WHAT ARE THE OTHER PROCEDURES FOR PILONIDAL DISEASE?
Excision and Primary Closure:
This means to remove the midline diseased tissue and saw it together in the middle of the cleft. This is the commonest procedure offered by most surgeons as it is simple. However, the failure rate is about 50-60% as the wound usually falls apart because it is in the moist, infected cleft. Another procedure to remove the infected tissue is usually offered and results in loss of more valuable tissue and again a wound in the midline that is subject to a higher failure rate.
Excision Only (wide excision):
This means that the disease is removed, but the wound is left to heal by itself. This usually requires frequent packing of the wound with wet gauze or ribbon gauze allowing the wound to heal from the depth to the surface. This usually means frequent visits to the wound clinic with wasted time and money. Also there is ongoing pain and drainage that usually limits daily activities and the ability to go to work or school. This is the oldest way of letting wounds heal since ancient times before sutures were devised. In Dr. Wadie’s opinion, this is the most “cruel” way of handling the disease and the patient. Sometimes, your surgeon will offer to apply a suction sponge called a “Wound Vac” to reduce the frequency of dressing changes. However, this will take months for the wound to heal and the sponge has to be attached to a battery operated suction device that you have to carry around wherever you go. Again, prolonged suffering and wasted time and money with frequent visits to the wound clinic. Despite the fact that the failure rate of this approach is slightly better than excision and closure (30-40% failure rate), it is far from the ideal procedure to treat this condition.
The diseased tissue is removed and the edges of the wound are sutured down to the base of the wound (sacrum) and left to heal. This again creates a cavity that needs to heal from depth to surface. Again, several weeks are wasted packing the wound and doing dressing changes. The healed area is usually shows a big unsightly dent. The failure rate is again 30-40%.
Pit Picking (Trephination, Bascom I Procedure or Gips procedure):
This procedure consists of coring out the midline pores, and the underlying sinus tracts to try to remove all the underlying hair tracts and debris.
In the Bascom I procedure, a second incision is made off to the side over the site of the previous abscess, and through this any hair or debris is swept out.
In the Gips procedure (named after Dr. Gips from Israel) there is no side incision made but a probe is placed from one pore to the other to remove the hairs and debris in the tracts. Often the tracts are injected with a chemical called Phenol, Silver Nitrate or plugged with fibrin Glue to enhance scarring and healing.
There are several variations on this technique described in the literature and all fall under the term “Minimally Invasive Pilonidal Excision” or “MIPE”. The term is very attractive to patients and novice doctors who have no experience with the cleft lift.
Dr. Wadie offered this procedure as the procedure of choice to most patients at the beginning of his practice. The procedure is simple, can be done under local anesthesia or minimal sedation in the office. There is a very small wound (or wounds) and the discomfort is not significant. However, it is a blind procedure that does not ensure removal of all hairs and debris. It also does not get rid of the main culprit: the cleft.
Dr. Wadie abandoned this procedure for most patients as the failure rate is still high (close to 30-40%). Even in Dr. Gips article published in 2008 where he treated 1,435 patients the long-term recurrence rate was close to 17%.
Most surgeons in the country who have good results with the cleft lift abandoned this procedure including Dr. Bascom who introduced it.
It still has a role in a very limited number of patients with extremely limited disease. Ask Dr. Wadie if you are a candidate for this approach. However, best case scenario, the failure rate is close to 17%.
This is a variation of the MIPE procedures where a small endoscope is placed into the sinus tract opening and the hairs and inflammatory tissue is removed. A laser probe is available that can go along the tract to cauterize (burn) it to promote scarring. This is still does not flatten the cleft, so does not address the primary problem. Success rate is not well studied as there are very few centers that offer this technique.
This is a “flap procedure” where the disease is removed and the skin is cut in 2 triangles that meet forming a “Z” shaped incision. It flattens the top part of the cleft and might be good for disease involving the top most part of the cleft. However, any disease that extends below that cannot be treated by this flap. This is particularly true for disease that reaches close to the anus. The cosmetic appearance of the final scar is also not natural and disfiguring. The pain is more intense than the cleft lift ad recovery takes longer time. If it fails, it is very difficult to correct as lots of tissue is lost.
V-Y Advancement Flap:
This is another “flap procedure”. The top part of the cleft is flattened using a V shaped incision that is closed as a “Y”. Again this is helpful if the disease involves the top part of the cleft but not if it involves the lower part or close to the anus.
Limberg Flap (rhomboid flap):
Another flap procedure. In this case the area removed is diamond shaped, and is filled with a square of tissue. Again, works well for flattening the top of the cleft but not good for more extensive disease and disease close to the anus. Failure is very bad and occurs in about 10% of patients. If this fails, correcting it with another flap or a cleft lift is difficult as there is already loss of a lot of tissue. Dr. Wadie specializes in re-do surgery after a failed rhomboid flap.