A Simple Marsupialization Technic for Treatmentof Pilonidal Sinus: '

Long-Term Follow up

DANIEL J. ABRANISON, MI.D..Washington, D. C.

THE MIARSUPIALIZATION operation for pi-lonidal sinuses was first described by Buie,3in 1938. In his procedure, the sac was com-pletely unroofed and the overhanging skinand adjacent edge of the sac was excised.The remaining skin edge was sutured to theedge of the sac wall. He believed that thehistologic nature of the sac wall, and itssimilarity to skin, made the lining peculiarlysuited for this type of operation. In an ef-fort to shorten the healing time, the pro-cedure was modified first 1 by excising mostof the lateral wall and later 2 by removingall the sac with the exception of a 1V4-inchmidline strip. The advantages of the mar-supialization operation are many. The pur-pose of this article is to review not only 225operated cases, but also to report on followup findings on patients followed from aminimum of one year to over eight years.

Procedure

There is minimal preoperative prepara-tion for this procedure. An oral antihista-minic drug is given when the patient comesinto the clinic prior to operation. Anesthesiais accomplished by local field block, utiliz-ing one per cent lidocaine (diethyl amino2,6-acetyloxylidide), with epinephrine. Ap-proximately 20 to 30 cc. of solution is ade-

* Submitted for ptublication May 21, 1959.* Surgical Consultant, Walter Reed Army Hos-

pital, Washington 12, D. C. Sturgical Staff George-town University Hospital, Walshington, D. C.

The views and opinions expressed herein donot necessarily represent those of The SturgeonGeneral, the Department of the Army, or the De-partment of Defense.

quate for anesthesia. It is necessary to in-ject only the deeper tissues because of thediffusion properties of lidocaine. The epi-nephrine provides hemostasis.A mosquito clamp or grooved director is

inserted into the sinus opening. The entiretract is laid open with a scalpel (Figs. 1and 2). The incision is continued into nor-mal tissue for a short distance. All grumousmaterial and hair is removed by wipingwith gauze. Then a search is made for addi-tional openings which indicate extensions.If any are found, these tracts are openedin entirety.The skin edges are circumcised. The edge

of skin and adjacent sac wall are graspedwith Allis forceps. After demarcating theamount of sac to be left (just lateral to themidline), the sac and skin edge are excisedwith scissors. The intact skin edge is thensutured to the edge of the sac with inter-rupted 2-0 chromic catgut-the bite in-cludes the deeper tissues in order to obliter-ate dead space. Four throw ties are madeand the sutures are left long to facilitateremoval. The procedure is then repeatedon the opposite side. The final appearanceis seen in Figure 3. A pressure dressing isapplied. The appearance during the healingstage is as indicated in Figures 4 and 5.The postoperative morbidity is minimal.

There is little pain. It is vital to stress thatthe patient should be followed closely untilhealing is complete. In fact, the operationis not undertaken if the patient cannot becompletely followed. On the second post-operative day, the pressure dressing is re-

261

ABRAMSON Annals of SurgeryFebruary 1960

FIG. 1. Incision of skin and sac over mosquitoclamp in the sinus. Open above and below intonormal tissue.

moved and the wound is cleansed. The su-

tures are removed, within seven to ninedays, and Sitz baths are begun. The patientis redressed in the clinic at approximatelyfive-day intervals. At each dressing the baseis rubbed with a cotton applicator stick to

prevent bridging. Intervening dressings are

done by the patient. Ingrowth of hair isprevented by frequent shaving of the area.

The patients are entirely ambulatory andare not hospitalized.The marsupialization operation can be

applied to complicated or simple cases. Acomplicated case treated by this method,is seen in Figures 6A, 6B, and 6C. Whenthere are many tracts, or when the tractsare thin and narrow, the procedure is some-

times modified. In such circumstances, thetracts are completely excised and the skin

FIG. 2. Entire sinus laid open. Debris and hair FIG. 3. Excision of skin edge and sac wall on

removed with gauze pad. Search for additional each side, leaving ¾4-inch strip of sac, in situ. Skinsinus openings. sutured to edge of remaining sac.

