Surgical treatment of chronic sacrococcygeal pilonidal sinus. Open method versus primary closure. Is closure of the peritoneal layer necessary in the repair of midline surgical abdominal wounds? V-Y advancement flap closures for complicated pilonidal sinus disease. Excision with or without primary closure for pilonidal sinus disease. Prevention of postoperative abdominal adhesions by a novel, glycerol/sodium hyaluronate/carboxymethylcellulose-based bioresorbable membrane: a prospective, randomized, evaluator-blinded multicenter study. Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision. Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus: a prospective, randomized clinical trial with a complete two-year follow-up. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial. A prospective randomized controlled trial of simple Bascom's technique versus Bascom's cleft closure for the treatment of chronic pilonidal disease. Which technique for treatment of pilonidal sinus--open or closed? Treatment of pilonidal sinus by primary closure with a transposed rhomboid flap compared with deep suturing: a prospective randomised clinical trial.
To study the comparison between the primary closure and open technique after excision of chronic sacrococcygeal pilonidal sinus.
                A randomized study was designed and 77 patients with chronic sacrococcygeal pilonidal sinus were included in this study. This study took place in Rizgary Teaching Hospital, Erbil, Kurdistan, Iraq, from January 1997 to August 2003. The patients were separated into 2 groups; Group A (37 patients) were treated by open method (excision and healing by secondary intention) and Group B (40 patients) for whom primary midline suturing was performed after excision of the pilonidal sinus. The follow up ranged from 1.5-5.5 years (mean 4.16) was through outpatient visits.
                The Student t test was applied for statistical analysis for the operating time, hospital-stay, time off from work and wound healing time; and the results show extremely significant differences between the 2 groups (p < 0.0001). The statistical analysis of the total number of postoperative complications of both techniques showed a significant difference (p = 0.0401), while the differences were insignificant for each complication when analyzed separately.
                Excision and primary closure for chronic sacrococcygeal pilonidal sinus is superior to excision and healing by secondary intention. We believe that primary midline suturing is a useful method for management of chronic sacrococcygeal pilonidal sinus. This study describes a prospective randomized controlled trial to evaluate whether suture of the peritoneal layer is necessary as a separate step in the closure of midline abdominal surgical wounds. Consecutive patients undergoing abdominal operation--elective and emergency surgery--through a midline abdominal wound were randomized to have the peritoneal layer closed with continuous catgut, or to have this step omitted. The linea alba was closed with interrupted stainless steel sutures, and the skin approximated with staples. Patients were evaluated for wound sepsis, wound dehiscence, and subsequent incisional hernia development. Postoperative pain was assessed by a self-administered visual analogue score, and by measuring narcotic requirements. There was no significant difference in narcotic requirements, pain scores, or wound complications between the 2 groups. Single-layer closure of the abdominal wall is quicker, less costly, and theoretically safer than layered closure, and it is recommended that separate suture of the peritoneum be abandoned. Hair entry into the midline is the generally accepted theory in pilonidal sinus formation. This theory is also involved in the pathogenesis of the recurrence after different types of operations for pilonidal sinus disease. The relationship of the suture lines and the midline was evaluated in this study.
                Thirty-four patients with stage 4 or recurrent pilonidal sinus disease who underwent V--Y advancement flap closure were randomized into two groups: vertical suture line unrelated to midline (VLUM, n=18) and vertical suture line related to midline (VLRM, n=16).
                None of the patients with or without a suction drain developed flap necrosis, local haematomas or seromas. The median length of the postoperative hospital stay was 3 days for theVLRM group and the VLUM group (p>0.05). The median follow-up period was 32 months. During the follow-up period, two recurrences were determined 22 and 15 months after operation in the VLRM group. Recurrences were situated in the scar tissue over the midline.
                Routine application of suction drains is not recommended after V--Y advancement flap closure. Avoidance of the relationship of the postoperative suture line and the midline, if possible, offers a safe method of definitive reconstruction. To evaluate the outcome of excision with or without primary closure in the management of chronic pilonidal sinus (PNS) disease.
                Between July 2002 and November 2006, a randomized trial was conducted in the Department of General Surgery, Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia. All the patients who presented with chronic natal cleft PNS disease were included in the study. They underwent either excision with midline closure (EMC group), or excision without closure (EWC group). Patients, who came with an acute pilonidal abscess (complicated) were excluded from the study. The principle outcome measures recorded were wound infection, healing time, time off work and the recurrence rate.
                A total of 380 patients of chronic PNS were divided into EMC group, (188 patients) and EWC group (192 patients). Majority of the patients were male in both the groups (93%). The hospital stay ranged from 2 to 5 days (mean = 3.6 +/- 1.4 days) for EMC group, while it was 3-5 days (mean = 4 +/- 1.1 days) for EWC group (p < 0.002). wound infection was 4.2% in EMC group, compared to 3.12% of EWC group (MS). The mean healing time and time off work in EMC group was significantly shorter than the patients in EWC group. Median follow up of EMC group was 36.3 months (range 10-52 months) while it was 35.2 months (range 13-51 months) for EWC group. Statistically there was no significant difference in the recurrence rate of both the groups (3.7% vs. 3%).
