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Endoscopic pilonidal sinus treatment (E.P.Si.T.) P. Meinero • L. Mori • G. Gasloli Received: 14 January 2013 / Accepted: 11 April 2013Ó Springer-Verlag Italia 2013 We present a new video-assisted minimally management of complex anal fistulas [we decided to invasive technique for the treatment of pilonidal disease treat pilonidal disease and its recurrence with the same (E.P.Si.T: endoscopic pilonidal sinus treatment). Between equipment and philosophy of sinus ablation. It is rec- March and November 2012, we operated on 11 patients ognized that other forms of more extensive pilonidal suffering from pilonidal disease. Surgery is performed sinus surgery are associated with a significant recur- under local or spinal anesthesia using the Meinero fistu- rence and morbidity rate ]. This new minimally loscope. The external opening is excised and the fistulo- invasive technique derives from the concept of operat- scope is introduced through the small hole. Anatomy is ing endoscopically and removing all the infected area identified, hair and debris are removed and the entire area no matter how large by way of small (0.5 cm) circular is ablated under direct vision. There were no significant complications recorded in the patient cohort. The painexperienced during the postoperative period was minimal.
At 1 month postoperatively, the external opening(s) were Materials and methods closed in all patients and there were no cases of recurrenceat a median follow-up of 6 months. All patients were The kit includes a Meinero fistuloscope (Fig. ), manu- admitted and discharged on the same day as surgery and factured by Karl Storz GmbH (Tuttlingen, Germany), an commenced work again after a mean time period of 4 days.
obturator, a monopolar electrode, a brush and endoscopic Aesthetic results were excellent. The key feature of the forceps. The fistuloscope has an 8° angled eyepiece and is E.P.Si.T. technique is direct vision, allowing a good defi- equipped with an optical channel and a working and nition of the involved area, removal of debris and cauter- irrigation channel. Its diameter is 3.2 9 4.8 mm, and its ization of the inflamed tissue.
operative length is 18 cm. A removable handle allowseasier manoeuvring. The fistuloscope has two taps one of Pilonidal disease  Pilonidal sinus  E.P.Si.T.  which is connected to a 5,000-ml bag of glycine–mannitol 1 % solution []. Ethics Committee approval wasobtained for the study. All patients signed a specifi-cally formulated informed consent form before the The patient is given a single dose of antibiotic prophy- Having achieved excellent results with the video-assis- laxis (sodium cefazoline 2 g). Spinal or local anaesthesia is ted anal fistula treatment (VAAFT) technique for the required, depending on the extent of the infected area. Thepatient is placed in the prone position with their legsslightly apart. The buttocks are separated by two big P. Meinero (&)  L. Mori  G. Gasloli plasters. The first surgeon can stand either between the Proctology Unit, ASL 4 Chiavarese, Sestri Levante Hospital, patient's legs or on the patient's right side depending upon Sestri Levante, Italye-mail: [email protected] the location of the external sinus opening(s).

Similar to the VAAFT procedure, E.P.Si.T. has two phases:a diagnostic phase and an operative phase.
In the diagnostic phase, the aim is to identify the anat- omy of the pilonidal sinus and any secondary tracts and/orabscess cavities.
The spontaneously draining opening which is normally situated on the midline cleft must be removed by making a0.5-cm-circular incision around the opening. The numberand site of incision vary, depending on the presence ofsecondary fistula tracts or abscesses as well as on theoverall size of the area involved, so that in some morecomplex cases, two incisions may be required. Using aKelly forceps, the edge of the incision is lifted in order to Fig. 2 Tuft of hair within the pilonidal sinus straighten the sinus area permitting easier insertion of thefistuloscope through the external opening, whilst infusion cavities. Necrotic material is removed with an endobrush of the glycine/mannitol 1 % solution assists in opening the passed through the fistuloscope or with a Volkmann spoon underlying tract (Fig. The obturator remains in place if more superficially located. Where two incisions have within the operative channel of the fistuloscope, allowing been used because the infected area is extensive, a special the fistuloscope to progress and providing correct orienta- brush, designed with bristles in the middle part of a flexible tion within the pilonidal sinus. Hair and all fistula tracts or metallic thread, is passed through the incision site(s). The abscess cavities clearly appear on the screen (Fig. By continuous jet of glycine–mannitol solution during the slow up-and-down and side-to-side movements, the infec- procedure ensures both a clear visual field and the elimi- ted area can be clearly delineated. The progression of the nation of the cauterized waste material brushed through the fistuloscope is easy even through long and angled sec- incision. Meticulous attention is paid to haemostasis ondary tracts.
through the fistuloscope during the procedure. At the end of The aim of the operative phase of the E.P.Si.T. proce- the procedure, a light dressing with no packing is applied.
dure is to ablate and clean the infected area. The obturator The patient is discharged on the same day of surgery.
is removed, and the forceps are inserted through theoperative channel in order to thoroughly remove all the hairand hair follicles under direct vision (Fig. This manoeuvre is considered to be a fundamental step to aidhealing. Once this procedure is completed, the forceps are Between March and November 2012, we performed the removed and the monopolar electrode is connected to an E.P.Si.T. technique on 11 patients (6 males, 5 females; electrosurgical knife power unit for cautery ablation of thesinus granulation tissue, commencing in the main tract andwhere appropriate traversing secondary tracts and abscess Fig. 3 The removal of all the hair and hair folliclesby forceps under Fig. 1 The Meinero fistuloscope

