Experts for Pilonidal Sinus Surgery

Diagnosis Sinus Pilonidalis - What next?

Dr. Bernhard Hofer, Head of the
Dr. Hofer, head of the treatment centre Pilonidal Sinus

Dr. Bernhard Hofer and his team welcome you to our special practice for the Pilonidal Sinusin the heart of Munich.

If you are familiar with the following symptoms, you are probably suffering from one (Pilonidal SinusSinus Pilonidalis, Latin for hair nest dimples).

  • bump on the bottom
  • pain over the coccyx
  • Moisture or blood on the laundry
  • Unpleasant smell
  • Small opening(s) in the gluteal fold 


Have you just come from the doctor who told you that only major surgery can relieve you of these symptoms?

Have you seen the surgeon who told you that minimally invasive techniques are not possible with your fistula?

Have you ever heard deterrent experiences about the operation of one Pilonidal Sinusfrom acquaintances, relatives or on the Internet?

Then we can reassure you. There are very good alternatives to standard surgery.

What is a (pilonidal sinusPilonidal Sinus, pilonidal sinus, pilonidal cyst, "coccygeal cyst", "sacraldermoid", "dermoid cyst")?

The clinical picture was first described in 1833 by Mayo described. Fistula (lat. fistula tube, pipe) is a tubular duct as a result of chronic inflammation. The term sinus pilonidalis was coined in 1880 by Hodge (lat. pilus = hair and nidus = nest). This type of fistula is only found in the area of the gluteal fold. It can be chronic (= Pilonidal Sinus) or acute (= coccyx abscess). Like a foreign body, hair that has penetrated into the subcutaneous tissue causes an inflammatory stimulus, which leads to a separation by scar tissue (foreign body granuloma). 

Diagram Pilonidal Sinuslateral
Schematic drawing of one Pilonidal Sinus: The fistula duct is a tubular cavity in the subcutaneous tissue above the coccyx. The periosteum (fascia) forms a stable separating layer between fistula and bone. The rectum and sphincter are never affected.

You can recognize a coccyx fistula by these 5 symptoms

and how the doctor makes the diagnosis in unclear cases

Openings in the center line (pits)

If small black dots or openings of variable size, the "pits", are found in the midline, the diagnosis is proven. Sometimes you have to look very closely to find them. It is not uncommon for the "pits" to lie at some distance from the obvious fistula opening or swelling.

Pain during sit-up training

pain, palpable hardening

The most common symptom is a pain or foreign body sensation when sitting. This is particularly noticeable on an unupholstered chair (school, lecture hall, further education, beer garden bench). The hardened region of the fistula can also be felt during sports exercises (sit-ups, bench presses).

In the case of inflammatory flares or pilonidal abscesses, it can become so painful within a short time that you can no longer sit.

Fistula opening with a dent in a small fluid

Visible bump or asymmetry of the intergluteal fold

Not always a clearly visible fistula opening is found in the pilonidal sinus. The only sign may then be an asymmetry of the gluteal fold or a visible bump.

exudation of blood and pus during acute inflammation

issue of blood, pus or clear secretion

The most common symptom is a pain or foreign body sensation when sitting. This is particularly noticeable on an unupholstered chair (school, lecture hall, further education, beer garden bench). The hardened region of the fistula can also be felt during sports exercises (sit-ups, bench presses).

redness, rarely general symptoms or fever

In pilonidal abscesses there is usually a clearly visible redness that goes far beyond the limits of the underlying Pilonidal Sinusone. Usually the abscess bursts open by itself at some point. If this is not done, general symptoms of illness and fever may rarely occur. Then an abscess splitting is urgently required.

During the ultrasound examination, the doctor can see and measure the extent of the fistula cavity and possible branching. On our side pictures you will see numerous photos and ultrasound images of the different types of a Pilonidal Sinus.

The high sensitivity of magnetic resonance imaging (MRI) is useful when the patient has symptoms but clinical examination and ultrasound cannot detect a clear fistula.

The pilonidal sinus is a simple disease.

1992 George E. Karydakis, Greek surgeon and founder of asymmetric wound closure during surgeryPilonidal Sinus, Anz Journal of Surgery, 62(5), 385-389.

Which doctor for coccygeal fistula?

Why does one need a specialist for a simple illness?

The coccyx fistula is a disease of the skin. Consequently, the dermatologist would be responsible. However, the first point of contact is usually the family doctor. He will refer the patient to a surgeon.

About 50,000 patients are operated on a pilonidal sinus every year in Germany. In other words, each surgeon treats on average only 1.4 Pilonidal Sinuspatients per year.

Pilonidal Sinus - OP: What's the problem?

The supposedly small intervention can have unexpectedly large consequences. Complications or a disturbed or missing wound healing make further treatments necessary. Healing times over months are not uncommon. Incapacity for work and sports are the result. 

Or the fistula is back faster than it has healed: The relapse rate (medically: recurrence rate) after conventional surgery is stated to be up to 57% (Deutsches Ärzteblatt 2019).

Pilonidal Sinus - All important facts

Picture of Pilonidal Sinus
Sinus Pilonidalis, clearly visible the tiny primary openings (pits)

The alternative

This must be prevented. I have specialized in the treatment of the Sinus Pilonidalis since 2004. With me you benefit from the experience of over 3600 Pilonidal Sinusoperations.

We operate on an outpatient basis without hospitalisation. We operate painlessly under local or tumescent anaesthesia. This means you do not need a general anaesthetic.

This page will inform you shortly about everything you should know. On the subpages you will find more detailed explanations, supplemented by the constantly growing list of medical articles.


Surgery for coccyx fistula (status 30.03.20)


Treatment cases coccyx fistula (status 30.03.20)


Experience since 2012 in laser treatment and laser surgery

Private and statutory insurances

Full approval for outpatient operations

Good decisions are based on experience.

John U. Bascom M.D., pioneer of modern pilonidal surgery, Eugene/Oregon U.S.A., 1925 - 2013
Dr. Bernhard Hofer
Dr. Bernhard Hofer
Practice owner
Specialist in surgery, visceral surgery and proctology.
Dr. Klaus Bärtl
Employed doctor
Visceral surgery specialist, emergency physician.
Dr. Susanne Schuster
Employee doctor
Surgery specialist. Conservative office hours.
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Surgery for sinus pilonidalis

Is there a cure without an operation? How to choose the best technique of surgery!

In the pilonidal sinus there is almost always hair completely embedded under the skin. You can't see them from the outside. As a result, shaving and intensive wound treatment can lead to the closure of a fistula opening. However, this apparent healing is not permanent. The fistula keeps bursting open. Physical rest, bathing in a sitz, train ointments and antibiotics also help only temporarily. At the very least, these measures can save time in order to plan gentle treatment.

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

Peter H. Lord and Douglas M. Millar, founders of the pit picking operation for the Pilonidal Sinus, BRIT. J. SURG, 1965, Vol. 52

Radical excision with open wound treatment ("butcher method")

The story of the operation that Pilonidal Sinusbegins with an error
Pilonidal Sinus OP incision
Cutting guidance during the conventional cutting of a Pilonidal Sinus

When the diagnosis of pilonidal sinus disease became increasingly common at the beginning of the last century, among soldiers in the First World War ("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 observed, the extent of the operations continued to expand. This radical distance (Latin 'radix', root) became established worldwide. Although this theory has been refuted since Patey, most surgeons still adhere to this outdated therapy concept today.

Cutting out with plastic wound closure (flap plastic)

Karydakis - OP, Limberg Flap, Dufourmentel Flap
Operation after Karydakis at Pilonidal Sinus
Mobilisation of the flap during the Karydakis operation

Although obvious, the closure of the surgical wound by suture is often unsuccessful. The suture in the midline often leads to disturbances in wound healing and infections. The result is that the seam must be broken or reopened.

Only a suture shifted to the side (medically: lateralized) can be promising. The prerequisite for such a suture, however, is a large-area detachment of the skin and subcutis from the base, the so-called mobilization of a flap. In our experience, the best results are achieved with Karydakis plastic. A correct cut in this technique, introduced by a Greek military surgeon, requires great experience. Even with optimal implementation, the rate of wound healing disorders is stated to be up to 20 %.

Less is more

How to avoid complications and shorten the healing time

The usual procedure after radical surgery, which is still recommended in many textbooks and guidelines, is open wound treatment. The often 5-10 cm long and 3-5 cm wide wound should slowly fill with scar tissue. To avoid a superficial, premature closure, the wound cavity is often stuffed with a tamponade.

