Surgical management of massive perianal hidradenitis suppurativa

Hidradenitis suppurativa of the perineum and buttocks is a devastating disease often causing patients years of pain, discomfort, and eventual social isolation. The chronic form of the disease results from a lack of aggressive surgical intervention when the patient is first seen. It is characterized by a malodorous drainage from multiple sinus tracts encased in marked scarred and fibrotic tissue. In contrast to axillary involvement, the perianal form of hidradenitis suppurativa is associated with an increased frequency of anemia, fistulous communications with bowel and urinary tract, and the development of carcinomas. Several cases illustrating the debilitating nature of the disease and its optimal management are presented. This report illustrates that (1) a well-planned preoperative and postoperative bowel regimen can eliminate the need for a diverting colostomy, even in the most extensive forms of perianal disease, (2) radical excision is expedited and blood loss is minimized by the use of a Shaw hot knife (Oximetrix, Mountain View, CA), (3) the quilted application of meshed split-thickness skin grafts as a primary procedure provides rapid closure of the surgical defect and minimizes patient discomfort, and (4) aggressive surgical intervention in severe cases provides a chance for a rapid recovery from this crippling disease.