rate (42%) after excision of a pilonidal sinus and primary midline closure.15 Duration of hospitalization was 2–10 days, and healing time was 2–8 weeks.16

There are limited studies regarding the use of lasers but results are very promising. Lindholt-Jensen et al.17 used the neodymium-doped yttrium–aluminium–garnet (Nd:YAG) laser in the treatment of 41 pilonidal sinus patients. Freedom from symptoms was reported in 75.7% of patients after a follow-up time of 15 months. Although there is a lack of studies on the benefits of using the laser, the results obtained so far are positive and promising, but more research is needed. Palesty et al.18 performed a 5-year retrospective study comparing the Nd:YAG laser with the standard surgical technique and concluded that both pain and length of hospitalization were reduced, return to work was faster and patient satisfaction was greater after laser excision.

Conclusion

A modified Lord–Miller procedure was shown to be highly effective in treating complex pilonidal sinus with a low recurrence rate (2/44 = 4.5%), faster healing rate and no significant post-operative wound complications.

References

1. 

Hodges RM. Pilonidal sinus. Boston Med Surg J 1880; 103:485–586. http://dx.doi.org/10.1056/NEJM188011181032101

2. 

Brearly R. Pilonidal sinus. A new theory of origin. Br J Surg 1955; 43:62–6. http://dx.doi.org/10.1002/bjs.18004317708

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Lesalnieks I, Deimel S, Kienle K, Schlitt HJ, Zülke C. Pit-picking surgery for pilonidal disease. Chirurg 2011; 82:927–31.

4. 

Soll C, Dindo D, Steinemann D, Hauffe T, Clavien PA, Hahnloser D. Sinusectomy for primary pilonidal sinus: less is more. Surgery 2011; 150:996–1001. http://dx.doi.org/10.1016/j.surg.2011.06.019

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Steinemann DC. Therapy of pilonidal sinus – is more always better. Ther Umsch 2013; 70:393–8. http://dx.doi.org/10.1024/0040-5930/a000423

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Lord PH, Millar DM. Pilonidal sinus: a simple treatment. Br J Surg 1965; 52:298–300. http://dx.doi.org/10.1002/bjs.1800520413

7. 

Bascom J. Pilonidal disease: long-term results of follicle removal. Dis Colon Rectum 1983; 26:800–7. http://dx.doi.org/10.1007/BF02554755

8. 

Senapati A, Cripps NPJ, Thompson MR. Bascom’s operation in the day-surgical management of symptomatic pilonidal sinus. Br J Surg 2000; 87:1067–70. http://dx.doi.org/10.1046/j.1365-2168.2000.01472.x

9. 

Karydakis GE. New approach to the problem of pilonidal sinus. Lancet 1973; 2:1414–15. http://dx.doi.org/10.1016/S0140-6736(73)92803-1

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Mohamed HA, Kadry I, Adly S. Comparison between three therapeutic modalities for non-complicated pilonidal sinus disease. Surgeon 2005; 3:73–7. http://dx.doi.org/10.1016/S1479-666X(05)80065-4

11. 

Al-Khamis AI, McCallum I, King PM, Bruce J. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev 2010; 1:CD006213.

12. 

Goodall P. The aetiology and treatment of pilonidal sinus: a review of 163 patients. Br J Surg 1961; 49:212–18.

13. 

Verbeck HO, Bender J. Results of treatment of pilonidal sinus by block excision and primary closure. Arch Chir Neerl 1974; 26:311–18.

14. 

Notaras MJ. A review of three popular methods of treatment of postanal (pilonidal) sinus disease. Br J Surg 1970; 57:886–90. http://dx.doi.org/10.1002/bjs.1800571204

15. 

Iesalnieks I, Fürst A, Rentsch M, Jauch KW. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate. Chirurg 2003; 74:461–8. http://dx.doi.org/10.1007/s00104-003-0616-8

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Allen-Mersh TG. Pilonidal sinus: finding the right track for treatment. Br J Surg 1990; 77:123–32. http://dx.doi.org/10.1002/bjs.1800770203

17. 

Lindholt-Jensen CSI, Lindholt JS, Beyer M, Lindholt JS. Nd-YAG laser treatment of primary and recurrent pilonidal sinus. Lasers Med Sci 2012; 27:505–8. http://dx.doi.org/10.1007/s10103-011-0990-2

18. 

Palesty JA, Zahir KS, Dudrick SJ, Ferri S, Tripodi G. Nd:YAG laser surgery for the excision of pilonidal cysts: a comparison with traditional techniques. Lasers Surg Med 2000; 26:380–5. http://dx.doi.org/10.1002/(SICI)1096-9101(2000)26:4<380::AID-LSM6>3.0.CO;2-X





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