262

A SIMPLE MARSUPIALIZATION TECHNIC

edges are sewn to the underlying fascia or

fatty tissue.

Study

This is the final summation of 225 un-

selected cases treated by the marsupializa-tion procedure between May 1950 and June1958 (Table 1). All were treated in the out-patient department of the Walter ReedArmy Medical Center, as ambulatory pa-

tients. The ages of the patients ranged from14 to 49 years. There were 202 men and 23women. Five were Negroes. The majoritygave histories of prolonged periods of drain-age, abscesses, or recurrences. Sixty-twohad had incision and drainage procedures,11 had excision and open packing, 17 hadexcision and primary closure, and one hadmarsupialization. A total of 31 acute ab-scesses were present, on initial examination,seven of which were treated by marsupial-ization as the initial procedure.

TABLE 1. Clinical Evaluation of 225 Patients

Age, in years 14 to 49

Number of patients:Male 202Female 23

Race:White 220Negro 5

Prior surgery :*Incision-drainage 62Excision and open packing 11Excision and primary closure 17Marsupialization 1

Acute abscesses** 31

Simple sinus 109

Complicated sinus 116

Average healing time, in weeks*** 3

Postoperative complications:Bleeding 6Wound infection 3Splitting of wound 3

* Most patients had a history of abscesses, drainage,and recurrences.

** Seven patients were treated primarily.Delayed healing in 17 patients.

FIG. 4. Sutures removed. Appearance of woundon seventh postoperative day.

A simple sinus tract (one cavity) was

present in 109 patients, and there were 116complicated by extensions. The average

sl2 iSzew...

F;c ;' N̂ieeet postopertivedaE*::: "}2:#s^8W o n heale*}d.- 8^ U

V'olume 151Number 2 263

ABRANISON Annals of SurgeryFebruary 1960

FiG. 6A. Patient referred for "perirectal" ab-scess. On examination numerous pitted areas andsinus openings are present. Also noted is the pres-ence of sebaceous cysts and hidradenitis of theanal area. At operation, a markedly complicatedsinus tract containing hair was found.

healing time was approximately threeweeks. Delayed healing (over six weeks)occurred in 17 patients.

Postoperative complications were min-imal. Bleeding-readily controlled-occurredin six patients. Wound infections developedin three patients. One of these had exten-sive furunculosis, secondary to an adhesivedermatitis, and one had had a small abscessat the time of surgery. The wound openedin three patients after complete healing hadoccurred.

Recurrences

Of 202 patients, followed for from one toeight years, two were deceased, leaving 200patients for follow up (Table 2). One hun-dred and fifty-nine patients responded toquestionnaires or were examined (79.5 percent). Recurrences took place in 11 patients,or 6.9 per cent. All patients who stated thatthey had noted drainage at sometime, were

classified as recurrences, despite the factthat this may have represented breakdown

of scar tissue only. Four of these patientswere subsequently operated upon.The hiistories and findings at the time of

operation were reviewed in an effort to dis-cover possible etiologic factors in these re-

currences (Table 3). In order of impor-tance, were extension to the anus and pre-vious abscesses, followed by markedly com-

plicated tracts, previous definitive opera-

tion and incomplete follow up care. Mostlhad a combination of factors. When exten-sion to the anus occurs, the healing or

healed wound is subjected to constanttrauma, irritation, infection, and moisture.Splitting of the wound may occur. Withprevious history of abscesses, reinfectioncan take place. When complicated tractsare encountered, the overlooking of a smallsinus tract is a constant threat. If the pa-

tient is not followed closely, the bridgingof skin with the formation of pockets can

occur. Any operative attack is a challengein patients who have had one or more pre-

vious operations.

Fic. 6B. Appearance at completion of opera-tion. At operation, a markedly complicated pilonidalsinus with numerous ramifications was found.

264

A SIMPLE MARSUPIALIZATION TECHNIC

An unuistual finding occurred in two pa-tients. An accessory sac was discovered atsome distance from, and not connectedwith, the primary sinus. These pockets werefound only after extensive undercutting andexcision of the lateral walls. Such a circum-stance may explain some recurrences afterpilonidal surgery. In one patient, a factitialelement was suspected-he had had fiveprevious definitive procedures. Many of thepatients had hidradenitis or sebaceous cystsabout the anus. All of our patients wereshaved frequently to prevent ingrowth ofhair and buried sutures were not used.

