Our operations for 
Pilonidal cyst

The experience of over 20 years of surgery flows into the surgical treatment of our patients. The minimally invasive therapy is always preferred by us.

There are various options for the therapy of the pilonidal cyst. The common factor is that so far only surgical therapy is available as a cure. Conservative therapy, even with the administration of antibiotics, is not possible. The surgical method depends very much on the severity of the findings.

Acute inflammation: This condition usually occurs with an accumulation of pus (abscess) and requires immediate surgical repair. An abscess is always an emergency indication. Smaller abscesses of up to 5 cm can usually be opened well on an outpatient basis under local anesthesia. It is important to cut out some of the skin to ensure good drainage. Only a small incision under icing is not sufficient. Larger abscesses should be operated on in the hospital under general anesthesia, especially if they are located near the anus. This often results in very large defects that heal slowly over 3-6 months. This is a great physical and psychological burden for the mostly young patients.

Small fistula tracts without inflammation: Here you can see the openings where hairs grow into the depth. These so-called pits can be operated on well as an outpatient in a small, painless operation called pit picking. Small wound defects remain that cause little pain and usually heal within 7-14 days. This procedure is purely outpatient, so no hospitalization is necessary.

Large fistula tracts without inflammation: In these findings, the pit picking procedure reaches its limits because there are cavities and scars at the end of the ducts that need to be excised. A combination here would be pit picking with sinusectomy, in which the scars and scar cavity are removed with multiple small incisions. In the case of recurrent (relapse) coccygeal fistulas without acute inflammation, plastic surgery according to Karydakis, for example, can be performed. In this case, the skin and the subcutaneous fatty tissue are completely removed and followed by a plastic surgery with shifting of the midline to the side in order to close the defect. The wound can be completely sutured closed in the process. This operation is always inpatient.

Overview of operations with open wound healing

Pit Picking

In classic pit picking, a punch is used to remove the small holes in the center line. The diameter of the wounds is 3-4mm.

Sinusectomy

In larger fistulas, these must also be removed, adding further wounding to the defects during pit picking in order to excise the fistula in a tunneled fashion.

Laser therapy

Here, too, the pits are removed and the laser is inserted over the lateral fistula opening. This procedure is particularly suitable for long, narrow fistula courses.

Excision

Classic and radical surgery. Often described as the "butcher method" by patients, as a large hole is created, with a long wound healing time.

Pit Picking

During pit picking, small hair channels are removed from the skin with a punch. These are believed to be the entry points for hairs into the subcutaneous fatty tissue, leading to the dreaded chronic inflammation. Therefore, the complete removal of these hairs is also part of the surgery, otherwise the inflammation will reappear, which is called a recurrence. Thus, there must be a lot of experience on the part of the surgeon and the procedure must be performed very thoroughly. The diameter of the punch is 3-4mm. 
 
However, pit picking always includes removal of the abscess cavity present under the pits, where the hair has been deposited. The cavity together with the wall and the hairs must always be removed to prevent recurrence of the disease. 
The surgical access is always somewhat lateral, in order to leave the smallest possible wound in the midline, which heals poorly. 
 
After the operation, the very small wounds remain open so that the wound secretion that forms can drain away, allowing the wound to clean itself. There is also the possibility of suture closure, but since there is always the residual risk of renewed inflammation with pus formation and the wounds close within 1-2 weeks without a suture, we prefer open wound healing as a safe option.
 
It is important to know that the disease can recur and the risk of this is about 20-30%. Unfortunately, the classic generous excision of the lesion is still the "gold standard" in surgery of the pilonidal sinus, since there are fewer recurrences.
However, the healing process is very lengthy and can take up to 6 months, which means that patients and their relatives, who have to help with the bandaging, are severely pushed to their physical and psychological limits.
 
Therefore, pit picking should always be considered as a treatment option if the findings are suitable.

Details about the Pit Picking

Punch

This is a typical skin punch with which the pit picking operation is performed.
The opening is usually 3-4mm in diameter and the canals are punched out as a whole, which is painless.
Through the resulting channel, the existing abscess cavity is cleaned, hair is removed and finally rinsed. 
After 1-2 weeks the wound is usually healed.

Operation

This figure shows the dimensions of the operation. The center line shows the small pits (1). These are removed with the punch. To clean out the underlying cavity, a lateral incision (2) is made on the left or right and over this the cavity is carefully cleaned of cell debris and rinsed. 

After the operation

Wounds after surgery are shown here. Since these are always potentially infectious wounds, they are not sutured, but heal openly.

