Techniques of Pilonidal Sinus - Operation explained in an easy to understand way

Pit picking instead of butcher - method

Pilonidal Sinus OP

Which surgical procedures are recommended?

The Pilonidal Sinus is a harmless disease. Many problems arise only as a result of extensive operations and neglect of follow-up treatment.

The variety of surgical procedures and medical opinions cause confusion. Our overview provides you with all the facts for a good decision.

Pilonidal Sinus Operations

Abscess Drainage

Defusing the acute inflammation

A small incision under local anesthesia or a puncture provides relief. Pain and inflammation are reduced. In mild cases the administration of antibiotics may be sufficient. We then operate on the fistula according to the guidelines under optimal conditions about two weeks later.

Our referral light:

Sections highlighted in green describe a treatment that we recommend

We consider yellow-shaded therapy options to be suitable under certain circumstances

Red indicates that we consider the treatment unsuitable or that it is not offered in Germany

Find the best surgical method...

... while achieving these 3 important goals:

  • Elimination of the chronic inflammation: Pit picking according to Lord and Bascom selectively removes ingrown hair roots and hair in the fistula tract. The FiLaC technique removes the internal fistula tissue with a laser probe. Fistulectomy or sinusectomy completely removes the fistula tube. In the conventional Pilonidal Sinus surgery, the fistula is cut out in a block with subcutaneous fatty tissue.
  • Closure of the wound(s): With pit picking and variants, the wounds are small and heal by themselves. In conventional surgery, either the wound is left open(open wound treatment) or closed by suturing, if necessary with displacement of adjacent tissue(plastic reconstruction).
  • Prevention of relapse (recurrence): Not only the type of operation is responsible for the rate of relapse. The importance of wound treatment after the operation and recurrence prevention by laser hair removal is often underestimated. In addition, giving up smoking and the design of a workplace with the possibility of temporary work while standinghelps.
pit picking
FiLaC/SiLaC
Sinusectomy
Radical Excision
Karydakis
Limberg
Availability
Special practice/clinic
Special practice/clinic
Special practice/clinic
General Surgeon
Special practice/clinic
Special practice/clinic
Inpatient/outpatient
outpatient
outpatient/inpatient
outpatient/inpatient
stationary
stationary
stationary
Type of anaesthetic*
LA
LA/ITN/SPA
LA/ITN/SPA
ITN/SPA
(LA)/ITN/SPA
ITN/SPA
OP Duration
20 min
20 - 30 min
30 - 120 min
30 min
40 - 90 min
40 - 90 min
Disability
0 - 2 weeks
0 - 2 weeks
2 - 3 weeks
1 - 12 months
4 weeks
4 weeks

* SPA = spinal anaesthesia, spinal cord anaesthesia, ITN = intubation anaesthesia, general anaesthesia, LA = local anaesthesia, local anaesthetic. 

Table: Overview of the most common surgical techniques for Pilonidal Sinus

This assessment is based on my personal experience with the patients presented in our practice. It is subject to a selection effect and a certain subjectivity. Conventionally operated patients will only seek a second opinion if there are problems in the course of wound healing or if a relapse occurs, and are thus disproportionately represented in our collective.

My rating of the surgical techniques ranges from 0 stars (not recommended) to 5 stars (method of first choice). We have highlighted the techniques that we recommend in our opinion in green, conditionally suitable ones in yellow, and less recommendable ones in red.

Pit Picking and further developments

The simple method according to Lord and Bascom: Pit-picking - A Simple Treatment

In 1965, the British Journal of Surgery published a two-page publication by the surgeon Peter Lord about a new, "simple treatment" of the Pilonidal Sinus.

On our page about the development of a Pilonidal Sinus we explained how small, inconspicuous openings allow the penetration of hair and bacteria, causing chronic inflammation. Peter Lord called these openings "pits".

He concluded that the complete removal of pits and impaled hairs was crucial for healing. He called the sparing excision of the pits "pit picking" and recommended a round brush for cleaning the fistula tract. In addition, Lord recognized the importance of hair removal for healing success, which he achieved by electro-epilation or shaving.

Original publication of the English surgeon Peter Lord
First description of pit picking by Peter Lord 1965  Schematic drawing Pit Picking and Relief Cut (Redrawn according to Bascom, Rob & Smith's Surgery)

At first, this "Lord Millar procedure" attracted little attention. It was not until John Bascom (Oregon, U.S.A.) ensured the worldwide dissemination of this advanced technique, which he called "follicle removal". With great dedication, he assisted surgeons worldwide in learning this technique.