Table 1 Patient characteristics M male, F female, ot previous open technique, ct previous closed technique average age 23.3 years (±7.14 SD). The only inclusion period, regular dressings may be required, the wound may criterion was pilonidal disease. The patients' characteristics take many weeks to heal and recurrences are possible.
are shown in Table Of 11 patients, 8 (73 %) had Better results seemed to have occurred with sinotomy undergone previous procedures. In 4 patients, due to the with flaps, (Karydakis flap [], Limberg flap the considerable width of the infected area, it was necessary to multiple Z-Plasty [], or platelet-rich plasma [], Manuka make two 0.5-cm-long incisions in the midline cleft, 6 cm honey [] and sinus excision [], but the ideal procedure apart. The lengths of the tracts treated ranged from 3 to has not yet been found. Bascom ], in 1983, described 10 cm. Average operation time was 40 ± 10 min. External a new technique involving short incisions and removal of opening(s) were not closed. There were no significant the infected area based on a minimally invasive philosophy complications recorded in the patient cohort. Patients which makes it very similar to our new E.P.Si.T. proce- experienced only slight pain or no pain at all in the early dure, but not performed under direct vision. The E.P.Si.T.
and later postoperative period (the average visual analogue procedure has many advantages compared with other scale (VAS) score, evaluated by a questionnaire, was 1.9 techniques. First of all, direct vision allows the surgeon to (±1.44 SD) during the first postoperative week and 0 after see perfectly not only the pilonidal sinus, but also any 2 weeks). Only 2 patients required analgesic (ketorolac possible fistula tracts or abscess cavities. Destruction of the trimetamine) on the day of surgery. No postoperative granulation tissue can be done under vision, and there is the antibiotic therapy was administered. After discharge, the certainty of the complete removal of the infected area.
patients were asked to wash the wound through the external Moreover, haemostasis is achieved entirely under direct opening once a day for at least 2 weeks using a syringe with saline solution.
Patients were seen for follow-up at 1, 2, 4, 6 and 9 months. At 1 month postoperatively, the external open-ing(s) had closed in all patients and there were no cases ofrecurrence at a median follow-up of 6 months (range 1–9).
The median time to return to work was 3.5 days (range1–5).
The aim of the traditional techniques used for surgicalmanagement of pilonidal sinus is the complete removal ofthe infected area with the surgical wound either closed orpacked open. This may cause pain during the postoperative Fig. 4 Treated sinus tract at the end of the procedure Direct vision also allows the complete removal of the versus excisional surgery, a retrospective study. ANZ J Surg hair and hair follicles which are often located not only in 3. Anyanwu AC, Hossain S, Williams A, Montgomery A (1998) the pilonidal sinus, but also in the surrounding tissue. The Karydakis operation for sacrococcygeal pilonidal sinus disease: aesthetic result appears to be good (Fig. and the pro- experience in a district general hospital. Ann R Coll Surg Engl cedure is well tolerated with prompt return to work. There is no need for painful dressings and healing occurs within 4. Azab AS, Kamal MS, el Bassyoni F (1986) The rationale for using the rhomboid fasciocutaneous transposition flap for the 2–3 weeks.
radical cure of pilonidal sinus. J Dermatol Surg Oncol 12:1295–1299 5. Sharma PP (2006) Multiple Z-plasty in pilonidal sinus—a new technique under local anesthesia. World J Surg 30:2261–2265 6. Spyridakis M, Christodoulidis G, Chatzitheofilou C, Symeonidis D, Tepetes K (2009) The role of platelet rich plasma in accel- The key difference between E.P.Si.T. and other techniques erating the wound process and recovery in patients being oper- is direct vision made possible by the fistuloscope. This ated for pilonidal sinus disease: preliminary results. World J Surg allows an excellent definition of the involved area, thor- 7. Thomas M, Hamdan M, Hailes S, Walker M (2011) Manuka ough removal of hair and debris complete cauterization of honey as an effective treatment for chronic pilonidal sinus granulation tissue.
wounds. J Wound Care 20:530–533 8. Kement M, Oncel M, Kurt N, Kaptanoglu L (2006) Sinus exci- Conflict of interest Piercarlo Meinero, M.D., has invented the fis- sion for the treatment of limited chronic pilonidal disease: results tuloscope, which is manufactured by Karl Storz GmbH Tuttlingen after a medium-term follow-up. Dis Colon Rectum 49:1758–1762 (Germany). He receives royalties.
9. Bascom J (1987) Repeat pilonidal operations. Am J Surg 10. Bascom J (1983) Pilonidal disease: long term results of follicle removal. Dis Colon Rectum 26:800–807 11. Nordon IM, Senapati A, Cripps NP (2009) A prospective ran- domized controlled trial of simple Bascom's technique versus 1. Meinero P, Mori L (2011) Video-assisted anal fistula treatment Bascom's cleft closure for the treatment of chronic pilonidal (VAAFT): a novel sphincter-saving procedure for treating com- disease. Am J Surg 197:189–192 plex anal fistulas. Tech Coloproctol 15:417–422. Erratum TechColoproctol (2012) 16:111 2. Rabie ME, Al Refeidi AA, Al Haizaee A, Hilal S, Al Ajmi H, Al Amri AA (2007) Sacrococcygeal pilonidal disease: sinotomy


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