Comparative Study between Rhomboid Flap and De-epithelization Technique in Management of Pilonidal Sinus

INTRODUCTION

In 1833, Herbert Mayo published the first instance of pilonidal disease in the modern medical literature, describing a young woman with a hair-containing sinus in the sacrococcygeal area. About one and half decade later, Anderson published another case report under the title of “Hair extracted from an ulcer”.¹

In 1854, J. M. Warren described extracting a hairball from a discharging sinus in the sacrococcygeal region. He left the wound to heal by secondary intention and obtained a good result. Later in 1877, Warren more presented three similar cases and stated that he thought the condition apparently derived by the ingrowth of a hair or hairs from a single follicle. ¹

Previously described lesions did not have a name until 1880 when Hodges released the name “Pilonidal” derived from the Latin meaning literally nest (nidus) of hair (pilus) proposing a congenital theory of its origin.^{1, 2}

Nowadays, the term sacrococcygeal pilonidal disease is used to describe the surgical entity describing the presence of subcutaneous infection with a characteristic epithelial track situated mostly in the upper half of the natal cleft and generally containing hair. It may present as an acute pilonidal abscess or an indolent seropurulent discharging sinus resistant to spontaneous healing.^3,6

The aim of the work is to compare between De-epithelization technique and Rhomboid flap in management of pilonidal sinus.

PATIENTS AND METHODS

This comparative study was carried out at Al Azhar University Hospitals' Department of General Surgery. After receiving approval from the local ethical committee and obtaining fully informed written consent from the patient. This research was done on 30 patients with sacrococcygeal pilonidal sinus. The following information was collected: age, gender, presentation, number of sinus pits, midline or lateral pits, therapies, complications, hospitalization stay, and postoperative results.

All patients were randomly assigned to one of two groups: Group A comprises of 15 patients who would be treated using the de-epithelialization technique. Group B: A total of 15 patients would be treated with a rhomboid flap.

Prospectively enrolled patients had: Understand proposed investigations, treatment and signed a detailed informed consent document, as well as, latest patient information leaflet.

Patients were enrolled in the study according to the following inclusion criteria: Prepared patients with clean non- infected pilonidal sinus, may be recurrent pilonidal sinus, Age: 16 – 50, and both sexes. While the exclusion criteria were: Patients with diseases making them un fit to surgery, infected pilonidal sinus, pregnancy and diabetic patients.

All patients undergo a preoperative workup that includes taking a history, a clinical investigation, and laboratory tests (CBC, kidney and liver functions and coagulation profile).

Preoperative care: Patients' age, sex, duration of symptoms, use of antibiotics prior to surgery, and prior therapies were all entered into a patient record form, all patients were subjected to full necessary laboratory tests before surgery. The day before surgery, all patients had been admitted to the hospital and underwent surgery under anesthesia.

Postoperative care: Drain will be installed mandatory in all patients. All patients will be followed up for 6 months.  Patients were seen routinely day after day for 14 days for wound examination and suture removal. Patients with delayed healing were followed up on until they were completely healed. The duration of hospitalization, coming back to work, and complications like wound collapse and contagion, as well as wound treatment duration, have all been tracked. Patients were asked to use the numerical rating pain scale for pain and effect of analgesia after surgery. Patients also had the option to verbally rate their scale from 0 to 10 to be recorded. Patients were advised to shave intergluteal cleft and adjacent buttocks, or use epilation creams, and keep the operative area clean and dry at all times. Patients were informed to follow-up every two weeks for 6 months.

In Rhomboid flap technique:(a) Resection of the sinus tract: After separating the buttocks, a rhombus has been drawn up through the gluteal area, coating all the visible lesions and going down as far as the presacral fascia, till the rhombus is removed completely. (b) Flap design: Outside the defect, a diagonal line dividing the 120o angle has been elongated to the same length as the diagonal in neighboring tissue. Following that, a donor region which can be closed mainly without tension and results in a scar parallel to skin tension lines has been favored based on skin laxity around the defect. (c) Defect Coverage: The flap was then moved over the defect after it had been prepared. The flap has been prepared, which includes the gluteus maximus fascia, and moved onto the flaw in the presacral fascia after careful hemostasis. Separate polyglactin-0 stitches were used to suture the flap's subcutaneous tissue to the gluteus maximus fascia. The skin has been stapled closed and the subcutaneous cellular has been sutured with polyglactin-00. Finally, the resected specimen can be observed.

