ORIGINAL ARTICLE
Endoscopic Pilonidal Sinus Treatment in the Asian Population Clement L. K. Chia, MRCS (Ed),* Vivyan W. Y. Tay,w and Surendra K. Mantoo, FRCS (Ed)*
Introduction: This study aims to evaluate the early results of endoscopic pilonidal sinus treatment (EPSiT) in the Asian population and illustrate the surgical technique and its modifications by a video presentation (Supplemental Digital Content 1, http:// links.lww.com/SLE/A115). Materials and Methods: Retrospective review of 9 patients with pilonidal sinus disease treated with EPSiT is performed in a single institution. Surgical outcomes of sinus healing, pain, and discharge were reviewed in the outpatient clinic and patient satisfaction levels were assessed through a standardized phone interview. Results: The median age was 24 years (range, 16 to 41 y). The median duration of follow-up was 2.5 months (range, 1 to 5 mo). Median duration of sinus healing is 6 weeks (range, 2 to 7 wk). One patient had pain despite sinus healing. Satisfaction rate was 78% (7/9). Conclusions: EPSiT is a minimally invasive and cosmetically favorable procedure. A larger sample size and a longer follow-up is required to determine if it improves healing time and long-term recurrence rate. Key Words: endoscopic, pilonidal sinus, Asian
(Surg Laparosc Endosc Percutan Tech 2015;25:e95–e97)
T
he ideal treatment of pilonidal sinus disease remains controversial despite various surgical options being proposed.1–3 In the west, Meneiro et al4 and Milone et al5 have published their early experience with endoscopic pilonidal sinus treatment (EPSiT) and video-assisted treatment of pilonidal sinus disease, respectively. Their results have been promising, with the purported advantage of being minimally invasive and allow removal of hair under direct vision. In Singapore, the findings of a local study6 performed on the clinical features of pilonidal sinus in the Asian population support the hair invagination theory7,8 behind the pathogenesis of this disease entity. We hypothesize that EPSiT would be an effective treatment of pilonidal sinus disease in the Asian population as it targets the disease pathogenesis. We present our Received for publication January 6, 2015; accepted January 22, 2015. From the *Department of General Surgery, Khoo Teck Puat Hospital; and wYong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. The authors declare no conflicts of interest. Reprints: Clement L. K. Chia, MRCS (Ed), Department of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore (e-mail: [email protected]). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.surgical-laparoscopy.com. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
institution’s initial experience with 9 patients treated with EPSiT and illustration of the surgical technique with video narration.
MATERIALS AND METHODS A retrospective study of patients who underwent EPSiT from July 2014 to December 2014 at Khoo Teck Puat Hospital, Department of General Surgery was conducted. The inclusion criteria were patients who presented to outpatient clinic with pilonidal sinus disease with an external sinus opening. Patients with pilonidal abscess and signs of acute infection were excluded. Procedures were performed by the senior author. The procedure was divided into 4 phases: positioning and preparatory phase, the diagnostic phase, the therapeutic phase, and excision of the sinus. In the positioning and preparatory phase, the patient is given general anesthesia and placed in the prone position with gel pads placed below the chest, hips, and knees. The buttocks are separated by 2 large plasters. A prophylactic dose of intravenous antibiotics (Augmentin 1.2 g) is given before the start of the surgery. The monitor is positioned on the right of the operation table while the surgeon stands on the left side. The surgical set is prepared and inspected before the start of the surgery. The kit consists of the Meinero fistuloscope, manufactured by Karl Storz GmbH (Tuttlingen, Germany), an obturator, a monopolar electrode, a brush, and the endoscopic forceps. The fistuloscope has an 8-degree angled eyepiece and is equipped with an optical channel and a working and irrigation channel. Its diameter is 3.2 4.8 mm, and its operative length is 18 cm. A 5000 mL bag of glycine-mannitol 1% solution is connected to the irrigation channel. In the diagnostic phase, a fistula probe and sometimes an artery forceps is used to gently dilate the sinus opening, followed by the injection of 10 mL of saline into the sinus opening to open up the sinus track. The fistuloscope is gently introduced into the sinus opening and the irrigation channel is opened. The endoscopic forceps is inserted into the working port and granulation tissue is gently pushed away under direct vision to delineate the anatomy of the main sinus tract up to the blind end of the tract. Once the main sinus tract is established, the fistuloscope is used to look for any secondary lateral tract openings. Secondary sinus tracts are similarly delineated. In the therapeutic phase, the aim is to remove all the hair and granulation tissue in the sinus tract. Hair and granulation tissue are removed by the endoscopic forceps and the tract is further cleaned with an endobrush and the continuous jet of glycine-mannitol promotes irrigation and washout of the debris. Finally, electrocautery probe is used to ablate the tract and achieve hemostasis.
Volume 25, Number 3, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
e95
Surg Laparosc Endosc Percutan Tech
Chia et al
Volume 25, Number 3, June 2015
study is the first to describe this novel treatment of pilonidal sinus in the Asian population via a video narration and evaluate its short-term outcome. Traditional attempts to achieve complete excision of the pilonidal sinuses and secondary tracts, down to the sacral periosteum have resulted in deep wide wounds left to heal via secondary intention because primary closure may result in excessive skin tension and subsequent dehiscence. This leads to large open wounds that cause significant pain, immobility, burdensome wound care, and potentially a disfiguring scar. Alternatively, complex flaps have been constructed but require postoperative subcutaneous drainage and a longer hospitalization stay and other morbidity. EPSiT has an advantage over these techniques as it is a minimally invasive treatment modality that can be performed as a day surgery procedure. The basis of EPSiT is to target the hair invagination theory in the pathogenesis of pilonidal sinus disease via complete removal of hair under direct vision using an endoscopic forceps that is introduced into the sinus opening. The sinus opening is excised at the end of the surgery and the size of the wound measures about 1.5 cm and gives the patient minimal postoperative pain and an excellent cosmetic outcome after surgery. Despite being less invasive than other conventional surgery, our preliminary results did not demonstrate an improvement in sinus healing time with endoscopic approach and a smaller incision as it took up to 45 days for most of the sinus to heal completely which is at most comparable to the mean of 42 to 56 days in other reports.10–12 We postulate that healing of the pilonidal sinus is not only dependent on the size of the external incision incorporating the sinus but internally the main and secondary tracts will require time to occlude as well. However, all patients in our study returned to work in
Endoscopic Pilonidal Sinus Treatment in the Asian Population Clement L. K. Chia, MRCS (Ed),* Vivyan W. Y. Tay,w and Surendra K. Mantoo, FRCS (Ed)*
Introduction: This study aims to evaluate the early results of endoscopic pilonidal sinus treatment (EPSiT) in the Asian population and illustrate the surgical technique and its modifications by a video presentation (Supplemental Digital Content 1, http:// links.lww.com/SLE/A115). Materials and Methods: Retrospective review of 9 patients with pilonidal sinus disease treated with EPSiT is performed in a single institution. Surgical outcomes of sinus healing, pain, and discharge were reviewed in the outpatient clinic and patient satisfaction levels were assessed through a standardized phone interview. Results: The median age was 24 years (range, 16 to 41 y). The median duration of follow-up was 2.5 months (range, 1 to 5 mo). Median duration of sinus healing is 6 weeks (range, 2 to 7 wk). One patient had pain despite sinus healing. Satisfaction rate was 78% (7/9). Conclusions: EPSiT is a minimally invasive and cosmetically favorable procedure. A larger sample size and a longer follow-up is required to determine if it improves healing time and long-term recurrence rate. Key Words: endoscopic, pilonidal sinus, Asian
(Surg Laparosc Endosc Percutan Tech 2015;25:e95–e97)
T
he ideal treatment of pilonidal sinus disease remains controversial despite various surgical options being proposed.1–3 In the west, Meneiro et al4 and Milone et al5 have published their early experience with endoscopic pilonidal sinus treatment (EPSiT) and video-assisted treatment of pilonidal sinus disease, respectively. Their results have been promising, with the purported advantage of being minimally invasive and allow removal of hair under direct vision. In Singapore, the findings of a local study6 performed on the clinical features of pilonidal sinus in the Asian population support the hair invagination theory7,8 behind the pathogenesis of this disease entity. We hypothesize that EPSiT would be an effective treatment of pilonidal sinus disease in the Asian population as it targets the disease pathogenesis. We present our Received for publication January 6, 2015; accepted January 22, 2015. From the *Department of General Surgery, Khoo Teck Puat Hospital; and wYong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. The authors declare no conflicts of interest. Reprints: Clement L. K. Chia, MRCS (Ed), Department of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore (e-mail: [email protected]). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.surgical-laparoscopy.com. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Surg Laparosc Endosc Percutan Tech
institution’s initial experience with 9 patients treated with EPSiT and illustration of the surgical technique with video narration.