Operation time: 10-15 minutes
Hospitalization: no, outpatient surgery.
Inability to work: approx. 1-5 days
General anesthesia: no, local anesthesia

Pit Picking with Sinusectomy

In more extensive findings, a lateral fistula outlet is found above the pits in the midline. Between this fistula outlet and the pits, a rough induration can often be palpated, which corresponds to the 2-5cm long fistula in the subcutaneous fat tissue.
This fistula structure must be completely removed, which we call sinusectomy

During the operation under local anesthesia, the fistula is cut out via the lateral exit (ectomy) after punching out the pits, without opening the overlying skin. This creates a tunnel, so to speak. Importantly, all diseased tissue must be removed to prevent recurrence.

After the procedure, the small wounds remain open to allow the wound secretions that form to drain away, allowing the wound to clean itself. The larger wound takes about 3-4 weeks to close.

Details about sinusectomy for pilonidal cyst

Sinusectomy

Here, the pits (1) are first punched out and then the fistula (3) is cut out via the fistula outlet (2). The entire cavity (3) with the scar and fistula tissue, which often contains the hair, must be removed. 

Result after operation

Eight weeks after sinusectomy, the wounds have healed completely. The center shows the overgrown pits and the lower left the scar of the fistula outlet, which has also healed without complications.

Fistula cavity in cross section

Operation time: 15-30 minutes
Hospitalization: no, outpatient surgery.
Inability to work: approx. 5-14 days
General anesthesia: no, local anesthesia

Laser therapy

SiLaC® is a safe procedure to treat coccygeal fistulas. Here, the pilonidal cyst is irradiated with a laser beam using a minimally invasive technique. Minimally invasive here means that only a small operation with minimal wounds is necessary. SiLaC means "Sinus Laser ablation of the cystic duct".
 
The operations are performed under general anesthesia. During the treatment, which takes only a few minutes, a probe is inserted into the inflamed fistula tract. Laser energy is used to precisely obliterate the fistula tissue without damaging or even removing surrounding tissue. Any incisions made to relieve the abscess are significantly smaller. As the probe is withdrawn, the fistula tissue is slowly and safely destroyed. The existing cavity collapses and eventually scars over. The extremely flexible probe is well suited for use even in slightly tortuous passages and can therefore be used anywhere. 
 
The small wounds are healed quickly and there is very little secretion of wound fluid in contrast to conventional surgical procedures, where an open wound area remains for several months. There is often swelling in the area of the cavity, which resolves after several weeks and is not painful. Our patients require very little to no pain medication. 

Advantages compared to the conventional surgery

  • Closure of the fistula tract
  • Very low pain
  • Minimal wound area
  • Excellent healing results
  • Removal of excess, inflamed tissue and
  • tissue and residual hair
  • Maximum patient comfort
  • Outpatient use possible
  • Short treatment time
  • Fast recovery
  • No pause in anticoagulation
  • Only a few days of inability to work - ideal for self-employed persons


Operation time: 10-15 minutes
Hospitalization: usually outpatient service, 1-2 days inpatient.
Inability to work: about 1 week
General anesthesia: yes

What is the procedure of laser surgery for pilonidal cyst?

Fistula course

The pit (arrow) is shown on the left. This pit is always located in the midline of the gluteal fold (rima ani) and is usually not painful. The outlet of the fistula lies above it and is marked here with 2 arrows. In between lies the abscess cavity (black line), which is the actual target of the laser operation and collapses due to the circular heat radiation.

Cleaning

First, the fistula tract is visualized with a probe and thoroughly cleaned. The hair in the cavity and dead tissue are removed. The hairs cause the chronic inflammation. This is followed by extensive irrigation with a disinfecting solution.

Punching

Then the punching out of the existing pits (here only one) is done with a special punch. The diameter is 3-4mm and results in a clean wound edge that can heal well. The canal is thereby completely removed

Laser therapy

Introduction of the laser diode into the fistula tract and the cavity. Closure of the cavity and the duct by multiple, slow retraction. After the first pass, the cavity is cleaned again with a small brush.

Result

After about 10-15 minutes the operation is finished and the final result is as shown here. There are small open wounds, so that the wound fluid can drain up to 6 weeks after the surgery and thus it does not come to a wound infection.

IMPORTANT: Since 01.06.2021, the costs of our gentle laser therapy and pit picking are covered by many company health insurance funds. Patients from other federal states can also be operated on minimally invasively. 

