Hastalığı bilimsel olarak inceleyen bilim adamları ve hekimlerin yayınlamış olduğu ve gerçekliği kanıtlanmış olan pilonidal sinüs hastalığı konusunda en detaylı ve orjinal bilgiler ışığında sizlere aktarmak istiyoruz. Aşağıdaki bilgiler ingilizce olma sebebi verilen orjinal olarak aktarılmasından kaynaklanmaktadır.
Treatment of chronic pilonidal sinus with local anaesthesia: a randomized trial of closed compared with open technique
- M. Testini1,
- G. Piccinni1,
- S. Miniello1,
- B. Di Venere1,
- G. Lissidini1,
- V. Nicolardi2,
- G. M. Bonomo1
To compare open with closed treatment of chronic pilonidal sinus.
Patients and methods
From 1993 to 1996, 100 patients were submitted to excision of chronic pilonidal sinus, with local anaesthesia and were randomized in two groups: group A in which open treatment and group B in which direct suture were performed. The follow-up, ranging from 37 to 89 months, was performed by outpatient visits or by phone.
Short-term results showed 6 (12.0%) post-operative complications in group A vs 10 (20.0%) in group B. Long-term results showed 9 (18.0%) complications in group A vs 7 (14.0%) in group B. Mean wound healing was 58 days (range: 29–93) in group A vs 12 (range: 9–61) in group B. The return to normal activity was 25.7 (range: 11–77) vs 10.4 (range: 5–32). Wound healing and the return to normal activity were the only statistically significant differences.
Regarding morbidity neither technique has particular advantages over the other. The closed technique produced quicker wound healing and a quicker return to normal activity.
Sacrococcygeal local anaesthesia versus general anaesthesia for pilonidal sinus surgery: a prospective randomised trial
M. Z. Naja1,
M. F. Ziade2,
M. El Rajab3
Sixty patients scheduled for pilonidal sinus surgery were prospectively randomly assigned to receive general anaesthesia or sacrococcygeal local anaesthesia with a newly-described technique. Patients in the general anaesthesia group spent more time in the operating theatre and recovery room than did those in the local anaesthesia group (p < 0.05). Two thirds (67%) of the patients in the local anaesthesia group left hospital on the day of surgery compared to only 17% of patients in the general anaesthesia group (p < 0.05). Visual analogue scale pain scores performed during the 3-day follow-up period favoured the local anaesthetic technique (p < 0.05). Postoperative analgesia requirements were greater in the general anaesthesia group than in the local anaesthesia group (p < 0.05). The majority of patients and surgeons expressed satisfaction with local anaesthesia. Sacrococcygeal local anaesthesia appears to be a successful alternative to general anaesthesia for pilonidal sinus surgery.
The surgical treatment of pilonidal sinus is often associated with considerable postoperative pain  and a hospital stay of up to 5 days . A variety of surgical and anaesthetic techniques have been used in an attempt to decrease postoperative pain or to limit the duration of hospital stay, e.g. the excision and skin flap technique , Limberg flaps with no surgical drains , Bascom’s operation , excision of the sinus down to the sacrococcygeal fascia and simple primary closure of the wound without tension sutures or surgical drains , and the use of hydrocolloid dressings . The laser excision technique [7, 8] has also been reported to minimise postoperative pain but does not decrease the duration of hospital stay .
In addition to the complications that may result from general anaesthesia, the performance of the operation in the prone position provides further opportunities for patient morbidity that include decreased pulmonary compliance, cardiovascular instability and airway problems [9–12]. Different anaesthetic techniques have been introduced as an alternative to general anaesthesia. Spinal anaesthesia has been reported to decrease the duration of hospital stay slightly but was found to be associated with an incidence of complications such as haematoma, wound infection and minor wound breakdown in 8% of patients . The use of local anaesthesia in combination with sedation [14, 15] has succeeded in decreasing pain  and hospital stay . However, the local anaesthetic used allowed only limited surgical procedures . It has been argued that in order to minimise, or even to avoid, hospital admission, the ideal management of patients undergoing pilonidal sinus surgery should include the avoidance of general anaesthesia and the provision of effective postoperative analgesia .