                Excision and primary closure is recommended, as a preferred procedure in the management of chronic PNS disease. It has the advantages of early wound healing, rapid return to work and comparable recurrence rate with excision and open wound. Postoperative abdominal adhesions are associated with significant morbidity and mortality, placing a substantial burden on healthcare systems worldwide. Development of a bioresorbable membrane containing up to 23 percent glycerol and chemically modified sodium hyaluronate/carboxymethylcellulose offers ease of handling and has been shown to provide significant postoperative adhesion prevention in animals. This study was designed to assess the safety of glycerol hyaluronate/carboxymethylcellulose and to evaluate its efficacy in reducing the incidence, extent, and severity of postoperative adhesion development in surgical patients.
                Twelve centers enrolled 120 patients with ulcerative colitis or familial polyposis who were scheduled for a restorative proctocolectomy and ileal pouch-anal anastomosis with diverting loop ileostomy. Before surgical closure, patients were randomized to no anti-adhesion treatment (control) or treatment with glycerol hyaluronate/carboxymethylcellulose membrane under the midline incision. At ileostomy closure, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision.
                Data were analyzed using the intent-to-treat population. Treatment with glycerol hyaluronate/carboxymethylcellulose resulted in 19 of 58 patients (33 percent) with no adhesions compared with 6 of 60 adhesion-free patients (10 percent) in the no treatment control group (P = 0.002). The mean extent of postoperative adhesions to the midline incision was significantly lower among patients treated with glycerol hyaluronate/carboxymethylcellulose compared with patients in the control group (P < 0.001). The severity of postoperative adhesions to the midline incision was significantly less with glycerol hyaluronate/carboxymethylcellulose than with control (P < 0.001). Adverse events were similar between treatment and no treatment control groups with the exception of abscess and incisional wound complications were more frequently observed with glycerol hyaluronate/carboxymethylcellulose.
                Glycerol hyaluronate/carboxymethylcellulose was shown to effectively reduce adhesions to the midline incision and adhesions between the omentum and small bowel after abdominal surgery. Safety profiles for the treatment and no treatment control groups were similar with the exception of more infection complications associated with glycerol hyaluronate/carboxymethylcellulose use. Animal models did not predict these complications. To determine whether a transverse incision is an alternative to a midline incision in terms of incisional hernia incidence, surgical site infection, postoperative pain, hospital stay and cosmetics in cholecystectomy. Incisional hernias after midline incision are commonly underestimated but probably complicate between 2 and 20% of all abdominal wall closures. The midline incision is the preferred incision for surgery of the upper abdomen despite evidence that alternatives, such as the lateral paramedian and transverse incision, exist and might reduce the rate of incisional hernia. A RCT was preformed in the pre-laparoscopic cholecystectomy era the data of which were never published.
                One hundred and fifty female patients were randomly allocated to cholecystectomy through midline or transverse incision. Early complications, the duration to discharge and the in-hospital use of analgesics was noted. Patients returned to the surgical outpatient clinic for evaluation of the cosmetic results of the scar and to evaluate possible complications such as fistula, wound dehiscence and incisional hernia after a minimum of 12 months follow-up.
                Two percent (1/60) of patients that had undergone the procedure through a transverse incision presented with an incisional hernia as opposed to 14% (9/63) of patients from the midline incision group (P = 0.017). Transverse incisions were found to be significantly shorter than midline incisions and associated with more pleasing appearance. More patients having undergone a midline incision, reported pain on day one, two and three postoperatively than patients from the transverse group. The use of analgesics did not differ between the two groups.
                In light of our results a transverse incision should, if possible, be considered as the preferred incision in acute and elective surgery of the upper abdomen when laparoscopic surgery is not an option. The best surgical technique for treating pilonidal sinus disease is controversial. The aim of this study is to compare the modified lay-open technique with primary closure following excision with respect to operating time, healing time, time before return to work, morbidity rate, and recurrence rate.
                After a pre-study power analysis, 142 patients with chronic sacrococcygeal pilonidal sinus were prospectively and randomly allocated, either to the modified lay-open group (Group A, n=73) or the primary closure group (Group B, n=69). In the former, incision, curettage, partial lateral wall excision, and marsupialization were performed. Single doses of cefazoline (1 g) and metronidazole (500 mg) were given intravenously 15 min before surgery to all patients.
                There were no differences with respect to gender, age, body mass index, and mean operating time between the groups. In Group A, healing failure and early bridging occurred in one patient each. In Group B, wound infection occurred in four patients, wound breakdown in three, one healing failure and hematoma in one patient each. Morbidity and recurrence rates were significantly lower in Group A (2.7 vs. 13%, P=0.028 and 1.4 vs. 17.4%, P<0.001 respectively). The median time before return to work in Group A was significantly shorter than in Group B (3 [range 2--8] vs. 21 [range 14--63] days, P<0.001). The median healing time in Group A was significantly longer than in Group B (7 [range 3--16] weeks vs. 2 [range 2--9] weeks; P<0.001).
