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Excision and Primary Closure of Pilonidal Sinus

Pre-operative Preparation for a Excision and Primary Closure of Pilonidal Sinus procedure

There is some important information about the pre-operative preparation for this procedure. It is imperative that you read this.

Read about Pilonidal Pre-operative Preparation

Procedure

Excision and primary closure is the standard technique for the management of a pilonidal sinus. Most sinuses are solitary and midline but occasionally can be multiple and off the midline. Even if solitary, the subcutaneous tracks can be multiple and can travel for a variable distance in any direction. The principle is to excise the sinus and all associated subcutaneous tracks, leaving a defect which, on most occasions, can be closed primarily. However it is desirable to leave the suture line off the midline because we know that in doing so the recurrence rate is somewhat less for reasons that are not clear. This is achieved by moving a flap of skin from one buttock over to the other. Deep sutures are placed and closed, effectively eliminating the cavity. Interrupted skin sutures are then placed. Finally the area is injected with long acting local anaesthetic for the purposes of pain relief and a water-tight dressing placed over the wound.

Excision and Primary Closure of Pilonidal Sinus


Post-operative Care following a Excision and Primary Closure of Pilonidal Sinus procedure

It is enviable that you will experience some discomfort after the surgery, in particular once the long acting local anaesthetic has worn off after about six hours. It is important that you have some pain relief on board before this happens and my preference is either Endone or Panadeine forte. These should be taken regularly as directed on the packet. When the pain decreases at about forty-eight hours then you can desist altogether or convert to something simple such as Nurofen or Panadol. You will also be sent home with a course of antibiotics (a type of penicillin if you are not allergic). Take these regularly as instructed.

The dressing that was placed on the wound at the time of surgery should be removed on the first post-operative day. The proximity of the lower end of the dressing to the anus means that it becomes quite easily soiled and it is much better to have a wound that is uncovered rather than one that it covered by a soiled dressing. Once the dressing has been removed then you should get into the shower two or three times a day and wash the wound gently with soap and water and simply dab dry with a towel. It is only necessary to replace the dressing if you feel that it makes it more comfortable from your clothing. However the process should be repeated on a daily basis.

Physical Activity

You should rest following your surgery but it is clearly important to undertake some physical activity. This should be limited to moving around the house and going for short walks but under no circumstances should you undertake any vigorous exercise. It is reasonably important to keep direct pressure off the wound so when sitting down either sit on one buttock or the other, but preferably recline. It is also important to avoid bending over acutely at the waist. Once it is clear that the wound is healing satisfactorily and there is no suggestion of a wound dehiscence (break down), then it is safe to gently reintroduce normal physical activity over a two to three week period. You should certainly avoid any activity where there is a risk of landing heavily on that area or where there is a risk of receiving a blow such as in contact sports.

Dr Renaut will see you in his office at day ten to twelve for a review and to remove the sutures. It should be clear at that point whether there is a further risk of dehiscence (wound breakdown).

If at any time between your discharge from hospital and your appointment to see Dr Renaut you have any concerns then feel free to call his office without undue delay.

Wound Dehiscence

A small percentage of primary closures will experience a partial or complete wound dehiscence (breakdown). This is somewhat inevitable and is based on the fact that the operation site is chronically infected in the first instance. If there is some minor breakdown this usually heals without any intervention other than keeping the wound clean with soap and water. If there is a significant breakdown then the wound will need to be allowed to heal by secondary intention (from the base up) and this will be achieved with the use of daily dressings that can be done by the GP practice nurse. Dr Renaut will issue these instructions if and when required. If the wound remains closed and healing appears to be satisfactory then it is a simple matter of continuing with the same wound care namely regular soap and water in the shower and then dab dry with a towel. The wound can be left open to the fresh air at this point.

Recurrence

There is always the risk of the pilonidal sinus recurring. As previously stated this is lessened by leaving a suture line which is off the midline. The other significant risk factor for a recurrence is not keeping the area hair free. It is therefore vitally important that regular depilation occurs even in the post-operative period. Until the wound is fully healed this needs to be done using a razor and needs to extend approximately 5-7cm all the way around the wound, including down towards the anus. Once the wound has healed then any depilatory method can be used (including depilatory creams and wax) but by far the best method is laser therapy as this is permanent.

Follow up

Dr Renaut will see you for a review and to remove the sutures on approximately day 10–12.

Related Information

Read about Pilonidal Sinus