The excision of a pilonidal cyst

Excision means cutting out the complete disease in the middle of the buttock. This standard method involves the radical removal of the subcutaneous fatty tissue down to the periosteum. The bone is not affected by the pure skin disease.
 
In order to be able to assess the extent of the tissue to be removed, the fistula tract used to be filled with a blue dye (methylene blue) and then blue dyed tissue was removed. This sometimes resulted in very radical operations, so that this technique is no longer used in most hospitals today.
 
The resulting wound is often up to 10cm long and 5cm wide. This is followed by open wound treatment, during which wound secretions are discharged daily with a yellowish, greasy secretion called fibrin. This is not pus, but a kind of "wound glue", which is very important for wound healing. The open wound itself cannot usually become infected, as infectious wound secretions can drain off. Only in the case of a congestion of secretions, such as when the wound is closed too early, does infection occur.
 
In the first 21 days, the wound may additionally hurt and is very sensitive. Small hemorrhages often occur from the wound edge if, for example, the dressing is too tight and is pulled off. These bleedings are annoying but harmless.
 
During the first 4 weeks, the wound must be cleaned twice a day and after every bowel movement with clear water without soap for about 2 minutes. If this is followed, no foul-smelling wounds will develop. After cleaning, a bandage must always be applied.
 
Operation time: 5-30 minutes
Hospital stay: 1-2 days, outpatient surgery possible according to findings.
Inability to work: approx. 2-12 weeks
General anesthesia: Usually yes, but also depending on the findings.

Plastic surgery

For larger findings that are not infected, plastic surgery can be performed instead of extensive excision. The best known methods are the Karydakis operation and the Limberg plastic. 

Karydakis operation - Evaluation

We recommend surgery only in case of recurrence. A risk is always a wound infection due to the proximity to the anus , so that in many cases the wounds must be opened early after 2-5 days and then heal like a cut out (excision). Outpatient surgery is generally not recommended due to the excessive movement of the patient.

Operation time: 30-60 minutes
Hospital stay: 3-5 days, outpatient surgery is possible according to findings, but not recommended
Inability to work: approx. 2-3 weeks
General anesthesia: Usually yes, for smaller findings local anesthesia is also possible.

Plastic surgery according to Karydakis

Initial findings

The pilonidal cyst shows several openings here, the so-called pits. One or more of these fistula outlets can also be located laterally. Here, in the upper left corner, is one of these lateral fistula outlets. 
 
If a larger piece of tissue is to be excised with subsequent suturing, plastic surgery according to the Greek surgeon Karydakis is an option.

Tissue excision

At the beginning of the operation, which is preferably performed under general anesthesia, the diseased tissue is excised asymmetrically. In the process, the defect is shifted mainly to the side with the main finding. 
 
In our example, the main fistula tract is located above on the left side, which is why as much of the left tissue as possible is removed. Complete excision of the fistula tract leaves only healthy tissue for subsequent plastic surgery.

Shifting plastic

After removal of the tissue, the resulting defect must be closed with tissue. To do this, the surgeon mobilizes the subcutaneous fat tissue on the right side (under the arrows) and pulls all the skin without tension to the left side to resuture the wound edges.  

 


Result

An asymmetrical suture is made, which should not be in the midline if possible, as wound healing is very poor here. A wound drain is inserted, which should remain in place for 2 days. 
 The sutures are removed after about 12 days. Often the wound is exposed to strong stress even if it is handled carefully, so that wound healing disorders and infections occur quite frequently due to the proximity to the anus.

Limberg operation - evaluation

This operation is a major plastic surgery with quite a large wound area.  Even with careful handling, the wound is exposed to strong stresses, so that wound healing problems and infections often occur due to the proximity to the anus. When the wound then opens, the wound area is very large and the healing time is correspondingly long. Therefore, we do not recommend this operation.

Operation time: 60-120 minutes
Hospital stay: 3-5 days, inpatient surgery
Inability to work: approx. 2-4 weeks
General anesthesia: yes

Limberg plastic surgery

Initial findings

The pilonidal cyst shows several openings here, the so-called pits. One or more of these fistula outlets may also be located laterally.

 

Tissue excision

At the beginning of the operation, which is always performed under general anesthesia, the diseased tissue is excised in a rhombus shape. The complete excision of the fistula tract leaves only healthy tissue for the subsequent plastic surgery.

Shifting plastic

A displacement plastic is prepared to close the defect. For this purpose, an identical rhombus is drawn in laterally so that this new rhombus can be displaced to the left. 