The special conditions in the area of the gluteal folds with constant movements, shearing forces, mechanical stress during sitting, moisture and bacterial colonisation of this region hinder normal wound healing. As already mentioned, the attempt to close the wound by suture has its pitfalls.

Typical problems after conventional pilonidal sinus surgery

9 reasons to think about the best surgical technique
  • Long healing period from months to years
  • Necessity of complex and painful wound treatments
  • Frequent wound healing disorders
  • Frequent recurrences due to hair growing into the wound bed
  • Tearing open the scar after wound closure by suture or plastic reconstruction
  • Repeated hospital stays and operations
  • Loss of income and career break due to long and repeated incapacity to work
  • Restrictions on athletic fitness and weight gain
  • Limitations of body feeling and sexuality
Pilonidal Sinus Inflammation of gluteal fold

The Alternative: "Pit Picking 2.0"

Pit Picking Operation, Laser - OP (SiLaC®), Sinusectomy, Endoscopy (EPSiT)

Laser Hair Removal
Laser hair removal as a supplement to pit picking surgery

On the basis of the "new" products developed in England and becoming popular in the USA pit-picking technique we offer various variants of this gentle treatment. Pit-picking refers to the selective removal of the affected hair roots as skin cylinders with a diameter of 2-5 mm and the cleaning of the fistula tract from deposited hair fragments.

The more perfectly this goal is achieved, the lower the risk of recurrence. Depending on the respective findings, laser treatment of the fistula from the inside using a glass fibre probe (SiLaC®) or precise peeling of the fistula capsule (sinusectomy or fistulectomy) is best suited.

With long and branched fistulas, optimal safety can be achieved by video endoscopic control (endoscopic pilonidal sinus therapy EPSiT).

Follow-up treatment after Pilonidal Sinus-OP

Optimize healing process and avoid relapses

No matter how far away you live away from us - we guide you on the process of healing with advice by mail and telephone. And with permanent hair removal using a state-of-the-art diode laser, we offer surgery and relapse prevention from a single source.

Pit picking under the guidance of Dr Bascom
With this little parcel from Pit Picking pioneer John U. Bascom M.D., the history of today's Pilonidal Sinus Center in Munich began.

Why a treatment centre?

This is how the idea of specializing in the coccyx fistula came about.

It must have been about 2003. After completing my specialist examination, I was entitled to operate without supervision. The first procedures waiting for a young surgeon are the supposedly simple ones - like the removal of a pilonidal sinus. In the specialist training, the complete excision of the fistula region down to the bone, which is today called the "butcher method" by many patients, was taught. My friend and colleague Dr. K. had to undergo a painful wound treatment lasting nine months after such an operation.

Pit picking according to Bascom picture
Pit picking: The ingrown hair root is removed as a tiny cylinder of skin. Bascom used an additional lateral incision, which we can avoid in most cases with grown routine today.

A revolutionary new method

to treat the Pilonidal Sinuscomes from England and the USA

"There must be another way," were his words, which I couldn't get out of my head. My research led me to the method of Dr. John Bascom. from the USA, the original from Dr. Peter Lord "Pit Picking". At that time, communication was still analogous. For this reason, a package of instructions, a video CD and self-drawn graphics gave the go-ahead to try a different way of healing onePilonidal Sinus.

Despite an initial success rate of only about 50%, the patients were happy to have escaped the standard operation. As a result, more and more inquiries came in. Today we achieve cure rates of almost 90% and operate in the year 800 - 1000 patients from all over the world. From this we have learned that minimally invasive techniques are not only suitable for a first operation. Rather, it can also be used to help patients with relapses and non-healing wounds after radical surgery.

Literature in general about Pilonidalsinus

Ommer, A., Berg, E., Breitkopf, C., Bussen, D., Doll, D., Fürst, A., Herold, A., Hetzer, F., Jacobi, T., Krammer, H., Lenhard, B., Osterholzer, G.., Petersen, S., Ruppert, R., Schwandner, O., Sailer, M., Schiedeck, T., Schmidt-Lauber, M., Stoll, M., Strittmatter, B., & Iesalnieks, I. (2014). S3 guideline: Sinus pilonidalis. coloproctology, 36(4), 272-322.