The Origin And Problems With The “Open Wound” Approach, From The Perspective Of A Pilonidal Specialist
For decades, surgeons have struggled with the handling of the wound following pilonidal cyst removal. Early on, the most perfect-appearing midline closures would invariably fail. Some surgical schools theorized that tension was the problem, and devised elaborate skin rearrangements (flaps) to offset this. Others tried skin grafts from the thigh with minimal success. One wound closure technique deserves special mention, that of “marsupialization”. In this largely abandoned technique, the edges of the wound were stitched down to the bone at the base of the wound, creating a deep “pouch”. The rationale for this latter approach remains unclear.
In recent American surgical history, the most common approach to the pilonidal cystectomy wound is to not attempt closure at all, but to let the wound heal by “secondary intention”, i.e. from the depths upward. Here, the likely rationale is that the diseased tissue being removed is too infected to foster closed wound healing. The result with this “lay open” technique, however, ranges from dismal to mediocre. This wound takes months to heal, if it ever heals at all. Painful, repetitive dressing changes are the rule. Most disappointing, once and if wound healing does occur, the recurrence risk remains high, because the natal cleft has not been lifted. The scar that forms is paper thin and lies directly over bone leading to its own set of problems. In summary, it is a flawed technique.