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Pilonidal Sinus - Pilonidal sinus?

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Bernhard Hofer - jameda.de
Florian Liebl - jameda.de
Bernhard Hofer - jameda.de
Florian Liebl - jameda.de

Do I really have a Pilonidal sinus?

Ignore? Operate? And if so, how?

I've already had surgery. The fistula's back. What to do?

Pilonidal sinus - What is it?

Schematic drawing Pilonidal Sinus, also called pilonidal sinus or pilonidal sinus
1 secondary opening, 2 primary opening ("pit"), 3 hair tufts in primary opening, 4 anal fistula, 5 anal canal, 5 rectum, 7 coccyx (os sacrum), 8 subcutaneous tissue

Mayo The term fistula (lat. fistula tube, pipe) denotes a tubular duct as a result of chronic inflammation. The term sinus pilonidalis ( pilonidal sinus, pilonidal cyst, coccygeal cyst, sacral dermoid, dermoid cyst) originates from Hodge 1880 (lat. pilus = hair and nidus = nest).

These fistulas are only found in the gluteal fold. They can be chronic (= Pilonidal Sinus) or acute (= coccyx abscess). Ingrown or spiked hair leads to a state of irritation as a foreign body. A protective wall of scar tissue forms, the fistula capsule (foreign body granuloma).

A stable layer of collagenous connective tissue, the fascia, protects the gluteus and coccyx.

The rectum and sphincter are never involved.

The pilonidal sinus is a simple disease.

Read also the interview with Dr Hofer

Which doctor is the best to go to?

Why does one need a specialist for a simple illness?

The Pilonidal Sinus is a skin disease. Consequently, the dermatologist would be responsible. However, the first point of contact is usually the family doctor. He refers the patient to the surgeon.

In Germany, approximately 50,000 patients undergo sinus pilonidal surgery each year. In other words, each surgeon treats an average of only 1.4 patients with a Pilonidal Sinus per year. With this number of cases, it is difficult to gain experience.

Look for a doctor who really has a lot of experience with his method and focuses on the treatment of coccygeal fistula. Do not choose the nearest hospital, not the fastest appointment, not the doctor with the best reputation in general, but the best doctor for your problem.

Pilonidal Sinus - OP: What is the problem?

The supposedly small intervention can have unexpectedly large consequences.

  • Long healing period with sick leave
  • Extensive and painful wound treatment,
  • frequent wound healing disorders
  • high relapse rate of up to 57 %(Deutsches Ärzteblatt 2019)
  • scarring 
  • Repeated hospital stays
  • Loss of income and career interruption 
  • Restrictions in sports fitness, weight gain
  • Restrictions of body feeling and sexuality
Statue newly exposed
The healing of a coccyx fistula gives you back physical well-being!

Good decisions are based on experience.

We are the experts

6123

Operations for pilonidal sinus (as of 29.03.2023)

8763

Treatment cases for pilonidal sinus (as of 14.04.2022)

Laser Treatments

Experience in laser therapy and laser surgery since 2012

Cash and private

Full authorisation for outpatient surgery and integrated care

Pit Picking Operation - The gentle alternative

According to the current state of science, a cure for Pilonidal Sinus is only possible through surgery. The factors that determine the success or failure of an operation were described as early as 1965 by the English surgeon Peter Lord.

  • The cause of Pilonidal Sinus is hair that has grown into the subcutaneous tissue.
  • All ingrown hairs must be completely removed.
  • All ports of entry (porus, pits) for hair must be identified and eliminated.
    These goals can usually be achieved by a relatively simple and minor surgery.

All fistulas will heal if they are not kept open. A pilonidal sinus is a foreign body - fistula, with hair being the foreign body. If the hair is removed, the fistula will heal

Surgical techniques

butcher2

Wide excision and leaving the wound open ("Butcher method")

The story of the operation of Pilonidal Sinus begins with an error.

At the beginning of the last century, when the diagnosis of the pilonidal sinus became increasingly common, including in soldiers in World War I ("Jeep's Disease"), one thought of the congenital disease of an embryonic malformation.

