Dermal Sinuses

A pilonidal sinus (dermoid sinus) is a congenital defect in which ectodermal cells fail to cleanly separate
from the neural tissue during embryogenesis. As a result, an epithelial tube forms below the skin surface
to variable depths; in extreme cases it can extend to the dura mater. Because the sinus tract is lined by
cutaneous epithelium, hair and epithelial debris will accumulate in the tract and elicit a foreign body
reaction. Bacteria can secondarily infect the sinus tract, compounding the problem. Although rare, for
those cases in which the sinus attaches to the dura mater, a septic meningitis and the onset of neurologic
signs may be noted. Rhodesian ridgebacks most commonly present with this condition, and it is
considered a simple recessive mode of inheritance (Fig. 6‐23). However, the condition also has been
reported in other dog breeds, including the boxer, chow chow, English bulldog, shih tzu, Siberian husky,
and springer spaniel. (The author has removed one pilonidal sinus from the dorsum of the head of a black
Labrador retriever, with the winding tract terminating at the level of the occipital crest.) The mode of
inheritance in these breeds is unknown. In Rhodesian ridgebacks, the sinus opening is usually found along
the spinal column and normally opens in the midst of a whorl of hair. Palpation of the subcutaneous
tissuesbetween the thumb and index finger often reveals a cordlike structure extending into the deeper
tissues. Radiographs can be taken to assess the underlying spinal column. Contrast studies have been
suggested to outline the extent of the tract, although filling of the cavity with a contrast medium can be
problematic due to the accumulation of discharge and tissue debris. If neurologic signs are present,
computed tomography (CT) and magnetic resonance imaging (MRI) are advisable to assess the extent of
the condition prior to surgery Surgical excision is the best course of managing a pilonidal sinus. The area
should be liberally clipped to compensate for the occasionally irregular course of the tract. A circular skin
incision is made around the sinus opening; skin incisions can be used to simplify exposure of the deeper
aspects of the sinus tract. Most pilonidal sinuses tend to taper as dissection progresses into the deeper
tissues (Fig. 6‐23). Insertion of a feline urinary catheter or metallic probe can orient the surgeon during
this process. Self‐retaining retractors improve visualization of the deeper portions of the tract. If the sinus
extends to the dura mater, a small dorsal laminectomy may be needed to assure that complete removal
of the sinus is accomplished. A culture of the deeper portion of the sinus tract is advisable in the face of
infection; broad‐spectrum antibiotic therapy can be initiated pending the final culture results.In general,
it has been the author’s experience that removal of most pilonidal sinuses is not difficult surgery, but
complete removal of the entire tract is critical for a successful outcome.

Nasal Dermoid Sinus Cyst

Nasal dermoid sinus cysts (NDSCs) are uncommon congenital lesions similar to the embryologic origin of
the pilonidal sinus. NDSC is recognized in golden retrievers. During embryologic development, the
meninges in the frontal bones protrude through the foramen cecum. This canal normally closes, but
persists in NDSC cases. As a result, a sinus opening can be found in the dorsal midline of the skull, caudal
to the external nares. The sinus passes through an incomplete suture line in the nasal septum. In the
young adult golden retriever with NDSC, a sebaceous discharge may be noted caudal to the nasal planum.
Surgical removal is indicated, with the assistance of a probe or catheter to facilitate dissection of the entire
tract. Communication with the meninges has been reported in humans; although meningitis has been
reported in humans, it has not been reported in the dog to date.

USE OF TOURNIQUETS FOR LOWER EXTREMITY PROCEDURES

A tourniquet is useful in creating a bloodless field for exploration of draining tracts for foreign bodies in
the limbs of small animal patients. However, tourniquets FIG. 6-23 (A) Pilonidal sinus in a Rhodesian
ridgeback. (B) Close‐up view of the tract. (C) The tract was cannulated with a tom‐cat catheter to outline
the tract. A circular incision was made around the sinus tract; skin incisions can be used to improve
exposure. The entire sinus “cylinder” progressively tapered and ended dorsal to the vertebral surface.
Epithelium, hair, and tissue debris are commonly observed when the tract is dissected open. 166 Atlas of
Small Animal Wound Management and Reconstructive Surgery

