|Year : 2014 | Volume
| Issue : 5 | Page : 574-578
A comparative study of open technique and Z-plasty in management of pilonidal sinus
Siddhartha Priyadarshi, Bharat Bhushan Dogra, Ketak Nagare, Karan V. S. Rana, Raveesh Sunkara, Ashwani Kandari
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||10-Sep-2014|
Padmashree Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Pilonidal sinus is one of the common problems encountered in general surgical practices and the management of this disease is variable, contentious and problematic. Principles of treatment require eradication of the sinus tract; complete healing and prevention of recurrence. Although several surgical techniques have been described over the years, the management remains controversial. Aims and Objectives: The aim of this study was to compare the two techniques of the open method and Z-plasty in the management of pilonidal sinus, in terms of incidence of post-operative pain, total hospital stay, total recovery time, complications and recurrence rate. Materials and Methods: This is a prospective comparative study which was conducted in the surgical department of a teaching hospital. A total of 50 cases were included in this study. Of these, 25 cases were operated by the open technique and 25 by excision and Z-plasty. Observation and Result: The mean age at presentation was 29.44 years. Male genders followed by age between 20 and 30 years were the most common predisposing factors. The mean body mass index, early and late post-operative complications were comparable between the two groups. Mean hospital stay and total recovery time was significantly more in open technique group compared with Z-plasty group. Visual analog score was also significantly more in open technique group when compared with Z-plasty group. Conclusion: Excision with Z-plasty was better technique in terms of lesser hospital stay, lesser recovery time, less post-operative pain.
Keywords: Open technique, pilonidal sinus, Z-plasty
|How to cite this article:|
Priyadarshi S, Dogra BB, Nagare K, Rana KV, Sunkara R, Kandari A. A comparative study of open technique and Z-plasty in management of pilonidal sinus. Med J DY Patil Univ 2014;7:574-8
|How to cite this URL:|
Priyadarshi S, Dogra BB, Nagare K, Rana KV, Sunkara R, Kandari A. A comparative study of open technique and Z-plasty in management of pilonidal sinus. Med J DY Patil Univ [serial online] 2014 [cited 2020 Sep 19];7:574-8. Available from: http://www.mjdrdypu.org/text.asp?2014/7/5/574/140398
| Introduction|| |
The term pilonidal is derived from the Latin word Pilus (hair) and Nidus (nest) and this term was coined and described by Hodges in 1880. It is diagnosed by the finding of a characteristic epithelial tract (the sinus) located in the natal cleft, a short distance behind the anal verge and generally containing hair.  It is a common disorder among young adults, in the age group 15-30 years, after puberty when sex hormones are known to affect pilosebaceous glands and change healthy body hair growth.
It can be associated with considerable morbidity and have significant socio-economic impact on affected individuals.  The management of pilonidal disease is variable, contentious and problematic. Principles of treatment require eradication of the sinus tract; complete healing and prevention of recurrence. 
Several techniques such as cryosurgery,  Z-plasty procedure,  lancing under local anesthesia, vacuum assisted closure,  excision with secondary healing, excision with primary closure , local flap surgery ,,, and Bascom procedure,  have been described by various authors. This study was undertaken to compare the results of excision of sinus followed by dressing the wound regularly versus primary closure of the wound by Z-plasty technique.
| Materials and Methods|| |
This was a prospective comparative study undertaken between July 2011 and September 2013 in 50 patients having sacro-coccygeal pilonidal sinus, who were admitted in the surgical department of our hospital. A proforma was designed which included demographic data, signs, symptoms, predisposing risk factors, investigations, diagnosis, type of operative technique, operative time and complications (early and late). Hairiness was estimated semiquantitatively and recorded as less than normal, normal and more than normal. Body mass index (BMI) was calculated for every patient and BMI >25 kg/m 2 were considered to be overweight and obese.
Patients were divided into two groups randomly. Group A included 25 patients managed by excision and regular dressing, keeping the wound open. Group B included 25 patients managed by excision and primary closure by Z-plasty technique. Institutional ethical committee clearance was obtained for the study. Statistical analysis of the results was performed using SPSS@17. Descriptive statistics were applied to calculate mean. Mann-Whitney test was applied to calculate the Z value of visual analogue score (VAS). Z-test was used to compare the BMI, hospital stay, recovery time, early post-operative complications and complications at follow-up. P < 0.05 were considered as significant.
- Pilonidal sinus in the natal cleft of the sacro-coccygeal area.
- Patients aged between 14 and 60 years.
- Pilonidal abscess.
- Patients having diabetes mellitus.
- Human immunodeficiency virus positive patients.
- Patients on cancer chemotherapeutic drugs.
- Patients on immunosuppressant therapy.
- Recurrent pilonidal sinus.
After preliminary investigations, confirmation of diagnosis and pre-anesthetic check-up, patients were counseled about the nature of surgery first case was allotted, by chit picked up by the patient and subsequently alternate patient was assigned in two different groups. Hairiness was estimated semiquantitatively and recorded as less than normal, normal and more than normal.
On the day of surgery, all the patients were prepared 2 h before the surgery by shaving of natal cleft and back areas, followed by painting with 10% povidone iodine solution.
All cases were operated under spinal anesthesia and in Jack Knife position. The natal cleft was mechanically exposed by strapping buttocks apart using adhesive tapes [Figure 1]. The natal area was thoroughly cleaned with 10% povidone-iodine. Prior to incision methylene blue was instilled using infant feeding tube into the sinus opening to map the sinus cavity and its lateral extensions if any and hence that the whole sinus and ramifications were fully demarcated. Vertical elliptical incision was made including the affected skin and deepened up to the fascia covering the sacrum. The sinus tract was excised en-block, including granulation tissue and sinus tracts at the lateral edges [Figure 2]. Pre-operative prophylactic antibiotics in the form of injection ampiclox 500 mg and injection metronidazole 500 mg intravenous were administered to all the cases in both groups.
|Figure 1: Pre-operative photograph: Pilonidal sinus with marking for Z-plasty|
Click here to view
The excised specimen was checked for adequacy of the excision. If part of any sinus tract was left behind, the wound was re-explored for further excision. Diathermy was used to achieve full hemostasis and sinus tract was sent for histopathological examination.
In the open method technique, after achieving complete hemostasis, the wound was packed with 10% povidone-iodine-soaked gauze and post-operatively daily dressing were carried out. The pack was removed after 24 h and the patient was given sitz bath with 1% potassium permanganate. Daily dressing was carried out using gauze soaked in 10% povidone-iodine solution and this was repeated daily until wound healed completely.
Elliptical excision of the sinus tract including the narrow margins of healthy surrounding skin was carried out down to fascia to achieve excision of main and secondary sinus tracts. Limbs of the Z-plasty were marked. If the defect was up to 5 cm in length then single Z-plasty was carried out [Figure 3]. If the defect was more than 5 cm then multiple Z-plasty were carried out [Figure 4]. Skin flaps were raised and transposed. Each limb of Z was equal in length. Angle of the flaps was roughly equal to 45°. The wound was closed in two layers after keeping a. suction drain (Romo Vac drain no: 14) [Figure 5]. The dressings was checked after 48 h and subsequently on alternate days till the sutures were removed. Suction drain was removed when drain output was <10 ml/24 h and it was serous in nature. Sutures were removed on 10 th post-operative day (POD).
Patients were nursed in the prone position post-operatively for first 48 h. All patients were given injection ampiclox 500 mg 6 hourly and injection metronidazole 500 mg 8 hourly for first 3 days followed by oral ampiclox 500 mg 6 hourly and metronidazole 400 mg 8 hourly for 5 days. Pain was assessed using visual analogscale on POD 1, POD 2 and POD 3 before analgesics were administered. VAS was recorded 8 hourly and the mean value was calculated for each POD 1, POD 2 and POD 3. In both groups, patients were started on full diet on the evening of surgery. Time of complete healing was recorded in each case.
| Results|| |
Predisposing risk factors
- Age and sex: In this study, maximum number of patients (58%) were in the age group of 21-30 years. The youngest patient was 17 years of age and the eldest being 60 years. Mean age was 29.44 years. In open technique group mean ± standard deviation was 30.36 ± 5.39 years and in Z-plasty group was 28.52 ± 8.77 years. This difference between the two groups as regard to age was statistically not significant (P > 0.05, Z = 0.89). There was a male preponderance noted in 100% of cases.
- Nearly 44% of patients were overweight and obese (BMI >25 kg/m 2 ) and 34% of patients were with abundant hair.
Early post-operative pain
The post-operative pain assessment was done by VAS and the mean was taken on PODs 1, 2 and 3. It was found that the mean post-operative pain score was higher in the open technique group on POD 1, 2 and 3. There was no statistically significant difference between the two groups as regard to mean post-operative pain on POD 1 (P > 0.05) but it was statistically significant as regard to mean post-operative pain on POD 2 (P < 0.05) and 3 (P < 0.001) [Table 1].
Total hospital stay and total recovery time
In the present study, mean hospital stay in open technique group was 31.7 and in Z-plasty group was 15.88 days. Mean recovery time in open technique group was 36.6 and in Z-plasty group was 19.6 days. It was statistically significant (P < 0.0001) in terms of total hospital stay and total recovery time in both the study groups [Table 2].
Early post-operative complications
In our study, redness around the wound was noted in 16% of patients in both groups. Indurations around the wound were noted in 16% patient in open technique group and 4% of patients in Z-plasty group. Discharge from the wound was noted in 4% of patients in open technique group and 8% of patients in Z-plasty group. Tip necrosis of the flap was found in 4% of patients in Z-plasty group. Partial wound dehiscence was also noted in one case (4%) in Z-plasty group. This difference between the two groups as regard to early post-operative complications was statistically not significant (P > 0.05) [Table 2].
Late post-operative complications
In this study, follow-up of the patients was carried out up to 6 months following complications were noted during follow-up. Recurrence was found in 5.88% in open technique group and there was no recurrence in Z-plasty group. Hypertrophy of scar was found in 5.88% in open technique group and in none of the cases in Z-plasty group. This difference between the two groups in terms of late post-operative complications was statistically not significant (P > 0.05) [Table 3].
|Table 3: Late post-operative complications: distribution of cases in study groups|
Click here to view
| Discussion|| |
Sacro-coccygeal pilonidal sinus has been surgically managed for many years, but the ideal surgical technique remains controversial.  The aim of treatment in pilonidal sinus disease is to render cure of the disease, minimize chances of recurrence and early return to work.  In our study, 100% of patients were male and 60% of patients were in the age group of 20-30 years. In a study done by Khan, maximum number of patients (52.9%) was in the third decade of life  and male:female ratio was 34:0, which is comparable with our study. In our study, mean post-operative pain score was higher in the open technique group on POD 1, 2 and 3 than in Z-plasty technique group. Aman et al. where open technique was employed noted pain in 75% of patients. 
In the present study, total hospital stay was taken as a time of complete healing of the wound. This was time elapsed from the end of surgery until complete wound healing. Mean hospital stay in open technique group was 31.7 and in Z-plasty group was 15.88 days. Total recovery time in our study was defined as time after surgery until date on which the patient returned to normal activities, including employment. Mean recovery time in open technique group was 36.6 and in Z-plasty group was 19.6 days, which also compares favorably with study carried out by Fazeli et al., where wound healed faster in Z-plasty group (15.4 days in Z-plasty group and 41 days in excision and delayed healing group and return to normal activity 17.5 days for conventional group and 11.9 for Z-plasty group. 
In our study, redness around the wound was noted in 16% of patients in both groups. Indurations around the wound were noted in 16% patient in open technique group and 4% of patients in Z-plasty group. Discharge from the wound was noted in 4% of patients in open technique group and 8% of patients in Z-plasty group had discharge. Tip necrosis of flaps and partial wound dehiscence was found in 4% of patients in Z-plasty group. These complications were managed conservatively by the broad spectrum antibiotics and daily dressing of the wound with betadine soaked gauze dressings. In a study by Fazeli et al. noted no difference in post-operative complications regarding bleeding, hematoma and infection between Z-plasty group and delayed healing by secondary intention of the wound after excision of the sacral pilonidal sinus.  Bose and Candy noted flap necrosis in 20 cases after Z-plasty.  In the present study, recurrence was defined as the presence of any persistent purulent or blood stained discharge from the previously operated or the nearby area during the follow-up. Recurrence was found in 5.88% in open technique group and there was no recurrence in Z-plasty group. Hypertrophic scar was found in 5.88% in open technique group and there was no hypertrophic scar was in Z-plasty group. Praveen et al. where Z-plasty technique was employed noted 5% recurrence  and Tolba et al. noted recurrence in one patient when open technique was employed.  Study done by Tschudi and Ris where Z-plasty technique was employed noted hypertrophic scars in 3 (14%) of patients. 
| Conclusion|| |
- Total recovery time and hospital stay was significantly more in open technique group than in Z-plasty group.
- Recurrence was insignificantly more in open technique group than in Z-plasty group.