Discussion

Despite the fact that pilonidal sinuses arerelatively minor lesions, morbidity and highrecurrence rate after operation make treat-ment an intriguing problem. Excision andprimary closure technics have not solvedthe issue. Primary union often fails to occurand recurrences are high. Hamilton, Custerand Kellner,4 in a series of 132 consecutivecases treated by excisional procedure, founda 53 per cent failure rate in patients with ahistory of recurrent discharge or abscessformation, in addition to other symptomswhich had existed eight weeks prior to ex-amination. Palumbo, Larimore and Katzalso report on 1,165 cases reviewed in theliterature with the finding of an overall re-currence rate of 21 per cent. It is interest-ing to note that Swinton and Markee,6 of

FIG. 6C. Appearance when healed, 34 days later.

the Lahey Clinic, found the recurrence ratewith marsupialization to be 6.6 per cent;there was an 18 per cent recurrence rate,with excision only; 32 per cent, with exci-sion and primary closure; and 19 per cent,with excision and closure utilizing a modi-fied Pope technic. In addition, the postop-erative treatment of patients treated byprimary closure technics, demands pro-longed immobilization and constipatingregimes.The causes of recurrence with primary

closure technics include the presence of

TABLE 2. Follow up Stuidy in 200 Consecutive UTnselected Cases

Patients Contacts ContactsContacted Answered Unanswered

382832373728

302527282920

835988

Cured

292323262819

Per CentRecurred Recurred

1

24211

3.38.0

14.87.13.45.0

Totals 200 (79.5,C%) 159 (79.5(/%) 41 (20.5/(%) 148 (93.1C) 11 (6.9%)

Two deceased patients were excluded.0-1 year group were excluded.

Volume 151Number 2 2665

DurationFollow up,

Years

1-22-33-44-55-6

Over 6

ABRANISON Annials of SurgeryFebrUary 1960

I'ABLE 3. Anol? vsis of Possible Factcors in Recutrrenzce

Compli- Opening Prior Incisioncate(l Near Previous Operation an(l Incomplete Accessory

Case Tracts Anus Ab)scesses (Definitive) Drainage Follow up Sac

+-+

+

+-

+-

±F

+

+

Totals 4 3 3 3 2

dead space, stitch abscesses, excessive ten-sion, and trauma. Operation is usually per-formed in the presence of infection. In our

study, routine examination of tissue fre-quently showed the presence of acute in-flammation in addition to chronic in-flammatory changes. Bacteriologic studiesof 25 patients at the time of operation, dem-onstrated the presence of a wide variety oforganisms. Alpha streptococcus, hemolyticstaphylococcus, and Alicrococcus tetragenuswere the most common organisms found.Escherichia coli and Streptococcus faecaliswere found on only one occasion. No ana-

erobic organisms were found. Extension toand proximity of the wound to the anus

makes secondary infection a constant threatto successful healing. It is not difficult tounderstand how infected tissue and tractsmay be overlooked with an en bloc exci-sion. Approximately 50 per cent of our pa-

tients had complicated pilonidal sinuses.M'Iarsupialization seems to offer a more

rational approach to the problem. Infectionis not a contraindication to operation, sincethe procedure is an open one and adequatedrainage is provided. The small amount ofsac wall that is left in situi forms a bufferand pad. The intergluteal contour is pre-served. There is minimal loss of tissue andaccessory tracts are easily visualized. Thereis little danger of overlooking an accessory

sinus tract. Since no buried sutures are

used, there is no danger of a retained stitchforming a nidus for subsequent infection.With this procedure, there is universal ap-

plicability in the treatment of pilonidal sinuswhether the sinus is simple or complicated.The procedure can be carried out as an in-and-out procedure and hospitalization isnot necessary. No extensive preoperativepreparation is needed and the technic itselfis simple. The healing time and convales-cent period is short and the morbidityminimal. The recurrence rate is low. Froma military standpoint these factors are im-portant, since the patient need not be hos-pitalized and can be returned to duty early.There has been a tremendous number ofman and hospital days saved with the re-

lease of hospital beds for treatment of moreserious cases.