                The results of the present study suggest that modified lay-open is superior to excision with primary closure for the surgical treatment of chronic sacrococcygeal pilonidal sinus with regard to morbidity and recurrence rates, and time before return to work, although healing time is longer. Vacuum-assisted closure has become a new technique in the challenging management of contaminated, acute, and chronic wounds. Although promising clinical results have been described, scientific proof to substantiate the mechanism of action of this therapy is scarce. In the present study, we examined whether the positive effect on wound healing found in vacuum-assisted closure-treated wounds could be explained by an effect on the bacterial load. Fifty-four patients who needed open wound management before surgical closure were included in this study. Wounds were randomized to either vacuum-assisted closure therapy (n= 29) or treatment by conventional moist gauze therapy (n= 25). Healing was characterized by development of a clean granulating wound bed ("ready for surgical therapy") and reduction of wound surface area. To quantify bacterial load, biopsies were collected. No significant difference was found in time needed to reach "ready for surgical therapy" comparing both therapies. Wound surface area reduction was significantly larger in vacuum-assisted closure-treated wounds: 3.8 +/- 0.5 percent/day (mean +/- SEM) compared to conventional-treated wounds (1.7 +/- 0.6 percent/day; p < 0.05). The total quantitative bacterial load was generally stable in both therapies. However, nonfermentative gram negative bacilli showed a significant decrease in vacuum-assisted closure-treated wounds (p < 0.05), whereas Staphylococcus aureus showed a significant increase in vacuum-assisted closure-treated wounds (p < 0.05). In conclusion, this study shows a positive effect of vacuum-assisted closure therapy on wound healing, expressed as a significant reduction of wound surface area. However, this could not be explained by a significant quantitative reduction of the bacterial load. The aim of this study was to determine which of Bascom's simple techniques, Bascom's simple surgery or Bascom's cleft closure, is preferred in the management of moderate-severity pilonidal disease.
                Fifty-five patients with chronic pilonidal disease were randomized to receive Bascom's simple surgery (n = 29) or cleft closure (n = 26) under local anesthetic. The primary end point was time to healing. Patients were followed up for a median of 3 years (range, .7-4 y).
                After Bascom's simple surgery, 5 of 29 patients did not heal and proceeded to cleft closure. The remaining patients healed at a median of 4 weeks (range, 3-35 wk). After cleft closure, 21 of 26 wounds healed primarily on removal of sutures at 10 to 13 days. The remaining 5 wounds healed at a median of 4.5 weeks (range, 2-5 wk). Fifty of 55 (91%) patients were contacted for follow-up evaluation, disease recurrence occurred in 2 of 24 after Bascom's simple surgery and in 0 of 26 after cleft closure.
                Cleft closure offers more predictable healing than Bascom's simple surgery, with less need for re-operation. Disease recurrence is more prevalent after Bascom's simple surgery. After excision of the pilonidal sinus, some surgeons leave the wound open, and others close the wound primarily. The aim of this study is to compare length of hospital stay, length of time to return to work, wound infection rate, and recurrence rate in chronic pilonidal sinus patients, after modification of both closed and open techniques.
                One hundred ten patients who had chronic-stage pilonidal sinus were randomly assigned to receive one of two excisional surgical procedures. One-half were treated by surgical excision and primary closure (closed technique, Group A). The other one-half were treated with Obeid's surgical excision (open technique, Group B).
                Ninety-one (46 in Group A and 45 in Group B) of 110 patients were followed for a period four months to three years. Although patients with primary closure had significantly longer hospital stays (P < 0.05) than patients in the open group, they returned to work significantly earlier (P < 0.05). In Group A and Group B, infection rates were 3.6 percent and 1.8 percent (P > 0.01), and recurrence rates were 4.4 percent and 0 percent (P > 0.01), respectively.
                Because both techniques have very low complication rates, treatment of chronic pilonidal sinus should be based on patient preference and characteristics, especially employment status. To assess two techniques of primary closure after excision of pilonidal sinus.
                Prospective randomised study.
                University department of surgery, United Arab Emirates.
                46 patients with chronic pilonidal sinus disease, 24 treated by rhomboid flap transposition, and 22 by deep suturing technique.
                Early mobility and recurrence.
                All patients in the rhomboid flap transposition group healed their wounds primarily compared with 17 in the primary deep suturing group (77%). (P = 0.02). Five patients wounds broke down as a result of haematoma and infection (23%). The mean hospital stay for the rhomboid flap technique was 6 days compared with 9 days after deep suturing, and the mean follow up for both groups was 18 months, the rhomboid flap group returned to work a mean of nine days earlier than the deep suturing group (23 days). No recurrence has been identified yet in the rhomboid flap group, while 2 recurrences have developed in the deep suturing group (9%).
                Primary closure after excision of pilonidal sinus with a transposed rhomboid flap is successful in the management of pilonidal sinus and is superior to primary closure by deep suturing.
No clear benefit was shown for open healing over surgical closure. A clear benefit was shown in favour of off-midline rather than midline wound closure. When closure of pilonidal sinuses is the desired surgical option, off-midline closure should be the standard management.