Result

After displacement plastic surgery has been performed, the tissue is taken in.
Patients should not move too much for 3 days if possible. 


Procedure of minimally invasive surgery in our practice

PRESENTATION

It is always important to have a prior examination. For this purpose, patients must book an appointment via our online appointment calendar DOCTOLIB in our Pilonidal Cyst consultation. After the consultation and examination, the optimal therapy is discussed and planned. Not all findings can be operated on minimally invasively. According to German law, planned operations may only take place 24 hours after the operation has been explained, i.e. not on the same day! 

Currently, our operations are performed under local anesthesia on Monday and Tuesday morning (Dr. Hertzsch/Dr. von Rüden) and on Wednesday afternoon (PD Dr. Jacob). 

DAY OF SURGERY

On the day of surgery, patients can anesthetize the skin area in the surgical field. For this purpose, we provide a prescription for local anesthesia during the patient consultation. For this purpose, please spread the entire tube (e.g. 5g Lidogalen) evenly 30-60 minutes beforehand and, if necessary, place plastic film on the skin so that the cream can be absorbed well. Also, an ibuprofen tablet (400-600mg) can be taken beforehand. We also recommend eating and drinking before the procedure. You do not have to be sober. Please wear dark underwear, preferably black, in case of minor bleeding.

After registration in our practice in Lankwitz, we will escort you to the operating room and you will have to lie on your abdomen. Then the skin is shaved, since hair interferes with wound healing. Now the local anesthesia with Xylocain takes place, which is somewhat unpleasant for 10-20 seconds (feeling of pressure, burning). 

After that, the actual operation takes place. First the desinfection, while cold and pressure are still perceived, which is quite normal. Only the feeling of pain is anesthetized. The covering and the actual operation follows, which takes about 10-20 minutes. Finally, we apply a tight bandage and the patients have to sit in our waiting room for about 20 minutes after leaving the practice. After that we check if there is any postoperative bleeding. If the bandages are dry, the patients are allowed to go home. Before that, we will give you prescriptions for wound compresses, painkillers if necessary, and an AU certificate (sick note), if required.

FIRST EVENING / NIGHT

We ask you to be very quiet on the first evening and not to sit on a hard chair etc. (no desk activity). A soft surface such as an armchair, sofa or bed would be best. 
If there is too much movement in the buttock area, the dressing may come off and there may be persistent bleeding. If this happens, please take a dark towel and press it on the wound for 10 minutes. Most of the time it will stop bleeding after that. However, if it continues to bleed, we ask you to come back immediately, or after 5 p.m. to the nearest hospital. Even if it looks bad, you will not lose much blood.  

Although the wounds are not too painful, you can take up to 3 tablets of ibuprofen if needed. If you take it for more than 3 days or if you have stomach problems, we will prescribe you a gastric protector (e.g. Pantoprazole), which you should take at night.

FIRST DAY AFTER SURGERY

On the first day, you will have an appointment at our practice in Lankwitz. Here we make the first dressing change. In the case of inconspicuous, small wounds, no further checks are carried out in our practice after this. Now your body has to do everything else.

The wound care afterwards is very simple. The small wounds must be washed out in the shower for 1-2 minutes in the morning, in the evening and after every bowel movement during the first week after the operation. Then dry the wound carefully with a towel and fold a compress in the middle and place it between the buttocks. If necessary, a wound ointment (e.g. panthenol) can be added.

Important: These are open wounds. Therefore, open wound healing occurs, which releases fluid that is orange/red in color. In addition, fibrin is formed as part of the wound healing process, which is equivalent to an endogenous glue. This fibrin is yellowish and slightly greasy. This is completely normal and no cause for concern. 

WHAT´S NEXT?

In the case of larger wounds, we still make a control after about 3-5 days. After that there is no scheduled wound control.

The period of time until a wound is completely healed can vary a lot. With pit picking, the small wounds should be completely healed after 6-8 weeks. If a small wound is still open at that time, we will ask to see you again for a checkup.
You can present at any time if there is a change for the worse:

  • The wound suddenly smells bad or is very painful
  • There is recurrent bleeding (not the normal wound water)
  • Small wounds have not healed after 8 weeks and larger wounds have not healed after 12 weeks.

Please always keep in mind. Despite the great success, pilonidal cyst can return in 20-25% of cases (recurrence). Wounds that do not heal are considered recurrences. However, before a new operation is planned, all, non-surgical, possibilities should be tried.