In other words, a relapse (recurrence) could not occur after complete removal. However, after recurrences were nevertheless observed, the extent of the operations was extended more and more.

This radical removal (Latin 'radix', root) became accepted worldwide. Although this theory has been Patey is regarded as refuted, most surgeons still stick to this outdated therapy concept.

Asymmetric wound closure according to Karydakis
Mobilization of the "flap" precisely at the level of the superficial fascia of the body.

Excision with closure of the wound by local tissue transfer (flap surgery)

Why not close the wound by stitches?

With a simple suture in the midline, wound infections are common, the suture bursts open or must be reopened to control infection.

In addition, the suture leads to a slight inversion of the wound edges, which favours the re-growth of hair and thus the relapse (recurrence).

The constant movements while walking and sitting cause shearing forces in the area of the gluteal fold, which prevent a stable healing of a sutured wound.

For this reason, procedures have been developed to reduce the tension in the sutures by relocating the patient's own tissue (flap plasty) and to enable a laterally displaced (medically: lateralised) suture:

The alternative

Pit picking surgery, laser surgery (SiLaC®), sinusectomy, endoscopy (EPSiT)

Less is more:

Based on the pit-picking technique developed in England and popularized in the USA, several variants of this gentle treatment are available.

Pit-picking is the selective removal of the affected hair roots as a skin cylinder of 2-5 mm in diameter and the cleaning of the fistula tract from deposited hair fragments.

The more perfectly this is achieved, the lower the risk of fistula formation again.

The decision as to which technology is best suited must be made on an individual basis:

  • Laser treatment of the fistula from the inside with a fiber optic probe (SiLaC®)
  • Precise peeling along the fistula capsule(sinusectomy or fistulectomy).
  • Video Endoscopic Surgery (Endoscopic Pilonidal Sinus Therapy EPSiT)
laser epilation
Aftercare through telemedicine

Aftercare after the operation

With us you will not be left alone after the operation.

The best operation does not guarantee a problem-free healing. In questions of aftercare, we advise you already at the surgery appointment.

Especially if you live further away, your relative can become your private wound specialist. We support you through all common digital communication channels.

From our information brochure you will learn what to expect in the course.

At the follow-up appointment in the practice, your surgeon will personally take care of the optimal healing process, if necessary.

In our special wound and laser consultation your wound will be professionally cared for by a trained and experienced therapist.

The success story of our practice

Mail from Dr. John Bascom from Eugene, Oregon

That must have been around 2003. After passing the specialist examination, I was allowed to operate independently. The first procedures that await a young surgeon are the supposedly simple ones - like removing a Pilonidal Sinus.

In residency, I learned the complete removal of the fistula region down to the bone, now referred to by many patients as the "Metzger Method."

My friend and colleague Dr. K. had to experience painful wound treatment lasting 9 months on his own body after such an operation in a large clinic in Munich.

Pit Picking under the guidance of Dr Bascom
Illustration of the Pit Picking after a drawing by John Bascom
Pit Picking - cutting out the hair roots the size of a grain of rice
A revolutionary new method from England and the USA

"There must be some other way to do this," were his words that stuck in my mind.

During my research on the then burgeoning Internet, I came across the method of Dr. John Bascom from the USA. Although the actual inventor was the British surgeon Dr. Peter Lord, Bascom made the "pit picking" operation known worldwide.

A big thank you goes out to John Bascom for his invaluable help and support! As a pioneer of the pit picking method, he sent me a package with instructions, a video CD and self-drawn graphics. In difficult cases, one could always get good advice from him by e-mail.

Evolution of the Pit Picking Technique Operation

Despite an initial success rate of only about 50%, patients were happy to have escaped standard surgery. Consequently, more and more requests came in. The optimization of the surgical technique through innovative technologies, fine special instruments, useful drugs and biomaterials combined with the experience of now more than 6000 operations could continuously improve the results.

Today we achieve cure rates of > 90 %. Currently, about 1000 patients per year visit our practice with a Pilonidal Sinus .

From this we have learned that minimally invasive techniques are not only suitable for a first operation. Also the relapse (recurrence) can be taken away with it the frights.