- VAS was statistically insignificantly more in open technique group on POD 1 and was statistically more in open technique group on POD 2 and 3 compared to Z-plasty group.
- Limitation of the study is the sample size of 50 cases which gave a good overview but when studying two groups the sample size was small and hence consistent inferences pertaining to each group cannot be derived. 15 patients out of 50 patients not turned up for follow-up at 6 months and hence the late complications of the two groups could not be evaluated as the follow-up patients were less.
- Thus, excision and Z-plasty may be may be a good alternative to open technique as it has lesser total recovery time, lesser hospital stay, less painful, lesser recurrence and better quality of scar, but a larger randomized study is required for definitive conclusions and recommendation.
| References|| |
|1.||Hodges RM. Pilonidal sinus. Bosten Med Surg J 1880;103:456-586. |
|2.||Allen-Mersh TG. Pilonidal sinus: Finding the right track for treatment. Br J Surg 1990;77:123-32. |
|3.||McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for pilonidal sinus: Systematic review and meta-analysis. BMJ 2008;336:868-71. |
|4.||Gage AA, Dutta P. Cryosurgery for pilonidal disease. Am J Surg 1977;133:249-54. |
|5.||Toubanakis G. Treatment of pilonidal sinus disease with the Z-plasty procedure (modified). Am Surg 1986;52:611-2. |
|6.||McGuinness JG, Winter DC, O′Connell PR. Vacuum-assisted closure of a complex pilonidal sinus. Dis Colon Rectum 2003;46:274-6. |
|7.||Obeid SA. A new technique for treatment of pilonidal sinus. Dis Colon Rectum 1988;31:879-85. |
|8.||Tritapepe R, Di Padova C. Excision and primary closure of pilonidal sinus using a drain for antiseptic wound flushing. Am J Surg 2002;183:209-11. |
|9.||Topgül K, Ozdemir E, Kiliç K, Gökbayir H, Ferahköºe Z. Long-term results of limberg flap procedure for treatment of pilonidal sinus: A report of 200 cases. Dis Colon Rectum 2003;46:1545-8. |
|10.||Bozkurt MK, Tezel E. Management of pilonidal sinus with the Limberg flap. Dis Colon Rectum 1998;41:775-7. |
|11.||Mosquera DA, Quayle JB. Bascom′s operation for pilonidal sinus. J R Soc Med 1995;88:45P-6P. |
|12.||Eryilmaz R, Sahin M, Alimoglu O, Dasiran F. Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap. Surgery 2003;134:745-9. |
|13.||Senapati A, Cripps NP, Thompson MR. Bascom′s operation in the day-surgical management of symptomatic pilonidal sinus. Br J Surg 2000;87:1067-70. |
|14.||Muzi MG, Milito G, Cadeddu F, Nigro C, Andreoli F, Amabile D, et al. Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease. Am J Surg 2010;200:9-14. |
|15.||Akca T, Colak T, Ustunsoy B, Kanik A, Aydin S. Randomized clinical trial comparing primary closure with the Limberg flap in the treatment of primary sacrococcygeal pilonidal disease. Br J Surg 2005;92:1081-4. |
|16.||Khan A. Prognostic factors of pilonidal sinus. J Med Sci 2006;14:40-3. |
|17.||Aman Z, Hadi A, Ahmad T, Khan SA, Shah FO, Iqbal Z. Comparison of wide open excision and karydakis procedure for pilonidal sinus disease. J Surg Pak (Int) 2011;16:136-9. |
|18.||Fazeli MS, Adel MG, Lebaschi AH. Comparison of outcomes in Z-plasty and delayed healing by secondary intention of the wound after excision of the sacral pilonidal sinus: Results of a randomized, clinical trial. Dis Colon Rectum 2006;49:1831-6. |
|19.||Bose B, Candy J. Radical cure of pilonidal sinus by Z-plasty. Am J Surg 1970;120:783-6. |
|20.||Praveen S, Shah SS, Hyder Z. Excision with Z-plasty in pilonidal sinus. J surg Pak Int 2011;16:94-7. |
|21.||Tolba AM, El-Wahsh M, Abd-Elpaset A. A prospective randomized study comparing open technique with closed technique using different type of flap coverage in chronic pilonidal disease. ZUMJ 2012;18:527-30. |
|22.||Tschudi J, Ris HB. Morbidity of Z-plasty in the treatment of pilonidal sinus. Chirurg 1988;59:486-90. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]