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General Perspective and Overview

The relative risks and complications increase proportionately according to the type of procedure performed and the nature of the pathology or underlying disease process. When complex pilonidal sinus or abscess problems are present, the risks are usually increased. This is principally related to the surgical difficulty, ability to obtain adjacent unaffected healthy tissue, infection, hematoma formation, and ability to resect the disease. Risk of failure of direct wound closure is associated with infection, and this is often present preoperatively.

Resections for chronic sinuses and in the presence of established infection often carry higher risks associated with wound problems, including dehiscence and chronic wound dressings. Persistent infection, incomplete sinus/abscess resection, and immunosuppression add to the chronicity.

The main serious complication is infection, which can be minimized by the adequate mobilization, reduction of wound tension, and ensuring satisfactory blood supply. Dehiscence and abscess formation and even systemic sepsis can occur. Multi-system failure and death are very rare except in diabetics and immunosuppressed individuals. Hematoma formation may arise from oozing and this may predispose to infection. Recurrence is a significant issue, and further surgery is often warranted.

Positioning on the operating table has been associated with increased risk of deep venous thrombosis and nerve palsies, especially in prolonged procedures.

Possible reduction in the risk of misunderstandings over complications or consequences from perineal surgery might be achieved by:

  • Good explanation of the risks, aims, benefits, and limitations of the procedure(s)

  • Useful planning considering the anatomy, approach, alternatives, and method

  • Avoiding likely associated vessels and nerves

  • Adequate clinical follow-up

With these factors and facts in mind, the information given in this chapter must be appropriately and discernibly interpreted and used.

Important Note

It should be emphasized that the risks and frequencies that are given here represent derived figures. These figures are best estimates of relative frequencies across most institutions, not merely the highest-performing ones, and as such are often representative of a number of studies, which include different patients with differing comorbidities and different surgeons. In addition, the risks of complications in lower- or higher-risk patients may lie outside these estimated ranges, and individual clinical judgment is required as to the expected risks communicated to the patient and staff or for other purposes. The range of risks is also derived from experience and the literature; while risks outside this range may exist, certain risks may be reduced or absent due to variations of procedures or surgical approaches. It is recognized that different patients, practitioners, institutions, regions, and countries may vary in their requirements and recommendations.

Pilonidal Abscess Incision and Drainage Surgery

Description

General anesthesia is usually used, but on occasions local anesthesia may be used. The aim of the procedure is to examine the natal cleft, pilonidal sinus(es), and pilonidal abscess, then drain the abscess or cyst using a cruciate incision, curette, lay-open the cavity, and pack with antiseptic gauze dressing, to settle the acute infection and pain. Adequate drainage is the main objective. GA affords better examination of the anus and palpation of the pilonidal cyst and is less painful. The prone jackknife or occasionally the lateral decubitus position can be used, depending on the surgeon’s preference. The prone jackknife position offers a better view of the natal cleft for the operating surgeon, and any bleeding usually runs away from the operating surgeon. Anesthetists sometimes object to the prone jackknife position, because of the physiological effects on the circulatory system and respiratory system. Drainage alone often reduces the infection but seldom settles the pilonidal problem sufficiently, and persistent or recurrent symptoms are usual. Further definitive surgery may be necessary.

Anatomical Points

The natal cleft is a narrow moist region, often containing hair, which can develop cutaneous sinuses extending deep into the subcutaneous fat almost to the deep posterior sacral fascia. Hair (usually from the head) enters the sweat glands and forms cystic collections of keratin, sebum, and hair. Multiple sinuses are common, usually close to the midline. Induration and inflammation may distort the anatomy.

Table 4.1 Pilonidal abscess incision and drainage estimated frequency of complications, risks, and consequences
Full size table

Perspective

See Table 4.1. Complications are usually of a minor nature but may be severe on occasions. Infection and inflammation are usually present as the main indication for surgical drainage. The main complications are infection, pain, and bleeding which are all extensions of the preoperative situation and dehiscence. Recurrence of the pilonidal sinus is very common after incision and drainage, since the underlying problem is often not alleviated.

Major Complications

The main complication is pain, which is often adequately controlled with oral analgesia. Pain with dehiscence (or open management) and chronic dressings is also common. Purulent discharge is not uncommon, but usually settles with repeated dressings. Bleeding is not uncommon, but is rarely great in volume. Infection is usually present before surgery, as is some element of surrounding cellulitis, but on occasions these can worsen. Systemic sepsis is very rare but can occur. Further surgery is usual after simple drainage. Urinary retention and catheterization are not uncommon in males with any form of perineal or groin surgery. Recurrence is not uncommon and often requires further surgery.

Consent and Risk Reduction

Main Points to Explain

  • Discomfort/pain

  • Infection

  • Recurrence

  • Bleeding

  • Delayed healing

  • Chronic dressings

  • Further surgery

Pilonidal Sinus Excision and Laying Open

Description

General anesthesia is usually used, but on occasions local anesthesia may be used. GA affords better examination of the anus and palpation of the pilonidal cyst and is less painful. The prone jackknife or occasionally the lateral decubitus position can be used, depending on the surgeon’s preference. The prone jackknife position offers a better view of the natal cleft for the operating surgeon, and any bleeding usually runs away from the operating surgeon. Anesthetists sometimes object to the prone jackknife position, because of the physiological effects on the circulatory system and respiratory system.

The aim of the procedure is to examine the natal cleft, pilonidal sinus(es), and pilonidal abscess, then excise the pilonidal sinuses and cyst using an elliptical excision, and then pack the cavity with antiseptic gauze, alginate, or occasionally vacuum-assisted dressings. Complete removal of the sinus tracts is the main objective. The other option is marsupialization of the skin edges to the base of the wound.

Anatomical Points

The natal cleft is a narrow moist region, often containing hair, which can develop cutaneous sinuses extending deep into the subcutaneous fat almost to the deep posterior sacral fascia. Hair (usually from the head) enters the sweat glands and forms cystic collections of keratin, sebum, and hair. Multiple sinuses are common, usually close to the midline. Induration and inflammation may distort the anatomy. The pilonidal cyst may be midline or eccentric.

Table 4.2 Pilonidal sinus excision and laying open estimated frequency of complications, risks, and consequences
Full size table

Perspective

See Table 4.2. Complications are usually of a minor nature but may be severe on occasions. Infection and inflammation may be present to some degree. The main complications are infection, pain, and bleeding which are all extensions of the low-grade preoperative situation. Recurrence of the sinuses and cyst can occur after excision.

Major Complications

The main complication is pain, which is often adequately controlled with oral analgesia. Pain with the chronic dressings is also common. Purulent discharge is not uncommon, but usually settles with repeated dressings. Bleeding is not uncommon, but is rarely great in volume. Infection is usually present before surgery, as is some element of surrounding cellulitis, but on occasions these can worsen. Systemic sepsis is very rare but can occur. Urinary retention and catheterization are not uncommon in males with any form of perineal or groin surgery. Recurrence is not uncommon and often requires further surgery.

Consent and Risk Reduction

Main Points to Explain

  • Discomfort/pain

  • Infection

  • Recurrence

  • Bleeding

  • Delayed healing

  • Chronic dressings

  • Further surgery

Pilonidal Sinus Excision and Primary Closure/Flap Repair (Karydakis Procedure)

Description

General anesthesia is usually used, but on occasions local anesthesia may be used. GA affords better examination of the anus and palpation of the pilonidal cyst and is less painful. The prone jackknife or occasionally the lateral decubitus position can be used, depending on the surgeon’s preference. The prone jackknife position offers a better view of the natal cleft for the operating surgeon, and any bleeding usually runs away from the operating surgeon. Anesthetists sometimes object to the prone jackknife position, because of the physiological effects on the circulatory system and respiratory system.

The aim of the procedure is to examine the natal cleft, pilonidal sinus(es), and pilonidal abscess, excise the pilonidal sinuses and cyst completely, and then close the defect. A rotation flap can be used to fill the defect. Complete excision is the main objective. The Karydakis method is an unequal elliptical excision, undermining one edge to create a local rotation flap which when closed moves the natal cleft and the wound laterally, reducing the depth of the cleft considerably and reducing risk of recurrence. Alternatively, a rhomboidal or other rotation flap repair or V-Y advancement flap can be used to fill the defect after pilonidal sinus/cyst excision.

Anatomical Points

The natal cleft is a narrow moist region, often containing hair, which can develop cutaneous sinuses extending deep into the subcutaneous fat almost to the deep posterior sacral fascia. Hair (usually from the head) enters the glands and forms cystic collections of keratin, sebum, and hair. Multiple sinuses are common, usually close to the midline. Induration and inflammation may distort the anatomy.

Table 4.3 Pilonidal sinus excision and primary or flap closure estimated frequency of complications, risks, and consequences
Full size table

Perspective

See Table 4.3. Complications are usually of a minor nature but may be severe on occasions. Infection and inflammation may be present at low levels preoperatively. The main complications are infection, pain, and bleeding which are all extensions of the preoperative situation. Recurrence of the sinuses and cyst can occur after excision and repair.

Major Complications

The main complication is pain, which is often adequately controlled with oral analgesia. Hemoserous discharge is not uncommon, but usually settles with repeated dressings. Bleeding is not uncommon, but is rarely great in volume. Infection is usually present to some degree before surgery, as is some element of surrounding cellulitis, but on occasions these can worsen and may be followed by dehiscence. Systemic sepsis is very rare but can occur. Flap necrosis can occur where this method is used for repair of the defect and can contribute to dehiscence. Urinary retention and catheterization are not uncommon in males with any form of perineal or groin surgery. Recurrence is not uncommon and often requires further surgery.

Consent and Risk Reduction

Main Points to Explain

  • Discomfort/pain

  • Infection

  • Recurrence

  • Bleeding

  • Delayed healing

  • Flap/wound dehiscence

  • Chronic dressings

  • Further surgery