Bascom Procedure

[Samantha Figueredo]

Themost important point to remember is that everyone with a bowel problem can be helped and many can be completely cured.

Whenever possible, we offer procedures using minimally invasive techniques.

A pilonidal sinus (PNS) is a small hole or tunnel in the skin. It may fill with fluid or pus, causing the formation of a cyst or abscess. It occurs in the cleft at the top of the buttocks. A pilonidal cyst usually contains hair, dirt, and debris. It can cause severe pain and can often become infected. If it becomes infected, it may ooze pus and blood and have a foul odour.

A pilonidal abscess is managed by incision, drainage, and curettage of the abscess cavity to remove hair nests and skin debris. The wound is left open and cleansed daily in the shower or with a sitz bath. In 90% of cases the wound is fully healed within a month. Unfortunately, this is not a long-term curative procedure and as many as 85% of patients require further surgical treatment.

Laser hair removal treatment to the region or ablation of the sinus has been proposed to decrease the likelihood of further exacerbations but has not gained popularity. Similarly, application of fibrin glue after curettage of the tract has no confirmed efficacy.

The pilonidal sinus is excised and the tract is laid open to allow healing by secondary intention; this technique avoids the wound infections that can be seen after primary closure. The average time for wound healing to occur is approximately 6 weeks. Application of negative pressure wound management systems (Vac therapy) might decrease healing times. The recurrence rate is in the range of 10-20%.

With marsupialization, after the pilonidal sinus is excised, the wound is sutured open and loosely packed; daily dressing changes are required. Marsupialization provides the patient with a smaller wound as compared with wounds that are left open to granulate. Healing is usually complete by 6 weeks, and the recurrence rate has been reported to be below 10%.

The Bascom procedure focuses on removal of the hairs and follicles with small wounds and a shorter healing time (usually less than 3 weeks). The disadvantages are wound infection and wound dehiscence. Recurrence rates are less than 10%.

This uses an asymmetrical or oblique elliptical incision in an attempt to keep incisions out of the natal cleft. Once the sinus is excised, a full-thickness flap is created on the opposite side allowing it to be mobilized for primary wound closure, thus avoiding a midline wound. The wound is closed in multiple layers over a closed suction drain. Recurrence rates are typically below 5% but flap failure and wound dehiscence can be problematic.

The techniques developed for recurrent disease and unhealed wounds generally involve the use of a flap procedure to achieve primary closure and to obliterate the deep natal cleft. The procedures available include the following:

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Objective This study is a report on 700 consecutive patients treated with the Bascom cleft lift as treatment for both simple and complex pilonidal diseases between 1993 and 2020. Patients and methods The Bascom cleft lift was used in patients with primary disease, recurrent disease, perianal disease, and failed flap procedures. Some technical modifications had to be made to accommodate patients with perianal disease, and they are described. All patients were treated by the author in private practice clinics and hospitals between 1993 and 2020 and were entered into a database concomitantly with their treatment. Patients were subsequently surveyed in preparation for this study, by phone, email, or email survey to determine the current status. The procedure consisted of excision of the sinus tracts, cysts, and open wounds; raising a skin and subcutaneous tissue flap; and flattening the gluteal cleft. Failure of the procedure was defined as lack of complete healing or recurrent pilonidal disease requiring revisional surgery. Complications were recorded and are described. Results We found that of the 700 patients, 3.4% required revision of the cleft lift (confidence interval for proportion based on binomial distribution: 2.1%-4.8%). The median follow-up time for patients without recurrence was six months (IQR: 2-19.5). Once primary healing was obtained, there were no late recurrences in the 156 patients followed beyond 24 months. Factors that negatively impacted the success rate were having had previous failed pilonidal surgery (5.3% required revision) and open wounds on the edge of the anus (15.5% required revision). Conclusions The Bascom cleft lift had an overall success rate of 96.6%. There was no category of patients for which this was not a good option, but analysis of this data reveals that patients who have had previous failed surgery, and patients with wounds on the edge of the anus had a higher failure rate than the group as a whole.