MATERIALS AND METHODS A retrospective study of patients who underwent EPSiT from July 2014 to December 2014 at Khoo Teck Puat Hospital, Department of General Surgery was conducted. The inclusion criteria were patients who presented to outpatient clinic with pilonidal sinus disease with an external sinus opening. Patients with pilonidal abscess and signs of acute infection were excluded. Procedures were performed by the senior author. The procedure was divided into 4 phases: positioning and preparatory phase, the diagnostic phase, the therapeutic phase, and excision of the sinus. In the positioning and preparatory phase, the patient is given general anesthesia and placed in the prone position with gel pads placed below the chest, hips, and knees. The buttocks are separated by 2 large plasters. A prophylactic dose of intravenous antibiotics (Augmentin 1.2 g) is given before the start of the surgery. The monitor is positioned on the right of the operation table while the surgeon stands on the left side. The surgical set is prepared and inspected before the start of the surgery. The kit consists of the Meinero fistuloscope, manufactured by Karl Storz GmbH (Tuttlingen, Germany), an obturator, a monopolar electrode, a brush, and the endoscopic forceps. The fistuloscope has an 8-degree angled eyepiece and is equipped with an optical channel and a working and irrigation channel. Its diameter is 3.2 4.8 mm, and its operative length is 18 cm. A 5000 mL bag of glycine-mannitol 1% solution is connected to the irrigation channel. In the diagnostic phase, a fistula probe and sometimes an artery forceps is used to gently dilate the sinus opening, followed by the injection of 10 mL of saline into the sinus opening to open up the sinus track. The fistuloscope is gently introduced into the sinus opening and the irrigation channel is opened. The endoscopic forceps is inserted into the working port and granulation tissue is gently pushed away under direct vision to delineate the anatomy of the main sinus tract up to the blind end of the tract. Once the main sinus tract is established, the fistuloscope is used to look for any secondary lateral tract openings. Secondary sinus tracts are similarly delineated. In the therapeutic phase, the aim is to remove all the hair and granulation tissue in the sinus tract. Hair and granulation tissue are removed by the endoscopic forceps and the tract is further cleaned with an endobrush and the continuous jet of glycine-mannitol promotes irrigation and washout of the debris. Finally, electrocautery probe is used to ablate the tract and achieve hemostasis.
Volume 25, Number 3, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
e95
Surg Laparosc Endosc Percutan Tech
Chia et al
Volume 25, Number 3, June 2015
study is the first to describe this novel treatment of pilonidal sinus in the Asian population via a video narration and evaluate its short-term outcome. Traditional attempts to achieve complete excision of the pilonidal sinuses and secondary tracts, down to the sacral periosteum have resulted in deep wide wounds left to heal via secondary intention because primary closure may result in excessive skin tension and subsequent dehiscence. This leads to large open wounds that cause significant pain, immobility, burdensome wound care, and potentially a disfiguring scar. Alternatively, complex flaps have been constructed but require postoperative subcutaneous drainage and a longer hospitalization stay and other morbidity. EPSiT has an advantage over these techniques as it is a minimally invasive treatment modality that can be performed as a day surgery procedure. The basis of EPSiT is to target the hair invagination theory in the pathogenesis of pilonidal sinus disease via complete removal of hair under direct vision using an endoscopic forceps that is introduced into the sinus opening. The sinus opening is excised at the end of the surgery and the size of the wound measures about 1.5 cm and gives the patient minimal postoperative pain and an excellent cosmetic outcome after surgery. Despite being less invasive than other conventional surgery, our preliminary results did not demonstrate an improvement in sinus healing time with endoscopic approach and a smaller incision as it took up to 45 days for most of the sinus to heal completely which is at most comparable to the mean of 42 to 56 days in other reports.10–12 We postulate that healing of the pilonidal sinus is not only dependent on the size of the external incision incorporating the sinus but internally the main and secondary tracts will require time to occlude as well. However, all patients in our study returned to work in