We have been successfully using the pit picking technique since 2004. With the experience of over 3500 operations we have continuously improved the technique. Expertise and technological progress (magnifying glasses, 4MHz radiofrequency surgery, laser surgery and fine instruments from plastic surgery, ENT and maxillofacial surgery) today allow us to treat every Pilonidal Sinus minimally invasive. You also benefit from this therapeutic principle in the event of a relapse after a (conventional) operation.

Your advantages with this treatment concept:

  • Examination, consultation and operation - all in one day
  • Treatment under local anesthesia, no general anesthesia
  • Treatment in the practice, no hospital stay
  • Substantially smaller wounds
  • Fast work and sport ability
  • preservation of the normal body contour, inconspicuous scars

Pit Picking "Classic": LORD - BASCOM - OP

Our evaluation:
3/5

According to the original description by Lord and Bascom, only the pits are cut out during this procedure as skin cylinders "the size of a grain of rice". We use biopsy punches of 2 - 6 mm for this. The enclosed hairs are pulled out with a fine clamp, the fistula tract is scraped out leaving the fistula capsule. Some surgeons also make a longitudinal incision of 1 - 2 cm in length at the side to allow the secretion to drain out, the relief incision.

The theory is that with the removal of the foreign body the inflammatory stimulus is eliminated and the fistula can heal. The wounds and the fistula tract close up over time without any further action by scar tissue.

Pit Picking "classic" - When do we use this method?

  • in the case of a Pilonidal Sinus without a history of surgery and a minor degree of scarring
  • for young people < 14 years

Pro

  • smallest possible intervention
  • ambulatory
  • short treatment duration 10 - 30 min
  • short healing time 1 - 2 weeks
  • Healing rate up to 70% 
  • replayable
  • all other techniques remain possible

Contra

  • not practicable for severely scarred fistulas
  • Cleaning of hair often incomplete
  • Hardened fistula cord remains
  • Recurrence rate up to 30
  • Fistula tract often noticeable despite healing of the openings
Studies on Pit Picking Classic
Author
Year
Quantity
% Follow up
Years Follow up
% Recurrence
% Complication
Bascom
1983
161
92
3,5
16
Not specified
Colov
2013
75
96
1
29
14
Iesalnieks
2014
153
97
2,5
25,7
1,3
Ehrl
2017
38
57,2
2,7
13,2
18,4
Oliveira
2019
44
Not specified
3,1
40,9
Not specified
Delshad
2019
58
88
0,4
8,0
Not specified

I started with this surgical technique in 2004 for simple, not too extensive coccyx fistulas. The experience was so positive that soon more and more patients asked for the pit-picking technique. At that time I was still of the opinion that in the case of a relapse after pit-picking, a major operation would then be unavoidable. At that time we performed Karydakis plastic surgery for recurrence. However, there was a frequent request to try pit-picking again.

 

Pit Picking + Laser (FiLaC/SiLaC): WILHELM Laser OP

Laser surgery (SiLaC - Sinus Laser Ablation of the Cyst)

Our evaluation:
3.5/5
Schematic drawing of a fistula tract and laser probe

In selected cases, renewed pit-picking was successful in the event of recurrence. Nevertheless, the success rate of the pit-picking operation of a maximum of 70% was not completely convincing. In 2011 Wilhelm and 2013 Giamundo presented the FiLaC laser technology for the treatment of anal fistulas.  

The idea was obvious to use the laser probe also for Pilonidal Sinus . And indeed, the success rate could be increased to over 80%

The laser treatment is to be seen as an additional measure to pit picking. Removal of the pits and cleaning of the fistula tract are performed identically. The laser probe is then pulled through the fistula canal several times while releasing energy, so that the inner layer of the fistula capsule is burned out and the capsule shrinks.

FiLaC / SiLaC - when do we use the method?

  • generally rare
  • for long fistula tracts
  • for numerous fistula openings
  • if the patient prefers the fastest possible convalescence ("downtime")
  • for symptom relief in difficult to cure multiple relapses and acne inversa

Pro

  • All the advantages of pit-picking
  • Improved healing rate up to 80
  • Rapid regression of bleeding and secretion

Contra

  • increased swelling in the first days after surgery
  • Self-payer service
  • Fistula tract often noticeable despite healing of the openings
Studies on FiLaC/SiLaC
Author
Year
Quantity
% Follow up
Years Follow up
% Recurrence
% Complication
Dessily
219
200
77,5
10,44
14,9
15,0

Pit picking + sinusectomy: Our preferred technique

"Pit Picking 2.0" Minimally invasive "tubular" peeling of the fistula tract

Our evaluation:
5/5
Diagram showing the extent of fistula removal in sinusectomy
The hatched area is removed during fistulectomy (sinusectomy), the skin above it is largely preserved. Source of error during pit picking: Leaving a diagonally running segment of the primary fistula This is removed during fistulectomy (sinusectomy)

What can be improved in Pit Picking and FiLaC?

The aim is to guarantee the complete removal of the trapped hair.

It has long been known that hair is not always found in the hollow space of a Pilonidal Sinus .

In this constellation, also known as "empty nest" - empty (hair) nest, microscopic examination often reveals hairs integrated into the wall of the fistula capsule - a possible cause of recurrence after pit picking.

In addition, the mechanical irritation caused by the cartilage-like hardened fistula capsule leads to complaints. With the removal of the fistula capsule, sitting on hard surfaces becomes comfortable again.

Evolution of the surgical technique

Is there a middle way between "brushing out" the gear during pit-picking and complete cutting out?

The first thought was a skin incision in the course of the fistula with a final skin suture. This works very well with lateral or oblique fistulas. If the fistula runs exactly in the middle, the problem of suturing in an unfavourable position is again present.

With increasing experience the necessary cut became shorter and shorter. Tubular fistullectomy (tubular fistula excision), also known as sinusectomy, solves the problems mentioned above.

Magnifying glasses, tumescent anesthesia and the 470 nm laser offer the highest precision and freedom from pain. Sinusectomy is therefore the standard method in my practice.

Source of error during pit picking: Leaving an oblique segment of the primary fistula

Pro

  • Complete fistula removal without large wound
  • Cure rate up to over 90
  • Removal or at least reduction of painful hardenings
  • Also applicable in case of recurrence
  • Outpatient surgery possible
  • A short absence from work 
  • No physical protection necessary
  • Cost absorption by all health insurance companies

Contra

  • Only a few doctors in Europe have sufficient experience
  • Longer surgery Duration 30 - 120 min
  • Inner wound cavity corresponds to the volume of the removed fistula
  • Initially secretion of wound fluid
  • Initially pain under stress

Endoscopic pilonidal sinus therapy: EPSiT

Keyhole surgery for difficult cases

Our evaluation:
4/5

A challenge in all minimally invasive procedures is the difficult view through small openings into a narrow fistula cavity. We routinely use magnifying glasses with 2.5x magnification and built-in, powerful illumination for this purpose.

In abdominal surgery and trauma surgery, endoscopic surgery via rod optics has long been standard practice. We have invested in this technology. If it makes sense, we use a 2.7 mm thin optic with a high-resolution camera from the Stryker company, such as is also used for joint endoscopy (arthroscopy). In this way, the fistula tissue can be vaporized with laser under video-assisted vision (laser ablation), bleeding can be stopped and the completeness of a fistula removal can be checked.

Meinero et al. use the anal fistula instruments of the company Storz (VAAFT) and have coined the term "Endoscopic Pilonidal Sinus Therapy - EPSIT" for this procedure. Milone uses a hysteroscope (camera to reflect the uterus) and bipolar current to remove fistula tissue.

... contribution in progress

Radical excision ("butcher method"): The conventional operation

Large-area removal with open wound treatment

Our evaluation:
1/5

Historical development

Based on the assumption of a congenital malformation, a radical (lat. radix = root) excision of the fistula-bearing tissue has been demanded since the beginning of the 20th century. In order to avoid recurrences, a "safety margin" of healthy tissue was also removed. Thus, no relapses (recurrences) could have occurred with complete removal. 

But there were relapses nevertheless!

Thus the theory of a disease existing from birth had to be questioned. The obvious consequence of reconsidering the surgical procedure was not generally drawn. The Chief of Staff of the American armed forces had already banned the radical operation after it had brought 79,000 soldiers into inpatient treatment for an average of 55 days (Jeep rider's disease).

Instead, new justifications for the radical operation were found. The resulting extensive scar was supposed to protect against the re-growth of hair by keeping the hair free.

And then? How can a wound closure be achieved?

Basically, there are 3 possibilities: open wound treatment, the hardly used hemming of the wound edges to flatten the wound (marsupialisation) and the closure of the wound by suture.

Open wound treatment

What is meant by this is not rare: We'll see. The 5-10 cm long and 3 - 5 cm wide wound should fill with scar tissue. To avoid premature closure, the wound cavity is stuffed with a tamponade.

There are two ways of wound healing: Primary wound healing occurs when the edges of the wound are in close contact, e.g. in a sutured wound. First, it sticks together with fibrin, a protein from coagulation factors in the blood. The scar gains firmness in the second step when connective tissue cells multiply and form stable collagen fibres.

After the radical excision only secondary wound healing is possible. First the wound cleans itself. Then it fills with granulation tissue. When the skin level is reached, new skin grows over the scar in a final step.

