Multiple Z-plasty for pilonidal sinus : How I do it

Correspondence: Atul Kumar Sharma, Midil School Street, Deeg (Bharatpur) Raj. Pin-321203 India Multiple Z-plasty is a novel recent technique for the treatment of symptomatic sacrococcygeal pilonidal disease. [1] A pilonidal sinus is a surgical conditions which, though appearing trivial to the patient, involves a radical surgical procedure entailing a considerable stay in hospital, discomfort and loss of earnings [2, 3]. It is responsible for much morbidity and its treatment places a burden on hospital and community resources.


How I do it
Correspondence: Atul Kumar Sharma, Midil School Street, Deeg (Bharatpur) Raj.Pin-321203 India Multiple Z-plasty is a novel recent technique for the treatment of symptomatic sacrococcygeal pilonidal disease.[1] A pilonidal sinus is a surgical conditions which, though appearing trivial to the patient, involves a radical surgical procedure entailing a considerable stay in hospital, discomfort and loss of earnings [2,3].It is responsible for much morbidity and its treatment places a burden on hospital and community resources.This technique was first reported in the literature in 2006 patronizing its superiority over z-plasty and other techniques for the treatment for pilonidal sinus [1].Sharma [1], concluded that it avoids a midline scar; it makes the natal cleft shallow, thereby eliminating the suction effect and reducing sweat accumulation; it is easy to learn, safe and effective.
1.The principle of the treatment of pilonidal sinus by excision and multiple Z-plasty reconstruction acknowledges contemporary concepts of the aetiology of this condition and seeks to eliminate these causal factors, thus making recurrence less likely.
2. Multiple Z-plasties excise the inflamed area as well as convert the deep natal cleft into a plateau.The complete sinus tract is excised using an elliptical incision encircling the sinus opening.(Fig 6)   The wound is dressed after applying povidone iodine ointment over the suture line using sterile cotton pads, and firm pressure is used while applying the adhesive plaster to keep the cotton dressing pads in position (Fig. 10 B).
The patient is kept in bed in the prone or lateral position for 5 days until the wound gets adequate tensile strength.The suction drain is removed on the 3rd to 5th post operative day depending on the cessation of drainage of fluid through it.
Alternate sutures are removed on the 5th postoperative day and the patient is usually discharged allowing routine activities and being instructed to avoid squatting for defaecation until two weeks postoperatively to avoid traction on the suture line.The patient is discharged on the 5th day if there is no other indication to keep the patient hospitalized.The remaining sutures are removed on the 8th -10th day.(Fig. 11) Pilonidal disease is a benign condition and patients apparently outgrow its infective complications.It is therefore imperative that the treatment is not worse than the disease itself.It is recommended the midline pits are excised with lateral open drainage of any associated abscess [4].
The ideal procedure for this condition would be an operation that: is in sequence simple to perform requires short hospitalization allows a rapid return to normal activity [5]  However, newer, less invasive techniques have been introduced, like vacuum assisted closure of wounds [6] and platelet rich plasma concentrate infiltration in the wound [7].However, these are in their experimental phase, and further long term studies are required to evaluate their efficacy in the treatment of pilonidal disease.

Figure 5 .
Figure 5. Injecting methylene blue into the sinus tract

Figure 9 .
Figure 9. Putting closed suction drain and applying holding sutures for interdigitating the flaps These flaps are suitably interdigitated and sutured in one layer with nylon 3-0 interrupted sutures.(Fig 10A)

Figure 10A .
Figure 10A.Suturing the wound after interdigitating the flaps

Figure 11 .
Figure 11.Completely healed sinus after suture removal plasty has surpassed other surgical modalities for the treatment of pilonidal sinus in terms of morbidity, healing time, complications and recurrence[1].It has the following advantages over other techniques: 1. Less healing time and less post operative hospital stay [1].2. No local hematoma, wound infection or wound dehiscence with minimal recurrence.3. Technically less demanding.4. Avoids a midline scar. 5. Makes the natal cleft shallow, thereby eliminating the suction effect and reducing sweat accumulation.6. Easy to learn, safe, and effective.