Healing of wounds treated by the mar-

supialization procedure occurs by oblitera-tion of the secreting surface followed byepithelialization. The patient is closely fol-lowed until completely healed. Bridgingmust be avoided and ingrowth of hair pre-

vented. The healing time is usually welluinder three weeks although, in a small per-

centage, delayed healing-over six weeks-occurs. In most cases of delayed healing,there was extension to the anus, where

again, the factors of trauma, infection, and

266

12345,67891011

Voluime 151 A SIMPLE MIARSUPIALIZATION TECHNIC 267Number 2

moistture slow the healing process. Whleredelayed healing occurs, the wound slhouldbe closed with stainless steel wire or theprocedure should be repeated in the local-ized area.

SummaryA simple marsupialization technic for

treatment of pilonidal sinuses is described.Two hundred and twenty-five patients weretreated by this method in the cut-patientdepartment of Walter Reed Army MedicalCenter. All procedures were performed un-der local anesthesia, using lidocaine withepinephrine as a local anesthetic agent. Notonly was hospitalization not required, butall military personnel were able to reportback to duty in a few days.There were 202 men and 23 women in

this series, and five patients were Negroes.Prior surgery had consisted of incision anddrainage procedures in 62, excisional pro-cedures in 28, and marsupializatien in one.The average healing time was three weeks;delayed healing (over six weeks) occurredin 17 patients. Postoperative complicationswere minimal. There were 202 patients, twoof whom were deceased, with a follow upperiod of a minimum of one to over eightyears. One hundred and fifty-nine patients,or 79.5 per cent, responded to a question-naire or were examined in person. Elevenpatients, or 6.9 per cent, were classified asrecturrences.The technic has universal applicability,

whether the case is simple or complicated.The procedure can be performed as an in-and-out procedure and hospitalization isnot required. No preoperative preparationis necessary, and the disadvantages of pri-mary closure technics are avoided. Infectionis not a contraindication to surgery, sinceadequate drainage is provided. The technicis simple and there is a minimal loss of tis-

suie. Accessory tracts are easily vistualized.No buried sutures are uised. The healingtime and convalescent periods are shortand the morbidity is minimal. The recur-rence rate is low. The patients are entirelyambulatory. The scar is narrow and ade-quate padding is present. The intergultealcontour is preserved.

Since there is no hospitalization requiredfor military personnel and an early returnto duty is possible, there has been a tre-mendous number of man days saved aswell as a release of beds for treatment ofmore serious illnesses.

Acknowledgment

The author wishes to acknowledge theassistance provided by Brigadier GeneralJames H. Forsee, Chief, Department ofSurgery, Walter Reed Army Hospital,Washington, D. C.

Photographs were taken by the MedicalIllustration Section, Laboratory Service,Walter Reed Army Hospital.

Bibliography

1. Abramson, D. J. and P. A. Cox: MIarstupializa-tion Operation for Pilonidal Cysts and Sinusesunder Local Anesthesia with Lidocaine: AnAmbulatory MIethod of Treatment. Ann. Surg.,139:341, 1954.

2. Abramson, D. J.: Modified 'MarsupializationOperation for Pilonidal Sinus: An AmbulatoryTreatment Using Lidocaine as a Local Anes-thesia. U. S. Armed Forces NI. J., 8:513, 1957.

3. Btuie, L. A.: Practical Proctology. Philadelphia,W. B. Saunders Co., 1938.

4. Hamilton, H. H., B. S. Custer and A. Kellner:Pilonidal Cyst: Analysis of 132 ConsecutiveCases. New England J. 'Med., 231:757, 1944.

5. Palumbo, L. T., 0. MI. Larimore, and I. A.Katz: Pilonidal Cysts and Sinuses: StatisticalReview. Arch. Surg., 63:852, 1951.

6. Swinton, N. W., R. K. Mlarkee: Present Statusof Treatment of Pilonidal Sinus Disease. Am.J. Surg., 86:562, 1953.