In De-epithelization technique: the patient has been positioned prone, with the buttocks taped apart to expose the natal cleft. For local anaesthesia, 20 mL of 2% prilocaine has been applied to the sacrococcygeal region around the operative site after skin disinfection with povidone iodine. A sterile methylene blue solution has been injected through a plastic cannula to delineate the tract. After that, a roughly 5 cm long flat intergluteal incision has been made up to the depth of the postsacral fascia. The pilonidal cyst and tract have been revealed and resected, along with the surrounding healthy fatty tissue. However, the surrounding cutaneous as well as subcutaneous tissue has been maintained. A number 10 scalpel blade was used to make an ellipsoidal intradermal incision of partial thickness, limited by the top and bottom points of the intergluteal incision, which included sinus orifices. As a result, such an ellipsoid region has been easily de-epithelialized by applying traction force to the surface with the scalpel blade at a 90° angle, a process identical to “peeling an orange”. In the cavity, a Penrose drain has been installed. The drain has been inserted into the orifice of the tract. The first sutures have been made with 0 nonabsorbable suture between the edge of the de-epithelialized skin, the presacral fascia, and the other reciprocal free edge, respectively. Following that, the de-epithelialized wound has been inverted and sutured with 3/0 nonabsorbable sutures to induce reciprocal overlapping. Eventually, nonabsorbable 3/0 sutures have been used to close the wound. Inverting de-epithelialized skin has been used to fill the cavity of the pilonidal cyst that's been excised.

Statistical analysis and data interpretation: The IBM SPSS software package version 26 has been used to analyse the data that's been fed into the computer. Numbers and percentages are being used to describe qualitative data. The median (min and max) as well as the mean and standard deviation are being used to describe quantitative data.

Data analysis: In 2*2 tables, the Chi-Square test has been used to compare two or more groups, while the Fischer Exact test has been used to correct the Chi-Square test when more than 25% of the cells have counted less than 5. To compare 2 independent groups, a student t-test is being used. To compare 2 independent groups, the Mann-Whitney U test is being used. The outcomes of significance tests are expressed as two-tailed probabilities. The level of significance has been tested for all of the above-mentioned tests, which has been represented as the probability of (p-value), and the outcomes have been explained as follows: If the p value is greater than 0.05, it is non-significant; if the p value is less than or equal to 0.05, it is significant; and if the p value is less than 0.001, it is highly significant.

RESULTS

P: probability.

Continuous data expressed as mean±SD

Categorical data expressed as Number (%)

t: independent samples t-test c2: Chi-square test

*: significant value < 0.05

Table 1: Analysis of demographic data in the two study groups

P: probability.

Categorical data expressed as Number (%)

t: independent samples t-test c2: Chi-square test

Table 2: Analysis of complaint and duration of complaint in the two study groups

The average age of the included 30 patients (15 patients for each group) became 21.67 ± 6.03 for the de- epithelization technique and 25.13 ± 8.73 for the rhomboid flap technique, with no significant difference (p-value > 0.05) in age, gender, or BMI among the two groups.The detailed demographic data is explained in Table 3.

P: probability.

Continuous data expressed as mean±SD

Categorical data expressed as Number (%)

t: independent samples t-test c2: Chi-square test

*: significant value < 0.05

Table 3: Analysis of clinical examination in the two study groups

Regarding the main complaint of both groups, discharge was the most frequent one, with an incidence percent 86.7 and 80 for De-epithelization technique and Rhomboid flap respectively. There was no significant difference in the duration of symptoms between the two groups (p-value > 0.05).

Regarding the clinical examination of both groups, the mean number of openings was 2 for both De-epithelization technique group (range 1:7) and Rhomboid flap (range 1:4), and regarding the clinical staging, stage 2 was the most frequent. In terms of the clinical examination, there was no statistically significant difference (p-value > 0.05) between the two groups.

There was a significant difference (p-value < 0.05) between both groups regarding the operative time with shortest time for De-epithelization technique.

There was a significant difference (p-value < 0.05) between both groups regarding the hospitalization with the longest time for Rhomboid flap technique; there was no significant difference in post-operative complications (p-value > 0.05).

There was a significant difference (p-value < 0.05) between both groups regarding the post operative pain according to VAS scale with highest scores for Rhomboid flap technique.

There was a significant difference (p-value < 0.05) between both groups regarding the duration for sutures removal and return to work with longest time for Rhomboid flap technique. Moreover, there was no significant difference regarding the recurrence rate or scar appearance

P: probability.

Continuous data expressed as mean±SD

Categorical data expressed as Number (%)

t: independent samples t-test c2: Chi-square test

*: significant value < 0.05

Table 4: Analysis of operative time in the two study groups

P: probability.

Continuous data expressed as mean±SD

Categorical data expressed as Number (%)

t: independent samples t-test c2: Chi-square test

*: significant value < 0.05

Table 5: Analysis of early postoperative data in the two study groups

P: probability.

Continuous data expressed as mean±SD

Categorical data expressed as Number (%)

t: independent samples t-test c2: Chi-square test

*: significant value < 0.05

Table 6: Analysis of postoperative complications in the two study groups

P: probability.

Continuous data expressed as mean±SD

Categorical data expressed as Number (%)

t: independent samples t-test c2: Chi-square test

*: significant value < 0.05

Table 7: Analysis of postoperative pain in the two study groups

P: probability.

Continuous data expressed as mean±SD

Categorical data expressed as Number (%)

t: independent samples t-test c2: Chi-square test

*: significant value < 0.05.

Table 8: Analysis of delayed postoperative data in the two study groups