Pilonidal sinus excision (with primary / flap closure)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• wound infection and wound breakdown
• recurrence of the sinus
• bleeding or haematoma under the flap
• seroma or collection needing drainage
• flap tip necrosis
• slow healing of an open wound, needing weeks of dressings
• numbness and a visible scar over the buttock

Pre-operative details for this operation

1. Disease statusChronic sinus, no active infectionRecurrent after previous surgeryAcute abscess (drain first; definitive surgery later)
2. Midline pits and lateral openings on examinationnumber of pits, side and distance of secondary openings from midline
3. Previous drainage or excisiondates, type, where the scars are
4. Planned procedure and closureLimberg (rhomboid) flapKarydakis flapZ-plastyModified BascomExcision with primary midline closureExcision laid open / marsupialisation
5. Blood sugar and other risk factors for poor healingdiabetes, smoking, obesity
6. Area shaved and flap markedmarking done before strapping, with measurements

Anaesthesia and position

1. AnaesthesiaSpinalGeneralLocal infiltration with lignocaine and adrenaline 1:200,000Local with sedation
2. PositionProne jackknifebuttocks strapped apart with adhesive tape; note pressure points padded

Operative findings

1. Midline pitsnumber and distance from anal verge
2. Tracts and secondary openingsdirection (cranial / caudal), side, lateral extensions
3. Cavity contentsHair and granulation tissuePusEpithelial liningOther
4. Depth of diseasesubcutaneous only / down to post-sacral fascia
5. Size of excised tissuelength x width x depth in cm

Procedure (steps)

1. Buttocks strapped apart, area preparedantiseptic used
2. Tracts outlinedMethylene blue injectedMethylene blue with hydrogen peroxideProbe only
3. ExcisionRhomboid excision including all pits and tractsAsymmetric ellipse 2 cm off midline (Karydakis)Midline ellipse (primary closure / Z-plasty)Pit excision with lateral incision (Bascom)Tracts laid open and curetteddepth: to, but not including, the deep fascia
4. All stained tissue and tracts removedYesResidual tract left (reason)
5. HaemostasisBipolar cauteryMonopolar cauteryLigatures
6. Flap raised (if flap closure)type, layers included (skin, fat, gluteal fascia), dimensions; bipolar or No. 15 blade to protect flap blood supply
7. Straps released before closureYes
8. Flap transposed or rotated into the defectdonor defect closed primarily
9. Marsupialisation / open wound (if not closed)skin edges sutured to the cavity base with absorbable suture, wound packed

Closure, drains and dressing

1. DrainClosed suction drain under flapNone (open wound)size, exit site
2. Deep layerabsorbable suture to fat and fascia, material and size
3. SkinInterrupted non-absorbable (e.g. polypropylene (Prolene) 3-0)SubcuticularLeft open and packed
4. Final scar positionOff the midlineIn the midline
5. DressingPressure dressingPack / wick in open wound

Specimens and implants

1. Excised sinus tissue sent for HPEYesNo (curettings only)orientation mark if needed
2. Pus sent for culture and sensitivityYesNo pus

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Dressing checklook for soakage or swelling under the flap
2. Drain outputrecord daily; removal criteria
3. Analgesiadrug, dose, frequency
4. Antibioticdrug, dose and number of doses, or none
5. Open wound carepack or wick removal day, dressing change plan
6. Mobilisationwalk from the same day or next morning
7. Suture removalday planned
8. Hair control after healingregular shaving or hair removal of the natal cleft, local hygiene
9. Follow-upOPD date, HPE report, watch for recurrence

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery