Open access peer-reviewed chapter - ONLINE FIRST
Abstract
The treatment of Hidradenitis suppurativa (HS) is complex and based on different treatment pillars, that often have to be combined in an individual and patient-oriented approach. Surgery is mainly reserved for advanced diseases with irreversible tissue remodeling, such as fistulas, contractions, and scarring. Moreover, surgical treatment may also be considered to achieve drainage and rapid pain relief in acute inflammatory lesions, however, relapse rates are high in these cases and often definitive surgery is required in the course of the disease. This chapter focuses on surgery as an integral component of HS treatment and provides an overview of different surgical techniques. Furthermore, recommendations for the surgical approach to HS patients and perioperative management are also discussed.
Keywords
- surgery
- hidradenitis suppurativa
- chronic inflammation
- multimodal therapy
- imaging
- surgical techniques
- wound management
1. Introduction
Historically, Hidradenitis suppurativa (HS) was considered to be a primarily sweat gland-based disease with radical surgical resection of sweat gland-bearing areas being the only curative treatment [1]. The widely used Pollock procedure allowed a simultaneous bilateral surgical resection of the axillary area followed by primary wound closure [2, 3]. In 1989, Hurley described a classification system, which allows an effective differentiation of HS patients from a surgical point of view and is still continuously used in clinical practice [4].
HS is currently understood as a chronic inflammatory skin disease, affecting primarily the intertriginous, apocrine gland-bearing areas, characterized by recurring inflammatory skin lesions, such as nodules and abscesses. In advanced stages of the disease, chronic inflammation promotes progredient and irreversible tissue destruction through fibrosis, tissue remodeling, and scarring [5]. In this understanding of the disease, early initiation of anti-inflammatory systemic therapy is of great importance to ideally prevent irreversible tissue damage [6]. With a better understanding of HS pathophysiology and the development of effective targeted anti-inflammatory medical therapies, the therapeutic spectrum of HS has evolved [7]. In this context, the surgical approach to HS has shifted from radical prophylactic surgical interventions to a more targeted and, if possible, minimal-invasive approach, leaving healthy and unaffected tissue in place [8]. In the modern therapeutic spectrum of HS, surgery represents a fundamental pillar and should be combined with medical anti-inflammatory treatments and supportive non-medical therapies in a multimodal and patient-oriented approach [7].
Indications for surgery are versatile and include acute inflammatory disease as well as the treatment of chronic irreversible tissue damage [9]. In this chapter, the authors describe established surgical techniques and comprehensive surgical treatment approaches for HS.
2. Perioperative considerations
Surgery in HS can be performed in an out-patient or in-patient treatment setting, depending on the extent of surgery, patient characteristics, and patient’s preference. Preoperative communication with the patient should establish a clear treatment plan including postoperative wound care, physiotherapy, and pain management. Potential surgical risks should be addressed and patients should also be informed about the possibility of an intraoperative variation of resection margins, as clinical evaluation of lesions is often more specific intraoperatively compared to the preoperative setting. Patient should become empowered to be actively involved in their own recovery and rehabilitation, which results in increased levels of autonomy and control post-surgery and improved treatment outcomes [10].
In general, clinical assessment of surgical margins is sufficient for HS surgery. However, in cases of advanced disease or high inflammatory activity, demarcation lines of HS lesions may be blurred. Preoperative imaging can provide an improved evaluation of surgical margins, particularly in complex areas or where infiltration of anatomical structures is suspected [11].
Ultrasonography (US) represents an established and widely used imaging tool in dermatologic surgery. Sonographic features of HS include a thickened, hypoechogenic dermis, pseudocystic lesions, anechoic fluid collections, increased peripheral vascularization, and hypoechoic interconnected fistulous tracts (Figure 1) [12]. In HS, the US can contribute to an enhanced visualization of the surgical area, allowing a more targeted surgical approach and reducing the risk of postoperative recurrence [13].
Figure 1.
Visualization of a pararectal infralevatory fistula in magnetic resonance imaging (MRI), T2-sequence, sagittal view (left). Sonographic image of a deep-reaching subcutaneous fistula in the left groin area, clinical margins marked with orange dots (right). (pictures courtesy Department of Dermatologic Surgery, Ruhr-university Bochum).
Magnetic resonance imaging (MRI) in HS mainly uses sequences with T2-weighted acquisitions and short tau inversion recovery (STIR) to enhance the signal of fluid collections [14]. Especially in the perineal and perianal region, MRI can improve the demarcation of HS lesions and can facilitate a differentiation from Crohn’s disease (Figure 1) [11].
Ideally, surgery in HS should be performed in periods of low inflammatory activity to facilitate clinical demarcation of lesions and reliable determination of surgical margins. In cases with highly inflammatory surgical sites and extensive drainage, pre- or perioperative anti-inflammatory therapies are often engaged to optimize surgical conditions. Perioperative combinations with anti-inflammatory therapies, including systemic antibiotics or targeted therapies, have been shown to improve treatment outcomes and reduce the risk of recurrence [15, 16, 17].
Another important aspect of HS surgery represents the selection of sufficient perioperative anesthesia and postoperative pain management [18]. While localized surgical resections can be performed under local anesthesia, extensive surgery may require general anesthesia. Tumescent local anesthesia (TLA), a subtype of local anesthesia, uses diluted local anesthetic solutions that are injected into the surgical area to achieve tissue hydro-dissection and improve surgical conditions (Figure 2) [19]. In HS surgery, TLA is widely used for extensive surgical areas and may be combined with other anesthesiology methods, such as general anesthesia. TLA has been reported to improve surgical conditions through tissue hydro-dissection, reduced intraoperative bleeding, and reduced postoperative pain [19]. Also, a sufficient postoperative analgetic regimen should be established in the preoperative setting and may be adapted in the postoperative course following current guidelines [20].
Figure 2.
Left: Preoperative situs with marked lesions (red: Fistula, green: Nodule); middle: Tumescence local anesthesia. Surgical margins are marked preoperatively; right: Completed surgical excision of the bilateral fistulas and deroofing of a nodule under tumescence local anesthesia. (pictures courtesy Department of Dermatologic Surgery, Ruhr-university Bochum).
3. Surgical techniques
Various surgical treatment approaches and techniques have been described for HS in the literature. However, surgical therapy is often performed in an individualized approach and inconsistent nomenclature was a major concern in the past. To enable higher standardization and comparability of surgical techniques in HS surgery, standardized definitions were developed in a Delphi consensus statement further specifying excisional and deroofing procedures depending on their site and extent [21].
3.1 Incision and drainage
Incision and drainage (I&D) is defined as “incision of skin with the intent to drain a collection of fluid” and represents a widely used and easy-to-perform surgical procedure for the treatment of skin and soft tissue abscesses [21, 22]. As the effect of local anesthesia is limited in acute inflammatory tissue, this procedure is often performed under cryo-anesthesia and/or sedation. After drainage is established, the wound cavity should be copiously irrigated with sterile normal saline solution. Tamponade is only recommended for abscesses greater than 5 cm in diameter and has not been shown to reduce recurrence rates [23].
Taking into account the chronic course of HS, incisions are associated with a high relapse rate and therefore cannot be considered a definitive treatment [24]. Nevertheless, incision and drainage may be implemented in a multimodal treatment concept as an exit strategy for highly inflammatory cases, when rapid symptom relief is desired. As deroofing can be performed in approximately the same amount of time, guidelines recommend deroofing over incision and drainage [7].
3.2 Deroofing
Deroofing describes a minimally invasive surgical procedure to remove the top layer (“the roof”) of inflammatory nodules, abscesses, solitary fistulas, or scars, leading to the exposure of its ground [25]. Incisions are usually performed in a diagonal cutting shape and followed by curettage of gelatinous mass and secondary intention healing (Figure 3). The advantages over excisional procedures are the simplicity of the procedure, low complication rates, reduced wound healing time, and high patient satisfaction [26]. Moreover, deroofing can be combined with other techniques in an individualized surgical approach if required [27].
Figure 3.
Deroofing of a subcutaneous abscess. Tangential resection of the lesion’s roof (left), uncovering the ground of the lesion with gelatinous granulation tissue (middle), and subsequent curettage of the granulation tissue followed by secondary intention healing (right). (pictures courtesy Department of Dermatologic Surgery, Ruhr-university Bochum).
Effective deroofing procedures have also been reported using CO2-laser ablation followed by secondary intention healing. This variant was associated with a faster time to wound re-epithelialization [28, 29].
“Skin-tissue-sparing excision with electrosurgical peeling” (STEEP) represents a similar electrosurgical treatment approach with successive tangential excisions, that are performed with an electrosurgical wire loop until the epithelialized bottom of the lesion is exposed, while saving as much healthy tissue as possible [30]. Although this surgical technique is associated with a short time for wound healing and a low risk of wound contraction, no long-term outcomes are reported and evidence is limited to small case series [31].
3.3 Excisions
The surgical procedure of excision in HS describes the complete resection of the irreversible tissue damage into healthy, non-affected subcutaneous tissue and is considered as first-line treatment option in HS surgery [21]. Based on the extent of the procedure, some authors differentiate between limited or localized, wide, and radical excisions [18]. Following the recent consensus statement on surgical procedures in HS, excisions should be categorized depending on the procedural location in lesional or regional excisions and their extent in partial and complete excisions [21]. With the development and implementation of effective anti-inflammatory systemic treatments, the concept of HS surgery has shifted away from extensive resections including non-affected tissue as a “safety margin” to more targeted approaches.
In this procedure, the cutis around the preoperatively marked lesions is cut, followed by a careful preparation of the lesion along the demarcation lines. Fistulas can be visualized intraoperatively using a probe or medical dyes such as methylene-blue, enabling a targeted surgical resection of the marked lesions (Figure 4). To prevent unnecessary deep preparation, the authors recommend a step-wise approach gripping the tissue with surgical clamps and applying light tension to facilitate preparation and tissue dissection. During surgery, fibrotic bands and scar contractures should also be dissolved to prevent postoperative wound contraction and movement restrictions. If possible, as much healthy and unaffected tissue should be left in place to improve postoperative wound healing.
Figure 4.
Excision of a fistula in the right axilla. Intraoperative visualization of the fistula using a surgical probe (left). A surgical defect is left to secondary intention healing (right). (pictures courtesy Department of Dermatologic Surgery, Ruhr-university Bochum).
4. Wound closure options
A variety of surgical approaches to wound closure have been described for HS including secondary intention healing, primary wound closure, skin grafting, and skin flaps. As there is no general consensus on the best option, the selection of wound closure is individual and depends on different factors such as the extent and location of the surgical area, disease-specific factors, patient compliance, and the surgeon’s preference and experience [32]. More importantly, an adequate and complete resection of the involved irreversibly destructed tissue is crucial before considering wound closure.
In the recent literature, varying recurrence rates have been found for different wound closure options in HS patients with the lowest recurrence rates after secondary intention healing or skin grafting and the highest rates after the use of skin flaps and primary wound closure [33, 34, 35].
In HS, secondary intention healing is an established alternative to direct wound closure approaches and describes the successive closure of a postoperative wound through all stages of the physiological wound healing process (Figure 5) [36]. Secondary intention healing allows a direct postoperative mobilization and enables early reintegration into the patient’s daily life [37]. In contrast to other wound closure options, there is no risk of flap or graft loss. Potential disadvantages include a prolonged time to complete wound healing with often need for specialized wound management and painful wound dressings. Physiotherapeutic support and scar massage are crucial to reduce the risk of postoperative wound contractions and prevent movement restrictions through fibrosis and scarring [37]. In most postoperative HS defects, secondary intention healing can be considered as a first-line wound closure option providing excellent long-term outcomes and a low risk of recurrence [33, 38].
Figure 5.
Secondary intention wound healing four weeks after excision in the axilla region. (pictures courtesy Department of Dermatologic Surgery, Ruhr-university Bochum).
Skin grafting is another wound closure option for extensive surgical defects. Most commonly, split-thickness skin grafts (STSG) are used in HS, as they allow coverage of all anatomic regions with the perineal, gluteal, genital, and inguinal areas being the most frequent application sites. Skin grafting can either be performed immediately after surgical excision of involved areas or in a staged approach after sufficient wound granulation is established, often leading to favorable postoperative outcomes. In clinical trials, STSG has been shown to reduce the time to wound healing in comparison to secondary intention healing and was associated with a reduced risk of wound contraction [39]. Another advantage of skin grafts is the coverage of large surgical defects. If needed, the use of meshed skin grafts can even provide larger defect coverage [40]. Possible limitations of skin grafting include the need for post-coverage patient immobilization to ensure graft healing, adequate postoperative wound management with moisture control, and donor site complications [37]. After graft take is established, the initiation of physiotherapy and scar massage is essential to ensure an optimal postoperative outcome (Figure 6).
Figure 6.
Split-thickness skin grafting of the genital-perianal area after extensive surgical excisions. Postoperative view after STSG-coverage of scrotum and perineum in a male patient (left). Postoperative result six months after radical excision of the genitofemoral region followed by meshed STSG coverage. Blue loops indicate intraoperatively marked vaginal fistulas (right). (pictures courtesy Department of Dermatologic Surgery, Ruhr-university Bochum).
Negative pressure wound therapy (NPWT) represents an adjunctive option for complex surgical wounds and improves the wound healing process through increasing wound oxygenation and reducing the bacterial wound load [41]. In HS, NPWT can be implemented for the postoperative treatment after extensive surgical resections and may be followed by either secondary intention healing or skin grafting [42].
Primary wound closure describes the adaption of surgical excision margins and may be considered after limited resections. The advantages of this relatively easy-to-perform approach are improved wound healing through definitive closure and favorable esthetic outcomes [43]. However, primary wound closure is primarily limited through defect size and has shown to be associated with a high risk of recurrence (up to 15%) and a risk of postoperative wound dehiscence and surgical site infection [33].
Flaps are another advanced surgical option for postoperative definitive wound closure in HS. A variety of flaps have been described for the reconstruction/coverage of surgical defects of the axilla including transposition flaps, advancement flaps, myocutaneous flaps (Figure 7), and fascio-cutaneous flaps, respectively [44, 45, 46, 47, 48]. Skin flaps provide accelerated wound healing, enabling early postoperative patient mobilization, and are associated with a reduced risk of postoperative contractions due to scarring [37]. However, studies have reported higher recurrence rates of up to 8% and recent guidelines do not consider skin flaps as a first-line option for wound closure in HS [33]. In specific cases, especially when critical anatomical structures like nerves, vascular structures, or musculature are exposed, the use of skin flaps may be necessary [49].
Figure 7.
Surgical reconstruction after resection of the axilla region with a VY-myocutaneous island flap. Left: Intraoperative view after wound closure. Right: Postoperative result after 6 weeks with improved mobility of the shoulder. (pictures courtesy Department of Dermatologic Surgery, Ruhr-university Bochum).
5. Postoperative wound management
In HS, postoperative wound management marks an essential factor in the successful surgical treatment of patients. Depending on the type and extent of surgical procedure, modality of wound closure, wound localization, and patient-specific factors, wound care in HS can be complex. The selection of sufficient wound dressings for the particular wound healing phase is crucial to maintain a moist and clean wound microenvironment [50]. Postoperative physiotherapy, patient mobilization, and scar massage are necessary to achieve optimal functional outcomes [37].
To ensure a seamless transition from operation to post-surgical care, wound management should already be coordinated in the preoperative phase. Depending on the complexity and location of the wound and patient characteristics, wound dressings can either be performed by the patient or family members or by a specialized outpatient nursing service. To optimize postoperative outcomes, patients should become self-empowered by involving them in wound care through information and basic training [51]. Regular postoperative follow-ups should be scheduled to control wound healing and adjust wound care if needed.
6. Postoperative complications and surgical challenges in HS
Postoperative complications can be divided into short-term and long-term complications depending on their time of occurrence. Short-term postoperative complications include postoperative bleeding, pain, and surgical site infections. Long-term postoperative complications include wound healing disorders, local recurrence, and contractures associated with scarring.
6.1 Short-term complications
Postoperative bleeding typically occurs within the few days after surgery and is often associated with the fading effect of tumescence local anesthesia, intake of anticoagulants, or coagulation disorders. Extensive or prolonged bleeding can lead to decreased levels of hemoglobin and may require transfusion. To prevent postoperative bleeding, meticulous intraoperative hemostasis with electrocoagulation and ligation of small vessels is recommended. Moreover, intraoperative drainage inlay can be considered in wounds with primary closure or flap coverage to prevent hematoma formation.
Surgical site infections (SSI) represent a relatively rare complication in HS surgery. In a retrospective study, the highest SSI rates were reported after incision and drainage procedures, which were performed in obese patients or in an outpatient setting [52]. Clinical warning signs indicating SSI are worsening pain, swelling, increased drainage, and localized overheating of the wound. Wound swaps should be extracted to allow microbiological identification and targeted antimicrobial therapy, taking into account microbiological resistance [53].
6.2 Long-term complications
Recurrence within the surgical site marks a major postoperative complication with varying incidence rates reported in the literature. However, there is no standardized definition of recurrence, making comparative analyses difficult. The risk of recurrence depends on various factors, such as resection technique, wound closure modality, the surgeon’s expertise, and patient-specific factors [18, 33, 34, 54]. In the concept of HS as a chronic inflammatory disorder, surgery has often to be combined with systemic anti-inflammatory therapy to achieve disease control and prevent recurrence [7]. Prospective clinical studies are needed to examine the effect of multimodal medical and surgical combination therapies [15].
Postoperative wound contractures can occur as a result of extensive scarring. Large excisions in the axillary region with secondary intention healing are at increased risk for the development of scar contractures, which can result in impaired mobility of the shoulder [18]. Postoperative mobilization of the patient with physiotherapeutic support and stretching of the wounds are crucial factors in wound management to prevent contractures and mobility impairment [37].
6.3 Surgical challenges in HS surgery
Chronic inflammatory HS of the perineal and perianal area with advanced irreversible tissue destruction represents a particular challenge for surgery as lesions can extend to critical anatomical structures, such as the rectum, sphincter musculature, or vagina. In these cases, the authors recommend a staged approach with the preoperative establishment of a non-inflammatory surgical field to enable optimal clinical evaluation of the disease. In suspected cases, further imaging (sonography or MRI) and endoscopic diagnostics can be considered [11]. Intraoperatively, cautious preparation of fistulas in the perianal area is recommended with the greatest possible protection of the sphincter musculature. The authors recommend an intraoperative proctological examination in case of extensive perianal fistulas [55]. When anal fistulas are present, temporally inlays of seton or loop drainage can be performed till definitive surgical therapy. Another specific complication, mainly after previous insufficient surgeries, is blind ending tracts and/or cavities that can extend deep parallel to the rectum. Lay-opening of these structures under preservation of the sphincter muscle can be challenging [55]. Consequently, in patients with extensive perianal HS, an individual decision toward an interdisciplinary approach including colorectal surgery should be discussed.
Moreover, the gluteal and perianal areas represent risk zones for the development of cutaneous squamous cell carcinoma, a rare but often fatal complication of long-standing inflammatory HS [56]. These tumors may present as unspecific ulcerations or indurated nodules and can mimic draining openings of sinus tracts or disturbed wound healing. To enable diagnosis in early tumor stages, biopsies of clinically atypical lesions should be performed on a low threshold and referred to histopathologic examination [56]. In locally limited disease, complete tumor resection with wide security margins can be curative. However, most of these tumors are diagnosed in an advanced stage with locoregional or distant metastasis and are then associated with a poor prognosis and high mortality. In these cases, systemic tumor therapies, radiotherapy, and palliative care may be considered as possible treatment options [57].
Recurrence of lesions within the surgical field represents a common complication of HS and may be a result of inadequate previous surgery, insufficient disease control, and patient characteristics [34, 54, 58]. Often, the demarcation of HS lesions is blurred within scarring of previous surgical interventions, making surgical treatment of these patients challenging. The authors recommend a step-wise approach, starting with establishing disease control and reducing inflammatory activity prior to re-surgery [7, 16]. In some cases, preoperative imaging can facilitate the adequate evaluation of the extent of lesions; however, precise intraoperative inspection and radical resection of the affected tissue are crucial to prevent further recurrence and establish disease control.
Post-inflammatory lymphedema is a relatively rare but debilitating complication of long-standing severe HS and most commonly affects the scrotum, penis, perineum, and labia majora [59, 60]. Chronic inflammation marks a major risk factor for impairment of lymphatic drainage and the development of secondary lymphedema [61]. Genital lymphedema can cause serious esthetic and functional impairment, and sexual dysfunction and may worsen the quality of life in affected patients [62]. Lymphedema in HS is often accompanied by severe and complex fistulas in the tissue. These patients often require professional interdisciplinary care including conservative and surgical treatment strategies to improve disease control and sexual function [59]. Complete decongestive therapy (CDT) with manual lymphatic drainage and medical anti-inflammatory therapy are established conservative approaches [63, 64]. The recommendations for surgical treatment of these patients are limited to case reports and include the radical resection of affected skin followed by coverage of the genital area with skin grafts [60, 65, 66].
Conflict of interest
L.O. has received honoraria as a speaker from Novartis Pharma GmbH. F.G.B. has received honoraria for participation in advisory boards, in clinical trials, and/or as a speaker from AbbVie Inc., AbbVie Deutschland GmbH & Co. KG, Boehringer Ingelheim Pharma GmbH & Co. KG, Novartis Pharma GmbH, UCB Pharma, Incyte Corporation, JanssenCilag GmbH, and MoonLake. The funders had no role in the design of the publication, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. N.A.R. declares no conflict of interest.
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