Overview
Definition:
Pilonidal sinus pit picking, often referred to as the Bascom procedure or cleft lift, is a surgical technique aimed at excising the sinus tracts and pits associated with a pilonidal sinus in the sacrococcygeal region, followed by closure of the wound in a way that flattens the natal cleft.
Epidemiology:
Pilonidal disease predominantly affects young adults, with a peak incidence between the ages of 15 and 30 years
It is more common in males than females (approximately 3:1 ratio)
Factors such as obesity, deep natal cleft, hirsutism, and prolonged sitting contribute to its prevalence
Caucasian individuals are more frequently affected.
Clinical Significance:
Pilonidal sinus is a common and often recurrent condition that significantly impacts a patient's quality of life due to pain, discomfort, and drainage
Effective surgical management, like the Bascom procedure, is crucial to achieve healing, prevent recurrence, and allow patients to return to normal activities, making it a vital topic for surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Asymptomatic pits in the natal cleft
Pain and swelling in the sacrococcygeal region
Purulent or serosanguinous discharge from the natal cleft
Recurrent abscess formation and drainage
Development of a palpable mass in the gluteal fold.
Signs:
Visible midline pits or openings in the natal cleft, typically a few centimeters above the anus
Erythema, tenderness, and swelling over the affected area, especially in acute abscesses
Palpable sinus tracts extending from the pits
Drainage of pus or serous fluid from the pits.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the presence of characteristic midline pits in the natal cleft with or without associated signs of inflammation or drainage
Imaging is generally not required for diagnosis but may be helpful in complex or recurrent cases to delineate the extent of sinus tracts.
Diagnostic Approach
History Taking:
Duration of symptoms
Nature of discharge (pus, blood)
Previous episodes of infection or abscess
History of trauma to the area
Occupation or lifestyle involving prolonged sitting
Family history of pilonidal disease
Red flags: fever, signs of systemic infection, or anal pathology.
Physical Examination:
Patient should be examined in the prone or lateral decubitus position
Inspection of the natal cleft for pits, hair extrusion, redness, and swelling
Palpation to assess for tenderness, induration, and sinus tract extension
Digital rectal examination to rule out communication with the anal canal or other anal pathologies.
Investigations:
Generally, no specific laboratory investigations are required for a straightforward diagnosis
However, in cases of suspected infection or systemic illness, a complete blood count (CBC) may be ordered
Imaging, such as ultrasound or MRI, may be used in recurrent or complicated cases to assess the extent of sinus tracts and abscesses, but is not routine.
Differential Diagnosis:
Pilonidal sinus must be differentiated from other conditions presenting with a gluteal mass or midline sacrococcygeal lesions
These include: Epidermoid cysts
Dermoid cysts
Sacral meningocele or teratoma
Pilonidal disease of the hand (rare)
Anal fistulas or abscesses
Spinal dysraphism (in infants)
Osteomyelitis of the sacrum.
Management
Initial Management:
For acute abscesses: incision and drainage
Antibiotics may be administered if there are signs of surrounding cellulitis or systemic infection
Definitive management of the pilonidal sinus is typically surgical.
Medical Management:
Antibiotics are primarily used to treat acute infections or cellulitis associated with the pilonidal sinus
Common choices include broad-spectrum antibiotics like amoxicillin-clavulanate or clindamycin for anaerobic coverage, especially if significant purulence is present
Antibiotics alone do not cure the underlying disease and are usually an adjunct to surgical treatment.
Surgical Management:
The Bascom procedure (pit picking and cleft lift) is a conservative surgical approach
It involves excising the inflamed pits and superficial sinus tracts, followed by flattening of the natal cleft to reduce the depth and prevent hair from entering the skin
This can be achieved by advancing flaps or directly suturing the subcutaneous tissues
Other surgical options include wide excision with primary closure, flap closures (e.g., Karydakis flap), and open healing.
Postoperative Care:
Wound care is crucial
Patients are advised to keep the wound clean and dry, and to avoid prolonged sitting
Shaving of the natal cleft is recommended to prevent hair from entering the wound
Follow-up appointments are essential to monitor wound healing and detect early signs of recurrence.
Complications
Early Complications:
Wound infection
Seroma formation
Hematoma
Delayed wound healing
Partial or complete wound dehiscence.
Late Complications:
Recurrence of pilonidal sinus is a significant concern with any surgical technique
Chronic pain
Scar tenderness
Formation of new sinus tracts.
Prevention Strategies:
Meticulous surgical technique to ensure complete excision of sinus tracts
Flattening of the natal cleft to prevent hair implantation
Postoperative hygiene, including regular shaving of the natal cleft
Patient education on risk factors and recurrence prevention.
Prognosis
Factors Affecting Prognosis:
Adherence to postoperative care instructions
Extent of disease at presentation
Surgical technique employed
Presence of comorbidities
Obesity
Deep natal cleft.
Outcomes:
The Bascom procedure, when performed correctly, offers a high success rate and lower recurrence rates compared to simple excision
Complete healing can be expected in most patients, with significant improvement in quality of life.
Follow Up:
Regular follow-up is recommended for at least 6-12 months postoperatively
Patients should be advised to report any signs of recurrence, such as discharge or pain, immediately
Long-term monitoring may involve periodic self-examination and shaving of the natal cleft.
Key Points
Exam Focus:
The Bascom procedure is a conservative approach focusing on eliminating pits and flattening the natal cleft
Recurrence is a major issue in pilonidal sinus management
Risk factors include deep natal cleft, hirsutism, and obesity
Acute abscess requires I&D prior to definitive management.
Clinical Pearls:
Careful examination of the natal cleft for all midline openings is essential
The goal of the Bascom procedure is to make the natal cleft shallower
Patient compliance with hygiene and follow-up is paramount for long-term success
Consider spinal dysraphism in pediatric or atypical presentations.
Common Mistakes:
Inadequate excision of all sinus tracts and pits
Failure to address the depth of the natal cleft, leading to recurrence
Not providing adequate postoperative hygiene instructions to the patient
Delaying definitive surgical treatment for asymptomatic disease or minor symptoms.