Pilonidal Cyst Excision with Primary Closure Using Vancomycin/Saline Reconstituted Full Thickness Fish Skin Underlay

Introduction: Pilonidal cyst treatment principles include the entire removal of the sinus tract, complete healing of the overlying skin, and minimizing the risk of recurrence. Management varies and ranges from simple incisional drainage, surgical excision of the sinus tract with secondary healing (SH) of the resultant wound and surgical excision of the sinus tract with primary closure (PC), either at the midline or off-midline.  Generally, advocates of PC site shorter healing times while those recommending SH claim less risk of recurrence (1). PC is also fraught with a reported 26-60% post-operative partial dehiscence rate (2,3). Intact fish skin and the support of healing it provides as an underlay to skin closure in wounds at risk for dehiscence would seem like an optimal matrix to employ in pilonidal cyst surgery when primary closure is chosen. Methods: Five consecutive patients undergoing pilonidal cyst excision with primary closure were included in this prospective clinical series over 10 weeks. All surgeries were performed with the patient in the prone position using local/IV sedation anesthesia. All patients received 2 grams cephazolin preoperatively. A #7 closed system drain was placed prior to closure. Layered repair was performed with 3.0 and 4.0 monofilament absorbable suture and 4.0 prolene for the skin. Full thickness fish skin reconstituted in a vancomycin/saline solution was placed as an underlay to the skin closure. Wound examination was done at post-operative days #4, #7 and #10. Results: We prospectively evaluated 5 consecutive patients (all male) who underwent pilonidal cyst excision with primary closure. The average patient age was 26 years (range 22-29). Patients were evaluated at post-operative Day #4, #7 and #10. Drainage never exceeded more than 10 cc in a 24-hour period. The drain was removed at Day 7 in four of the patients and at Day 10 in the other. All sutures were removed at Day 10.  No wounds demonstrated any signs of infection or wound dehiscence.   Discussion: This small pilot study suggests the possible role of full thickness fish skin underlay in preventing wound dehiscence in patients undergoing primary closure after pilonidal cyst excision. Larger, controlled studies are warranted. References: