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Is pilonidal sinus tract suturing new?

Q - Recently patients have come back to us having had pilonidal sinus tracts laid open but then sutured. They have broken down and needed to heal in the way I was taught (by granulating from below). Is this a new technique and what is the evidence that it is any better?

A - Fifty years ago, pilonidal sinus was treated by wide excision down to the fascia overlying the sacrum, and the wound was then left open to granulate.

This took three months of regular dressing before healing was completed, and some 20 years ago it was realised that simple laying open of pilonidal sinus tracts could halve the healing time.

Concurrently, it became apparent that excision of pilonidal sinus tracts with primary closure could achieve primary healing in more than 90 per cent of cases, thereby avoiding a prolonged period of open wound dressing.

More recently, it has been shown that asymmetric excision of a wide area of skin with primary closure (Karydakis procedure) flattens the natal cleft and reduces the long-term risk of recurrence to approximately 5 per cent.

A similar approach (Bascom's procedure) is based on excision of pilonidal sinus tracts via a laterally placed elliptical incision which is left open to granulate, thereby avoiding a large granulating midline wound. The midline pilonidal pit is excised and the defect sutured.

This technique has now superseded the simple laying open of pilonidal sinus tracts. In a small proportion of cases the persistence of an unhealed pilonidal sinus wound causes great anxiety and inconvenience.

Early referral of patients with complicated pilonidal sinuses that are proving resistant to treatment can save the patient a great deal of avoidable difficulty.

Timothy Allen-Mersh, is professor of gastrointestinal surgery, department of surgery, Chelsea and Westminster Hospital, London

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