The aim of this study was to compare a sacrococcygeal local anaesthesia technique with general anaesthesia for the surgical treatment of pilonidal sinus. The outcome indicators of the study were postoperative pain, consumption of postoperative analgesic medications, duration of hospital stay and the satisfaction of both patient and surgeon.
Following Local Research Ethics Committee approval and written, informed consent, 60 patients scheduled for the surgical treatment of symptomatic pilonidal sinus were included in the study. Patients allergic to lidocaine or with multiple pilonidal orifices were excluded from this study. The patients were randomly assigned by sealed envelopes to receive either local anaesthesia (LA group) or general anaesthesia (GA group). Due to the substantial difference between the two anaesthetic techniques, a double-blind design was not possible. Instead, an observer-blinded design was used, with nurses who were unaware of the anaesthesia technique collecting the postoperative data. In addition to standard demographic and clinical data, the times spent by the patients in the operating theatre and in the recovery room were recorded.
The patients were followed up for 3 days after surgery. Postoperative pain was assessed with a non-graduated 100 mm visual analogue scale (VAS). Pain during movement was assessed at 6, 12, 24, 36, 48 and 72 h after surgery.
During the first 24 h after surgery, intramuscular pethidine 1 mg.kg−1 was given if necessary. If pain relief was not achieved within 30 min of pethidine administration, oral coproxamol was given. For patients who were still in pain after the first postoperative day, further coproxamol was given.
The criteria for discharge from the recovery room were haemodynamic stability, VAS pain scores < 40 mm and full consciousness. The decision to discharge the patient from the hospital was made by the surgeon who performed the operation on the basis of wound haemostasis, pain score < 40 mm and overall medical status.
At the end of the operation, the surgeon was asked whether he was satisfied with the operative conditions. Patients undergoing surgery under local anaesthesia were asked whether they felt discomfort during the insertion of the block or at any time during surgery.
The sacrococcygeal block was performed with the patient in the prone position, after intravenous access had been gained and routine monitors had been attached. The buttocks were pulled laterally with adhesive tape, exposing the sacral area and the pilonidal sinus. After aseptic preparation of the skin, four injection sites were marked: 4 cm above and below, and 3 cm lateral to the centre of the pilonidal sinus on both sides (Fig. 1). A ‘lozenge’ shape is thus formed by connecting the injection sites. At each of the four injection sites, plain lidocaine 1% 0.3 ml was injected subcutaneously using an 8-mm 30G needle (Micro-Fine Plus, Becton Dickinson, Dublin, Ireland).
Figure 1. Diagram detailing the local anaesthetic technique.
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Each 20 ml of the local anaesthetic mixture used for the main block contained: lidocaine 2% 6 ml, lidocaine 2% with epinephrine 1 : 200 000 6 ml, bupivacaine 0.5% 6 ml, fentanyl 50 μg.ml−1 1 ml and clonidine 75 μg.ml−1 1 ml. In our experience, this mixture provides excellent postoperative analgesia of surprisingly long duration when used for peripheral nerve blocks [19–22]. A total of 30–40 ml of the local anaesthetic mixture was used, depending on the patient’s weight. The technique is as follows.
A 10-mm 27G needle (Becton Dickinson) is introduced at each of the four injection sites in turn. The needle is first introduced perpendicular to all planes, and 1 ml of the local anaesthetic mixture is infiltrated. The needle is then partially withdrawn and reinserted at an angle of 45° to the skin, aiming towards the centre of the pilonidal sinus, where another 1 ml of the mixture is injected. The needle is then partially withdrawn and reinserted at an angle of 45° to the skin in the direction of one side, and then the other, of the lozenge, 1 ml of the mixture being injected along each side (see arrows in Fig. 1). The above steps are then repeated but with a 33-mm 27G needle (Becton Dickinson).
The injections should be performed slowly so as to minimise discomfort. The procedure takes 10–15 min. The onset time of the block, as determined by sensitivity to pinprick within the incision area, is a further 10–15 min. Even though all LA group patients were offered sedation, none requested or received sedation during the performance of the block or during the surgical procedure.