Ambulatory surgery, also known as outpatient surgery, is surgery that does not require an overnight hospital stay. Before your surgery, a surgical coordinator will schedule your surgery and preoperative visit, coordinate your financial information and verify your means of transportation to and from the hospital on the day of your procedure. We are here to help you in every phase of your surgery.

Treatment of pilonidal disease can be a challenging and frustrating experience for both the patient and the physician. Dealing with this problem has been a challenge that Dr. Steven Immerman has accepted since he began his surgical practice in 1981. His current results are excellent: in 2013 he published a paper which described that approximately 90% of his patients demonstrated complete primary healing after one procedure, and 98% complete healing after a second procedure. He published a second paper in 2021 showing a success rate in simple cases of 98.7%. Of the more complicated patients Dr. Immerman sees, who are requiring surgery after previous failed operations, the results are only slightly less successful, with an approximately 95% success rate.

Surgeons are taught to remove all the visible disease and either attempt closure or leave the wound open to heal secondarily. These approaches fail to address the fact that the disease process is caused by the deep buttock crease (also called either the natal cleft or gluteal cleft). A deep buttock crease remains moist at almost all times, promotes growth of bacteria, and creates pressure gradients which suck hairs into enlarged pores. Any procedure that does not address the shape of the buttock crease has a high failure rate; and that failure usually shows up as new pilonidal disease or a wound that will not heal. Unfortunately, the standard treatment in the United States and Canada does not address the shape of the cleft.

When selecting a surgeon to care for this disease process, the important issue is not whether you see a General Surgeon, Colorectal Surgeon or Plastic Surgeon. The key factor is whether the surgeon has expertise and interest in pilonidal disease, and is an expert on the cleft-lift operation.

The aim of this study was to evaluate and compare clinical safety and efficacy after Bascom's cleft lift and rhomboid flap (Limberg) procedures for the treatment of primary sacrococcygeal pilonidal sinus (SCPS).

This study included 100 adult patients with primary (nonrecurrent) SCPS who were randomized to Bascom's cleft lift procedure (n = 50) or to rhomboid flap procedure (rhomboid-shaped excision and Limberg flap) (n = 50). Through the follow-up period, which ranged from 6 to 12 months, with an average of 9.1 1.7 months, patients were evaluated for wound-related complications and recurrence of symptoms after complete wound healing.

Although Bascom's cleft lift operation involves a shorter duration of operation, the rhomboidshaped excision with the Limberg flap procedure was superior in terms of early wound healing, with similar incidences of wound-related complications and recurrence after treatment of primary SCPS.

Other techniques have been used and are variations of these techniques, including an elliptical flap and an oblique excision. [10, 11] Simple cystectomy with primary closure is reserved for small cysts.

Endoscopic pilonidal sinus treatment (EPSiT) has been described. [12, 13] A number of studies have found EPSiT to be a safe alternative with a low short-term complication rate. [14, 15, 16] This technique has been applied to pediatric patients as well (PEPSiT). [17, 18] Additional data from randomized controlled trials are needed for a fuller determination of the therapeutic role of EPSiT.

The primary treatment for any infected pilonidal cyst with an underlying abscess consists of antibiotic therapy with incision and drainage. Antibiotics should cover skin flora; some recommend anaerobic coverage with metronidazole. Surgical referral for definitive pilonidal cystectomy should be made after the infection has cleared.

Practice parameters for the management of pilonidal disease were published in 2019 by the American Society of Colon and Rectal Surgeons (ASCRS). [25] The updated German National Guideline for the management of pilonidal disease was published in 2021. [26]

The patient is prepared by clipping any hair around the affected area. (See the image below.) The natal cleft is exposed by applying tape to the gluteals, gently stretching the tissue to the lateral sides, and securing the tape to the table. Iodine-based solution is generally used for prepping unless the patient has an allergy.

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