How do we Teach Proper Pilonidal Surgery Technique?
It’s hard to teach an old dog new tricks! And it’s a challenge to get surgeons to change the way they treat a particular condition after residency training. Surgeons are trained by their mentors to do things in a certain way. Most are wedded to that way. Change is difficult and many surgeons are cautious in adopting new surgical techniques. But we have known for 30 years that asymmetric flap procedures such as the Cleft Lift Procedure for treating pilonidal disease are superior to excisional operations. Yet most operations performed for pilonidal disease are out-moded excisional operations.
Much of what is done in the Cleft Lift Procedure (also termed the Pilonidal RAF, for rotation and advancement flap) goes against what we are taught in training: don’t close infected wounds! But paradigm advancements can occur that render the old teachings outdated. Closing infected wounds will successfully heal if: 1) the abscess cavity is carefully cleansed, 2) the abscess cavity wall is rearranged so that it can’t reform an abscess and all dead space is eliminated, and 3) the wound is placed off to the side so that it’s in the open air and heals.
My goal in this part of my career is to teach other surgeons how best to approach pilonidal disease and successfully cure patients with pilonidal disease.
The pilonidal RAF is a learnable procedure, but it takes time to learn, particularly for challenging cases. So, teaching surgeons after they have finished residency is a bit tricky as watching a few procedures in a day isn’t sufficient. Learning the technique is worthy of an apprenticeship but that’s not an easy task once someone has begun to practice and has family and financial obligations.
I feel that surgeons should step up to the plate, admit that traditional excisional operations are often unsuccessful, and agree to change. Academic programs should commit to teaching the Pilonidal RAF to their trainees. Only then will this superior technique become widely adopted.
Here’s a reference to a well done meta-analysis.