General anaesthesia for patients in the GA group was induced with intravenous fentanyl 1.5 μg.kg−1 and thiopental 3–5 mg.kg−1, followed by tracheal intubation facilitated by atracurium 0.5 mg.kg−1. The patients were then turned to the prone position. Anaesthesia was maintained with isoflurane 1–3% in nitrous oxide 70% and oxygen 30%. The isoflurane concentration was adjusted so as to maintain blood pressure within 25% of pre-induction values. At the end of the operation, the patient was returned to the supine position and residual neuromuscular blockade was antagonised with neostigmine 0.05 mg.kg−1 and atropine 0.01 mg.kg−1.
The cavity of the pilonidal sinus was marked by injecting 10 ml of Methylene blue through one of the sinus openings. Elliptical incisions (1–2.5 cm from the centre of the sinus) were made using cutting diathermy down to, but preserving, the presacral fascia. Excision of the pilonidal sinus was then performed, followed by careful haemostasis. Depending on the degree of infection of the pilonidal sinus, one of the following two procedures was chosen:
Primary closure using interrupted 2/0 nylon sutures was used if there were signs of modest infection.
If the pilonidal sinus was considered to be significantly infected, the wound was left open and packed with antibiotic dressings (Sofratull, Roussel, England), as recommended by Menzel et al..
Student’s t-test or Wilcoxon’s test was performed as appropriate to determine the difference between the two study groups with regard to age, height, weight, duration of surgery, recovery stay, need for supplementary opioid administration and pain scores. The Chi squared test was used to test the differences in sex, postoperative nausea and vomiting and hospital stay. A probability value of < 0.05 was considered to be significant. In order to detect a 20% difference in the primary study end-point (pain score) with α = 5% and β = 10%, a sample size of 30 patients in each group was found to be necessary.
Demographic and operation data are given in Table 1. Patients in the GA group spent more time in the operating theatre (p = 0.004) and in the recovery room (p = 0.011) than patients in the LA group (Table 2). On average, patients in the GA group spent 10 min more in the operating theatre and 20 min more in the recovery room than those in the LA group. Patients in the LA group had a shorter hospital stay than those in the GA group (p = 0.0001) (Table 2). Two thirds of the patients in LA group (67%) left the hospital on the day of surgery compared to only 17% of patients in the GA group.
|Table 1. Demographic and operation data. Values are mean (SD) or number (%).|
|GA Group (n = 30)||LA Group (n = 30)|
|GA: general anaesthetic. LA: local anaesthetic.|
|Sex; M: F||20 : 10||21 : 9|
|Age; years||24.8 (5.5)||26.9 (16.2)|
|Height; cm||168 (8.0)||168 (7.0)|
|Weight; kg||79.5 (13.9)||79.0 (13.0)|
|Body mass index|
|< 25 kg.m−2||5 (17%)||6 (20%)|
|25–30 kg.m−2||18 (60%)||15 (50%)|
|≥ 30 kg.m−2||7 (23%)||9 (30%)|
|Primary closure||3 (10%)||2 (7%)|
|Wound left open||27 (90%)||28 (93%)|
|Table 2. Postoperative outcome measures. Values are mean (SD) or number (%).|
|GA Group (n = 30)||LA Group (n = 30)|
|Duration in the operating theatre; min||47 (13)||36 (15)||p = 0.004|
|Recovery room stay; min||87 (38)||64 (32)||p = 0.011|
|Discharged same day||5 (17%)||20 (67%)||p = 0.0001|
|One night in hospital||22 (73%)||10 (33%)|
|≥ two nights in hospital||3 (10%)||–|
|Number of patients free from postoperative nausea and vomiting||28 (93%)||29 (97%)||p > 0.05|
|Number of patients expressing satisfaction with anaesthetic technique||21 (70%)||28 (93%)||p = 0.045|
|Bleeding||1 (3%)||1 (3%)||p > 0.05|
Two patients complained of discomfort during the performance of the local anaesthetic block. The majority of patients expressed satisfaction with the local anaesthetic technique while in the operating theatre (28 patients, 93%). This proportion was significantly higher than the number of patients in the GA group who expressed satisfaction when asked in the recovery room (21 patients, 70%) (p = 0.045). Most surgeons were satisfied with the operating conditions produced by the local anaesthetic technique (28 operations, 93%). Bleeding was the only surgical complication reported, being of equal incidence in the two groups.
