Total subcutaneous fistulectomy combined with Karydakis flap for sacrococcygeal pilonidal disease with secondary perianal opening

Abstract

Flap techniques have been performed with success in the treatment of pilonidal disease. However, some complex cases such as perianal pilonidal disease need special attention. We describe a modification of a well-known flap technique for secondary perianal pilonidal disease and its early results. Total subcutaneous fistulotomy combined with Karydakis flap was performed on 14 patients. An elliptical incision, described by Karydakis, was made while not including the perianal opening. Both sides of the elliptical incision were deepened down to the gluteal muscle and postsacral fascia. At the level of subcutaneous tissue, attention was directed to the secondary perianal opening. A fine probe was inserted through the perianal skin pit, and the connection site between the fistula and the cyst was observed. A small circular skin incision was made around the probe and the fistula tract was totally excised using electrocautery together with the main cyst. The flap was prepared as described by Karydakis. Before suturing the flap to the other side, perianal subcutaneous tissue was sutured with a fine absorbable material, then, the flap was sutured with 4/0 polypropylene. One patient developed seroma. Neither early failure in wound healing nor recurrence was observed at a mean of 16.2 months (range 4-36 months) follow-up. Total subcutaneous fistulectomy plus Karydakis flap as a single-stage procedure is an effective surgical modality for sacroccocygeal pilonidal disease with secondary perianal opening.