FailedPilonidalSurgery

NewParadigms
AndNewOperationsLeadingtoCures

JohnBascom,MD.PhD
SacredHeartMedicalCenter
Eugene,OR
PILONIDALDISEASE
Manyforms

FrompimpleorPIT
Toatragedy.
ThePITisthesourceofALL
trouble.
 OptionsforSimpleHome
TreatmentofEarlyPits
1)Usetweezersto
removehairs(pull
outatsurface)

2)Curretteoutkeratin.
Usetheeyeofa
darningneedle.
Allowspittoshrink
Thissimplemovewill
cure~30%ofearly
pilos.
Youwillneverstart
troubleifyoubeginwith
this.
 WhenIamaskedhowtodealwith
simplepilonidals,
incontrasttocomplexproblemsthatcallforcleftlift,
Ifocusonthesource,thestretchedandelongatedhairfollicle,

thePIT.

Andrecommendsimplecontrol.
Localanesthetic,inofficeifpossible.
List2pointstorememberonpilos

PICKALLPITS
1________________________

STAYOUTOFTHEDITCH
2_______________________
PICKALLPITS!
Whenthispitwalksintoyouroffice
minimalsymptoms,singlepit,
shallowcleft..
Keepitsimple.
Injectadropoflocal.
Dotherightthing
thrustonejawofa
mosquitoforceps
intothepit
ClampDown
CutAroundIt
AllAround.
Unroofingthefollicle
thespecimenthesizeofa
grainofrice.

Youdidthis..
 Youhavejust
Keratin
cutthiswall
Washes
awaytocure
away!
New
thedisease!
epidermis!
WhenthisAcuteAbscessWalksinto
YourOffice.
ThisistheRightThingtoDo
Drainlaterally

Afingerswidthoffthemidline.
STAYOUTOFTHEDITCH
 OncetheAbscessisOpen

STOP!
For10DaystoletEDEMAfade.DONTPACK.
WhenthisdrainedabscessRETURNS
toyouroffice

10daysafterIncision
&Drainage
Edemahascleared;

nowyoucansee
thepitsotreatit
 Insight!

PICKALLPITS
Ifacavityispresentitisa
CHRONICABSCESS:

Insight!
STAYOUTOFTHEDITCH
 PreventEarlyAbscesses
Topreventearly
Scrubouttheabscesscavity
abscessreseal,
throughanincision
cutoutskinplug..,
apainlessalternativetopacking lateraltothemidline

Keeplongincisions
outoftheditch!
WhatisthisOpeningwecallaPit?

PitNursery
 ThePitNursery

Singlehairin
normalfollicle

Crudgatheringaround
hairsinstretchedfollicles
 ThePilonidalPistol
ShootsaholeintheSaranWrap(epidermis)

Driveshairandcrudintofat,

Whichputsbacteriainfat
tostarta

PILONIDAL ABSCESS!!!
 GrowingaPilonidalPistol
GUNBARREL=
Folliclestretchingto
becomeapit

BULLET=Hair

GUNPOWDER=Keratin
ThePitaLoadedPistol

Normal
Stretched
ThePilonidalPistolFires
Throughthe
Tipofthe
Follicle
 EarliestInfectedFollicle

Blowupon
nextslide
 StartofanAcuteAbscess
Follicle
wall
breaking

Keratin
Hairpunches explodes
through through
 Summary:
Pick(Clean)ALLPits!
AndPick(Out)EarlyPits
Keepitsimple!
Learntoavoidtrouble!
2PointstoRememberonPilos

1________________________
PICKALLPITS

2_______________________
STAYOUTOFTHEDITCH
 CuringComplexProblems
WhenyouaskHowcanIcurecomplexpilonidalproblems?

Ireply, CleftLift.

(Overlookedsimplecareorfailedprevioussurgery
oftenstartsthesecomplexproblems.)
 ASmallTragedy
21yroldafter
Fouryearsofdisease& ThisisaSEWER!
Fiveoperations(2were Hereanaerobicbacteria
hugeRotationFlaps) destroy
LearntoPREVENT skin&suturelines.
theseWRECKS Ifyouheldyourfinger
herefor4years,
itsskinwould
rotofftoo!
Insight!
Redtissueisnormal
andhealable!
GiveemAIR!!
 623Patients

Outof623Pilonidalpatientswe
treated,
welocatedchartsonthe31WORST
These31hadendured

141!Prioroperations
252!Yearsofopenwounds
All31healedafter1cleftlift
After4
yrsand
Preop CleftLiftResult
1weekpost
operative

Readyfor
dressing
 Failuretohealreasons
inour31patients

In16Surgeonleftadeepcleft
In7Surgeonleftanoverhang
In5Surgeonleftpits(ornewonesgrew)
In3Scartootight,notenoughskinleft
WhenCleftsWillNotHeal

WHATGOESWRONG?
CluesfromaCaseThatFailedtoHeal.

IncisionhealedOK
Incisionhealed wherecleftwas
OKwhenin shallow
air

Deepcleftsealsin
pus.Yetoffers
bigflapforcleft
liftoperation.
 t ,
Insight! u fa
t h r l &
Apitpumpspus t s ne
r
ui stu ng. n
q
S ke eni

es
ma op

ez
w
ne

ue
t sq
Si
i t s e als
S

Whenpatientstands,the Whenpatientsits
Fig. 6. cavitysucksindebris.
Ingestion of hair by a chronic pilonidal abscess cavity. Scales on hair convert the in and out
flow of cavity contents to a steady inward motion of the hair. Left, standing; right, sitting
 Processesthatkeepwoundsopenforyears.
1.Tightscar
generates

2.ahiddenoverhang.

3.Debriscollects,
anaerobeseat
anewholein
skin

4.Primaryopening
collectspusanddebris.
Itpumpspus
andhairupward.
 Exitsecondaryopening

Wouldhealwithouttreatment
onceyou
healtheentrance!

Tunnel
Entrance
primaryopening
 Technique
Pushbuttockstogetherandmarktheouterlineofcontact.
 Incise
Incisethroughtheheavyredlinefirst,thenelevateallskin
tintedblue.Plantoremovetheskintintedpink.
 FlapsTurnedBack,Redisexposedabscess
cavity
1.Weoftenscrub
cleanwhereothers
wouldexcise
 WhattoSave

2.Skintosavefornew,
shallowcleft

3.Savefatfor
padding
 CutAway

4.Measure
beforecut
away
 CheckforCoverage

Linetoguidecutaway
ofunderflap

Pushbuttockstogethertocheckfitofbluecoverageflap,
markalineandcutawaypinkdiscardflap(covered).
 ControlShearingForces

TapestripsareappliedinanXshapetocontrolshearingforces.
Subcuticularsuturesareremovedat10days.Nosuturestosacrum.
After4
yrsand
Preop CleftLiftResult
1weekpost
operative

Readyfor
dressing
3pointstorememberonPilonidals

1. PICKALLPITS

2. STAYOUTOFTHEDITCH

3.CLEFTLIFTforworstcases
 FailedPilonidalSurgery
NewParadigms
AndNewOperationsLeadingtoCure
ArchSurg2002;137:11461150

Available:
CDofthisPowerPointtalk
DVDofcleftliftoperation
Reprints

Questions? thomasbascom@yahoo.comor<JBascomR@pacinfo.com>