All pain scores performed during the fellow-up period (Table 3) were in favour of the local anaesthetic technique, with significant differences throughout this period.
|Table 3. Visual analogue scale scores during the postoperative period. Values are mean (SD) and median [range].|
|GA Group (n = 30)||LA Group (n = 30)|
|VAS = visual analogue scale.|
|VAS score 6 h after surgery; mm||47.5 (11.5)||15 (18.1)||p = 0.0001|
|50 [0–55]||10 [0–70]|
|VAS score 12 h after surgery; mm||38.5 (16.5)||15 (18.0)||p = 0.0001|
|45 [0–55]||10 [0–60]|
|VAS score 24 h after surgery; mm||30 (19.07)||17.6 (19.6)||p = 0.0001|
|37.5 [0–50]||15 [0–55]|
|VAS score 36 h after surgery; mm||24 (18.5)||10.5 (17.6)||p = 0.001|
|25 [0–45]||0 [0–15]|
|VAS score 48 h after surgery; mm||13 (16.0)||5.8 (12.1)||p = 0.0001|
|10 [0–45]||0 [0–45]|
|VAS score 72 h after surgery; mm||8.67 (14.1)||2.5 (6.26)||p = 0.002|
|0 [0–45]||0 [0–25]|
The need for postoperative analgesia was found to be higher in the GA group than in the LA group (Table 4). Patients in the GA group required significantly more analgesic drugs (p < 0.01).
|Table 4. Total opioid consumption during the postoperative period.|
|Time interval||Drug||GA Group (n = 30)||LA Group (n = 30)|
|0 h−6 h||Coproxamol||22 tablets||2 tablets||p = 0.001|
|Pethidine||1292 mg||147 mg||p = 0.0001|
|6 h−12 h||Coproxamol||32 tablets||4 tablets||p = 0.0001|
|Pethidine||890 mg||85 mg||p = 0.001|
|12 h−24 h||Coproxamol||78 tablets||14 tablets||p = 0.0001|
|Pethidine||604 mg||155 mg||p > 0.05|
|24 h−48 h||Coproxamol||68 tablets||12 tablets||p = 0.001|
|48 h−72 h||Coproxamol||28 tablets||–|
These results suggest that the local anaesthetic technique used is a realistic alternative to general anaesthesia, being associated with a shorter hospital stay, lower pain scores and a lower consumption of opioid analgesic drugs. Two thirds of the patients in the LA group became day-stay cases. Two patients in the LA group complained of pain during the performance of the block. This pain may be due to injecting the local anaesthetic mixture in a relatively small space over a short period of time. The pain was transient, lasting only 2–3 min. We therefore suggest that the injections should be performed slowly and progressively to minimise discomfort.
Some authors have reported that local anaesthetic techniques produce poor results in the presence of acute inflammation . However, our technique of infiltrating the local anaesthetic mixture along the border of the lozenge, some 3 cm away from the sinus, and thus affecting the nerves supplying the surgical area, seems to produce an effective block. All patients in the LA group had a clinically effective block, and no patient required conversion to a general anaesthetic. In two patients in the LA group, the pilonidal sinus was highly inflamed, and the surgeon needed to extend the area of incision beyond the anaesthetised area. Not surprisingly, this produced pain for the patients and dissatisfaction in the surgeons. These operations were completed successfully after infiltration of a further 10 ml of the local anaesthetic mixture. Although the surgeons were asked to delineate the extent of the incision before the block was performed, surgeons often decide to extend the incision during the procedure. We suggest that the inflamed area should be carefully palpated before local anaesthetic injection so that the lozenge can be enlarged if necessary.
