Advanced Treatment Of Pilonidal Sinus:

Ali El-hady Ali

A pilonidal sinus is a cavity in the subcutaneous tissue which is lined by granulation tissue, generally contains hair, and communicates with the surface by a track which is usually lined by squamous epithelium containous with the epidermis. The usual site for the pilonidal sinus is in the midline between the buttocks about 5 cm behind the anus it has been reported in other sites suchas axilla, interdigital cleft of the hand and umbilicus.The ateiological theories of pilonidal sinus are :1-Congenital theory :Sequestration dermoid cyst getting infected and ruptured leading to a sinus. This is no longer accepted scince it does not date since birth is not proceeded by a cyst and is not lived by epithelium.2-Acquired theory :The most accepted it is an inclusion of loose hair under the skin due to continous friction and negative pressure of area may suck other hairs into the sinus. Pilonidal sinus occure in young male more than female and in hirsute people than blond one. This condition increases during second world war in many individuals who travelling in jeep lead some writers to refer to pilonidal sinus as jeep disease. The main pathological features is primary track lined by granulation issue and hairs inside it secondary track were found in about 50% of cases and on pressure on this area may cause escape of pus of seropurulent exudate to come out of the opening. Diagnosis of pilonidal sinus reaches by proper history clinical examination and sinogram using methylene blue dye injection into the main sinus. The complication of the pilonidal sinus canbe divided into two main group : (A) complication due to operative procedures as :1-The recurrence problem after surgical exision.2-Wound infection, breakdown and wound haematoma.3-Wound necrosis specially with the use of skin flaps.(B) Complication not related to surgical management as :1- Acute pilonidal abscess.2-Rarely malignant changes in pilonidal sinus specially the well differentiated squanous cell carcinoma.3- Secondary T.B. infection.4-Toxic shock syndrome.The are many approaches for the treatment of pilonidal sinus disease (a) conservative method, (b) surgical method the conservative method. For treatment of pilonidal sinus by phenol injection produces results which are simillar to those achieved by surgical excistion but has the advantages of a reduced requirement for analgesia and dressing this method is used for uncomplicated cases. Cryo-surgery in associated with period of disability and needs a well trained surgeon in the field. The surgical treatment is used today is :1- Incision and the wound is left to heal by open granulation.2-Excision and the wound is left to heal by open granulation.3-Excision and partial wound closure (Marsupiatization).4-Excision and primary closure.5-Excision and delayed primary closure.6-Excision and closure by plstic procedures such as :a) Z plasty operation b) Closure by split of skin graft.c) Closure by rotational flap d) Cleft closure technique.e) Transpositional rhomboid flap.It is a new technique presented by prof. Dr. (A. S.G) Azab in 1984. He utilized the flap of - limberg and Defounnentel in closure of rhomboid shaped defect which resulted from excision of pilonidal sinus. In conclusion the transposition themboid flalp in highly suitable operation for primary non infected piolnidal sinus, recurrent cases of pilonidal sinus and it should be avoided in acute pilomidal abscess so. The surgical treatment depond on the condition of the sinus.If the pilonidal sinus presented by acute abscess it should e treated by simple incision. Simple excision and healing by granulation is sutable in simple primary cases. The closed technique is ideal for thin individual with poor muscular development. Primary reconstriction using Z plasty or rhomboid flap reduces the incidence of recurrent pilonidal disease. Marsupiatization is mid way between the open and closed method giving excellent results in primary and recurrent disease. The patient must be followed up for one year and must shave any airin this area by using a depilatory cream to prevent further drilling of skin by hair.