EPSiT

Invented by Piercarlo Meinero MD, the EPSiT procedure is a new video-assisted thechnique for the treatment of the pilonidal sinus disease and its recurrences.

Having achieved excellent results with the VAAFT technique (Video Assisted Anal Fistula Treatment) for the management of complex anal fistulas, we decided to treat pilonidal sinus disease and its recurrences with the same equipment and philosophy of sinus ablation where it is recognized that other forms of more extensive pilonidal sinus surgery have a significant recurrence and morbidity rate. The kit includes the Meinero fistuloscope (Fig. 1), manufactured by Karl Storz GmbH (Tuttlingen, Germany), an obturator, a monopolar electrode, a brush and the endoscopic forceps.

The fistuloscope has an 8° angled eyepiece and is equipped with an optical channel and a working and irrigation channel. Its diameter is 3.2 X 4.8 mm, and its operative length is 18 cm. A removable handle allows easier maneuvering. The fistuloscope has two taps one of which is connected to a 5,000 ml bag of glycine–mannitol 1% solution.  

The aims are to ablate and clean the infected area. The obturator is removed and the forceps are inserted through the operative channel in order to thoroughly remove all the hairs with their follicles under vision (Fig. 4). This maneuver is considered to be a fundamental step to aid healing.

Once this procedure is completed, the forceps are removed and the monopolar electrode is connected to an electrosurgical knife power unit for cautery ablation of the sinus granulation tissue, commencing in the main track and where appropriate traversing secondary tracts and abscess cavities. Necrotic material is removed with an endobrush passed through the fistuloscope or with a Volkmann's curette if more superficially located.

Where two incisions have been used because of a wider infective process, a special brush designed with bristles in the middle part of a flexible metallic thread is passed through both incision sites is used. The continuous jet of glycine-mannitol during the procedure ensures both a clear visual field and the elimination of the cauterized waste material brushed through the incision. At the end of the operation, meticulous attention is paid to haemostasis with application of a light dressing and same-day patient discharge.

The aim of the traditional techniques is the removal of the infected area by closing or laying open the skin. This may cause painful progress during the postoperative period, requiring regular dressings, take many weeks to heal and recurrences are possible.

The E.P.Si.T. procedure has many advantages compared with other techniques. First of all, the direct vision allows the surgeon to see perfectly not only the pilonidal sinus, but also any possible fistula tracts or abscess cavities. The destruction can be modulated and there is the certainty of the complete removal of the infected area. Moreover, the haemostasis is done thoroughly under direct vision.

This direct vision also allows the complete removal of the hairs and their follicles, often located not only in the pilonidal sinus, but also in the surrounding tissue. The aesthetic result is excellent (Fig. 5) and the patient’s quality of life is better compared with traditional techniques.

There is no need for painful dressings and healing occurs within two to three weeks. The EPSiT procedure is performed in day surgery (the patient is admitted and discharged the same day of surgery).