Patients in the LA group spent significantly less time in the operating theatre than those in the GA group. This may be the result of the additional time required to turn a patient carefully into the prone position. Patients in the LA group were fully conscious during the operation, and were thus able to position themselves comfortably and quickly. Patients undergoing surgical procedures in the prone position under general anaesthesia may experience an increased incidence of a variety of complications [9, 10, 25–27]. The incidence of such complications may be substantially decreased if the patient is awake.
In accordance with our previous published experience [19–22], the period of improved analgesia in patients undergoing surgery under local anaesthesia is remarkably long, exceeding the anticipated duration of the local anaesthetic effect itself. There may be a number of reasons for this. Several studies have reported surprisingly long durations of improved pain relief following the use of the local anaesthetic/opioid/α2 adrenoceptor agonist mixture used in this study [28–30]. This, taken together with the recent finding of decreased pain both at rest and on swallowing for 5 days after the use of a local anaesthetic/α2 adrenoceptor agonist mixture for tonsillectomy , may indicate a potential pre-emptive analgesic action of this type of mixture. Another factor is that injecting morphine accurately around the nerves has been reported to improve pain relief of long duration [32, 33]. The decreased need for opioid analgesia in the LA group resulted in a shorter hospital stay.
In summary, the use of the local anaesthetic technique described in this paper for pilonidal sinus surgery seems to result in greater patient and surgeon satisfaction, shorter hospital stay and better overall pain relief.
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Surgical treatment of complicated pilonidal disease: limited separate elliptical excision with primary closure
- O. F. Akinci,
- A. Coskun,
- A. Ozgonul,
- A. Terzi
Article first published online: 16 AUG 2006
Objective We aimed at treating complicated pilonidal sinus (PS) patients by a simple and effective surgical procedure.
Method Between 2000 and 2004, 24 selected complicated PS patients were treated with ‘limited separate elliptical excision and primary closure’. Patients with extensive or bilateral gluteal involvement, having more lateral, caudal or cephalic sinuses, multiple recurrences and unhealed chronic wounds after pilonidal surgery were included. Asymmetric excision and primary closure was performed to main diseased tissue in the midline. Additionally, small separate elliptical excisions with primary closure were performed in other involved tissues. The fistula tract or granulation tissue were excised subcutaneously if present. All patients were operated under local anaesthesia. The fascial attachments between the skin and coccyx were released at the deep point in the midline and at one side of wound. Suction drains and prophylactic antibiotics were used; subcutaneous tissues were closed with running polyglactin sutures and skin with polypropylene subcutaneously.
Results The mean age of patients was 28.4 years (range 18–38). The mean follow-up time was 2.8 years. One recurrence, one seroma, one wound infection and one wound breakdown were recorded. Healing was always by first intention except in patients with wound infection and breakdown.
Conclusion Most of the complicated PS patients can be operated with acceptable rates of recurrences and complications by using ‘limited separate elliptical excisions with primary closure’.
Bascom’s operation in the day-surgical management of symptomatic pilonidal sinus
- A. Senapati1,2,*,
- N. P. J. Cripps1,
- M. R. Thompson1
Many treatments for symptomatic pilonidal sinus disease have been described. Ambulatory treatment with minimal morbidity and a rapid return to normal activity is desirable. Bascom’s operation fulfils these requirements. This paper describes the operative technique and results of treatment.
Some 218 patients of mean age 27 years were treated as day cases. The mean duration of symptoms was 2·4 years. Sixty-eight per cent of patients had complex disease with more than two midline pits and/or a lateral discharging sinus. One hundred and eighty-three patients (84 per cent) were operated on under local anaesthesia.
Ninety-five per cent of patients have been followed up for a mean of 12·1 (range 1–60) months. All except one midline wound healed. Lateral wounds healed after a mean of 4·0 (range 1–15) weeks. Postoperative complications were few, including bleeding in 4 per cent and abscess formation treated by reopening the lateral incision in 6 per cent. Twenty-one patients (10 per cent) have had recurrence and have needed reoperation.
Bascom’s operation is simple and results in considerable financial savings with minimal social disruption and an early return to work. Recurrent disease is no more frequent than after other treatments. © 2000 British Journal of Surgery Society Ltd