World Journal of Surgery

, Volume 32, Issue 10, pp 2305–2308

Evaluation of the Outcome of Complete Sinus Excision with Reconstruction of the Umbilicus in Patients with Umbilical Pilonidal Sinus

Authors

    • Department of General Surgery, Imam Medical ComplexTehran University of Medical Sciences
  • Amir H. Lebaschi
    • Department of General Surgery, Imam Medical ComplexTehran University of Medical Sciences
  • Maryam Ghavami Adel
    • Department of General Surgery, Imam Medical ComplexTehran University of Medical Sciences
  • Ali Reza Kazemeini
    • Department of General Surgery, Imam Medical ComplexTehran University of Medical Sciences
Article

DOI: 10.1007/s00268-008-9626-5

Cite this article as:
Fazeli, M.S., Lebaschi, A.H., Adel, M.G. et al. World J Surg (2008) 32: 2305. doi:10.1007/s00268-008-9626-5

Abstract

Umbilical pilonidal sinus is a cause of umbilical discharge. In this study, the outcome of complete excision of the umbilical sinus with umbilical reconstruction is considered. Adult patients with umbilical pilonidal sinus who had not undergone any previous surgeries were operated on using a technique that involves complete excision of the sinus after eversion of the umbilicus followed by reconstruction of the umbilicus. Patients were then followed; and wound complications, recurrence, and patient satisfaction were evaluated at postoperative visits. A total of 45 patients underwent the operation; 39 (86.5%) were male, and 6 (13.5%) were female. The mean age was 22.6 years (18–27 years). Six male patients had synchronous sacrococcygeal pilonidal disease. The mean follow-up period was 34 months (3–62 months). Only four patients had wound drainage after operation, and all required drainage of the wound. No recurrence was observed during the follow-up period, and all patients were satisfied with the appearance of their umbilicus. The technique of complete sinus excision and umbilical reconstruction is an effective and acceptable method for treating umbilical pilonidal sinus and may be recommended for primary treatment of this disease.

Introduction

Although umbilical discharge is not uncommon in infants and children [1], it is observed infrequently in adults. Various pathologies can produce an umbilical discharge [2, 3]. Pilonidal sinus is a common condition in the sacrococcygeal region in adults, although it is also observed in the umbilicus [48] and is regarded as an etiology for umbilical discharge.

The exact pathogenesis of pilonidal sinus remains unknown [7]. Clinical and pathologic observations lend support to the hypothesis of a congenital origin [9], although some experts maintain that the disease is an acquired one [6]. Umbilical pilonidal sinus is most commonly encountered in adults who have a hair tuft around their umbilicus and is more common in males [46] It is important to differentiate umbilical pilonidal sinus from other umbilical affections by careful clinical observation; and because there is a risk of peritoneal extension of the associated inflammation, umbilical pilonidal sinus should be taken seriously and treated more aggressively than its sacral counterpart [10]. Also, whenever one comes across a case of resistant or recurrent “omphalitis,” pilonidal sinus should be considered as an alternative diagnosis [8].

Various techniques have been suggested as treatment for umbilical pilonidal sinus. They include removing the hair and cotton-like dirt in an outpatient fashion [2, 5], excising the umbilicus without reconstruction [6], sinus excision [11] with cosmetic umbilical reconstruction [8], and total omphalectomy as a primary treatment [9, 12] or for treating recurrent disease [8].

In this article, the authors have evaluated the outcomes of an operative technique that involves complete excision of the sinus while saving the umbilicus.

Materials and methods

Between January 1997 and January 2005, adult patients with bloody or purulent discharge form their umbilicus who had never undergone surgery for their disease were considered (Fig. 1). Patients who had a history of previous abdominal surgery were excluded. If a sinus orifice could be detected in the umbilicus, the patient was entered into the study.
https://static-content.springer.com/image/art%3A10.1007%2Fs00268-008-9626-5/MediaObjects/268_2008_9626_Fig1_HTML.jpg
Fig. 1

Umbilical sinus with purulent discharge

The patients were admitted the day before operation, and all received preoperative intravenous antibiotics (cefazolin 500 mg) 30 minutes before the start of the operation. All operations were performed by a single surgeon under general anesthesia.

Technique

The patient is prepared and draped in supine position. A curved incision is made along the inferior border of the umbilicus starting at 5 o’clock and extending to 8 o’clock. It is important to adjust the distance of the incision from the center of the umbilicus based on the location of the sinus; if the sinus has a central position, an incision near or at the inferior border of the umbilicus is appropriate. If the sinus is located in the lower half of the umbilicus, the distance of the incision from the inferior border of the umbilicus should be as much as the distance of the sinus from the umbilical center. The incision is deepened to cut the dermis, and the subcutaneous tissue is dissected to arrive at the fascia along the full length of the incision. Then, using scissors to cut through the subcutaneous fat and just superficial to the fascia, a plane is developed around the umbilical attachment to the fascia to encircle this attachment. After full detachment of the umbilical stalk from surrounding subcutaneous tissue, the stalk is cut from its point of attachment to the underlying fascia (Fig. 2). The umbilicus is then completely everted by inserting an index finger from underneath and pushing the cut stalk outward while holding the cut edge of the umbilicus with the thumb of the same hand (Fig. 3). It is important that one should not lift the umbilical fold too much as in some cases it may affect the blood supply in its most distal part, thereby causing problems of necrosis. With this maneuver the sinus becomes everted too, although it may be necessary to use a small-tipped instrument to drive the base of the sinus out. A transverse elliptical incision is made on the everted side of the umbilicus, and the sinus is excised completely (Fig. 4). The incision should be kept as small as possible to keep umbilical skin loss to a minimum. This elliptical incision is then repaired by separate absorbable sutures from underneath. The center of the repaired umbilicus is now secured to the old attachment point to the fascia by a single nonabsorbable or delayed absorbable suture. If the sinus had a central position, the umbilicus should be sutured to the fascia at the center of the repaired elliptical incision made for removal of the sinus. If the sinus was peripheral, a new center of the umbilicus is chosen. Then the skin is closed using running subcuticular technique with either absorbable or nonabsorbable suture. Selecting the location of the initial infraumbilical incision is critical to provide an adequate skin margin for closure and maintenance of umbilical symmetry. The new umbilicus invariably has less depth than the original one.
https://static-content.springer.com/image/art%3A10.1007%2Fs00268-008-9626-5/MediaObjects/268_2008_9626_Fig2_HTML.jpg
Fig. 2

Umbilicus is dissected and detached from fascia

https://static-content.springer.com/image/art%3A10.1007%2Fs00268-008-9626-5/MediaObjects/268_2008_9626_Fig3_HTML.jpg
Fig. 3

Sinus is completely everted. The whole sinus is now seen

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Fig. 4

Sinus is completely excised. The defect in the umbilicus is ready to be repaired

Postoperatively, the patients received three more doses of the same intravenous antibiotic and were discharged the day after surgery with oral cephalexin 500 mg four times a day for 10 days. An outpatient visit was scheduled for each patient the next week. The other visits were scheduled based on the patient’s condition. After complete healing of the wound, the patient was advised to pay a visit every 3 to 6 months.

Evaluation of results

The main outcomes of the study were wound complications (bleeding, infection, nonhealing), recurrence, and patient satisfaction. Patient satisfaction was assessed using a verbal scale (dissatisfied, acceptable, satisfied). These outcomes were evaluated at each postoperative visit. Regarding satisfaction, the patients’ last opinions were used for analysis. This study was not meant to evaluate any hypothesis, and no control group was considered for comparison of the collected data.

All data were recorded on a dedicated data form and entered into a database (Microsoft Access 2003). Data were analyzed using SPSS 11.0 for Windows, and descriptive statistics were applied to generate the results.

Results

A total of 45 patients were operated on. Prior to surgery, all patients had undergone conservative management, such as hair control, treatment with povidone-iodine solution or white alcohol, and local antibiotics with no improvement. Patients were symptomatic for a mean of 16 months (6–48 months).

Among the 45 patients, 39 (86.5%) were male and 6 (13.5%) were female. The mean age was 22.6 years (18–27 years). Three female patients had a history of hirsutism. All male patients had hair tufts around their umbilicus. Six male patients had synchronous sacrococcygeal pilonidal disease. Two male patients had undergone operation for treatment of sacrococcygeal pilonidal disease prior to participation.

During the first postoperative visits, four patients had wound discharge. These patients were followed conservatively at first, but in the end it became necessary to open and drain their wounds after incessant discharge for about 3 weeks. The wounds healed in all other patients without any complication. Pathology reports could be obtained and reviewed for 43 patients, and they invariably revealed chronic inflammation.

The mean follow-up period was 34 months (3–62 months). Symptomatic keloid developed in one patient, and no recurrences were observed throughout the follow-up period. None of the patients was dissatisfied with the appearance of his or her umbilicus (80% were satisfied, 20% said that its appearance was acceptable).

Discussion

One of the important causes of umbilical discharge in adults is pilonidal disease of this region. It can present with discharge, soreness or pain, swelling, and cellulitis [12]. As an alternative to surgical management, some experts have recommended conservative treatment, such as removing the hair [5], but none of our patients had any improvement following nonoperative measures. Total omphalectomy is advocated as the definitive treatment by many authors [6, 7, 9, 12] to avoid recurrence. We performed sinus excision with cosmetic umbilical reconstruction in all 45 patients with umbilical pilonidal disease. We encountered no recurrences or serious complications in our study, and the patients were content with the surgical results.

Total omphalectomy may still be indicated, but it is probably justified only for treating recurrent disease [8]. In a retrospective study by Haj and Cohen, 12 ambulatory patients with umbilical pilonidal sinus underwent an operation similar to the one described here to excise the sinus complex with primary repair of the umbilicus. Few wound complications were observed (one case of serosanguineous discharge and one of periincisional hyperemia). The patients were satisfied with the resultant new umbilicus, and no recurrences were observed during the 2-year follow-up. The authors ascribed the lack of recurrence to a shallow umbilicus that was easy to keep clean [13].

This study suffers from some limitations. First, the follow-up period may not have been long enough to detect recurrences. Our esthetic evaluation was also imperfect because we have not provided our patients with any objective means of assessment, nor have we asked any expert (e.g., a reconstructive surgeon) to give his or her opinion about the appearance of the “new” umbilicus.

Conclusion

Umbilical sinus excision with umbilical reconstruction is a relatively simple and effective surgical option for treating umbilical pilonidal disease with acceptable patient satisfaction and no serious complications. It may also be associated with a low risk of recurrence.

Copyright information

© Société Internationale de Chirurgie 2008