should be avoided in traumatized limbs or limbs with vascular injury or circulatory compromise.
Pneumatic tourniquets are the best available method of applying uniform pressure to a wide area. Venous
blood is expelled prior to tourniquet application by elevating the affected limb for 5 minutes.An Esmarch
bandage or elastic wrap can be used as a short‐term tourniquet by applying it from the digits

proximally without excessive tension (or tissue compression). An Esmarch bandage can be used alone or
in conjunction with a pneumatic cuff. Exsanguination should not be done in the presence of local
suppuration, deep venous thrombosis, or neoplasia. A thin layer of cotton padding may be applied before
wrapping the limbs for more uniform pressure distribution. The elastic wrap is removed upon inflation of
the pneumatic cuff. The cuff is positioned at the point of maximal limb circumference where the bulk of
the muscle protects underlying nerves and vessels from compression over bone. Tourniquets are not
without risk. Muscle ischemia,nerve palsies, and tissue necrosis may result from improper application or
prolonged usage of tourniquets. When using a pneumatic cuff, pressure should be kept to the minimum
required to provide a bloodless field; pressures greater than 300 mmHg should be avoided. While a
properly applied tourniquet can beapplied for up to 3 hours, the surgeon should minimize its usage. Some
recommend releasing the tourniquet 10minutes for every hour of inflation, although the benefits of this
maneuver are questionable. Fortunately,most cases of tract exploration involving the extremities can be
performed within 30–45 minutes. Removalof the tourniquet is normally followed by hemorrhage,
allowing the surgeon to identify and target the individual bleeders with electrocautery and ligatures prior
to closure Vetrap (3M Corp.) can be autoclaved and used effectively as a short‐term tourniquet to obtain
a relatively bloodless surgical field. After wrapping the limb, beginning at the toes and working proximally,
scissors can be used to cut the Vetrap and expose the surgical area for exploration. Retaining the roll of
Vetrap allows the surgeon to add additional loops if hemostasis is not sufficient. Care must be taken to
avoid excessive elastic tension during application and minimize the time of application, as discussed
previously

SEROMAS

Seromas are pockets in which serum accumulates, usually as a result of trauma. Seroma formation is most
commonly associated with surgery, especially in areas whereconsiderable dissection has been performed,
leaving a dead space or pocket where serum can accumulate. Capillary leakage and lymphatic injury
secondary to inflammation result in fluid accumulation. Traumatic surgical technique, harsh wound‐
cleansing techniques, the presence of foreign debris and irritants, and areas subject to constant
movement also contribute to seroma formation. Small seromas beneath the skin are of no major
consequence and resolve in time. Larger seromason many occasions will require drainage (in Chapter 4,
see the sections Passive Drains and Active Drains). Postoperative seroma of an abdominal incision may be
difficult to distinguish from a hernia. Careful aspiration can help confirm a seroma; removal of the fluid
can facilitate palpation of the abdominal incision for any herniaring or herniated tissue in the area
Treatment and Prevention

A single aspiration is generally insufficient for treatment of large seromas. On occasion, the application of
a firm compression bandage after aspiration may helpto control dead space to promote healing of the
separated tissue planes. Intermittent seroma drainage by aspiration every few days is occasionally
successful (usually over a 2‐week period): however, rapid fluid reformation (usually within 24 hours) after
initial aspiration is a clear indication that drain insertion isrequired to definitively manage the serum
pocket. Prior to any attempt at aspiration, the area must have a basic surgical preparation before
introducing a sterile hypodermic needle. An 18‐gauge hypodermic needle and 35–60‐ml syringe may be
used to aspirate the serum pocket; the addition of a three‐way stopcock will facilitate evacuation of the
syringe. Butterfly catheters are useful for aspiration in restless patients, since the tube extension reduces
the risk of needle displacement during movement. Larger‐gauge needles or a trocar (14‐ to 6‐gauge) can
facilitate drainage but would require a lidocaine block at the point of insertion. Serum may be allowed to
escape passively from the dependently placed trocar (facilitated by the manual compression of the serum
pocket) or by application of a syringe and three‐way stopcock or vacuum pump. A compression bandage
may be applied to help prevent reformation. There is minimal risk of infection after seroma aspiration
provided that strict aseptic technique is maintained.