In case of secondary wound healing, physical protection is of no use. Wound infections are rare. In the coccyx region, regrowing hair and loose hair from other parts of the body as well as textile particles from clothing are the most frequent disturbing factors. We have already found hair from other family members and pets in non-healing wounds at Pilonidal Sinus .

Here the seam in the midline is torn open. The situation is therefore the same as with primary open wound treatment.

Seam closure in the center line - usually not a good idea

It would be an obvious thought to sew up the wound. Especially with a small wound one could imagine that.

Unfortunately, the suture in the midline heals without problems only in part of the cases.

Regrowing and loose hairs penetrate the sutured wound, the stitches hinder the necessary shaving.

Moisture and bacterial colonisation favour wound infections. The suture bursts open again or must be opened prematurely.

Shear forces and constant movement cause the seams to become loose.

For these reasons, techniques that attempted to compensate for the loss of soft tissue by mobilizing fatty tissue(flapplasty according to Maruyama) were not successful because the wound was ultimately closed in the midline.

Suturing in the midline is not recommended in the current guideline. In well justified individual cases, such a suture can nevertheless help to shorten the healing time. From my experience, the prerequisites are

  • inflammation-free conditions during the operation
  • Treatment with laser epilation on the day of surgery
  • meticulous removal of hair in the wound area 1 - 2 times a week
  • early suture removal around the 10th day after surgery
Complication of Pilonidal sinus surgery with primary wound closure
1 week after suturing, numerous hairs have already penetrated the wound. In this case, problem-free healing after suture pulling and removal of the hairs.
Diagram of the "Butcher's method"
Spindle-shaped cutting for en-bloc removal of a Pilonidal Sinus

How the wound can look like after such an operation, you can see for example on this page of an affected person

Operation procedure Radical surgery ("Excision in toto")

  • Usually surgery under general or spinal anaesthesia (spinal anaesthesia) 
  • Mostly in-patient surgery performed in hospital as an in-patient.
  • The sleeping patient is first turned into the prone position. The skin is disinfected and the surrounding area sterilely covered.
  • Most surgeons first inject a blue dye to be able to recognize the dimension of the fistula by the blue coloration.
  • Using a scalpel or electric knife, a spindle-shaped ("whetstone") block of tissue is cut out "safely in the healthy" down to the periosteum (fascia). 
  • The wound remains open. Tamponade (stuffing of the wound) is often carried out with sterile compresses or iodoform-soaked textile strips.
  • These tamponades are changed regularly. Patients are usually instructed to wash out the wound regularly.

Here you can find a Video of conventional cutting. Formulations of the operation protocol can be found, for example, in OP-Bericht.de.

Radical surgery - when do we use the method?

  • at typical Pilonidal Sinus: Never
  • inversa acne: when conservative therapy and minimally invasive surgery have not been successful

Pro

  • Simple surgical technique
  • available nationwide
  • complete fistula removal easy to achieve

Contra

  • major wound 
  • protracted healing
  • unfavourable scars
  • high rate of failure to heal
  • high recurrence rate

Lateral wound closure: KARYDAKIS - OP

Plastic reconstruction

Our evaluation:
4.5/5

This technique goes back to the Greek military surgeon George E. Karydakis back. He recognized the problem of difficult healing and high recurrence rate. With his 1974 published technique of a laterally (laterally) displaced incision and reconstruction of the wound in 1974, he significantly improved the results of Pilonidal Sinus surgery.

Asymmetrical incision Schematic drawing of Karydaki's OP at the end of the operation

Operation procedure Karydakis OP

  • General or spinal anaesthesia (spinal anaesthesia)
  • Inpatient treatment and abdominal positioning 
  • The cut-out is made offset to the side. The length of the cut is at least 5 cm.
  • Closure by suture is achieved on the side "lateralised", "off-midline" - at least 2 cm to the side of the midline - and with flattening of the gluteal fold.
  • A suction drainage (Redon) can be inserted.
  • 3 weeks are indicated to take iteasy .
  • If the course is uncomplicated, healing is then achieved. The flattening of the gluteal fold should prevent relapses.
  • You can change the course of the operation, for example, to www.webop.de understand.
Schematic drawing of a sinus pilonidalis in axial section
Scheme of a Pilonidal Sinus in cross section (1 glutaeus max., 2, glutaeus med., 3 subcutaneous fat, 4 sacral os, 5 fistula cavity, 6 pit, 7 femoral head, 8 superficial body fascia)
Asymmetrical cutting during removal
Preparation of the wound closure, presentation of the deep suture
Closure of the wound with flattening of the gluteal fold

Karydaki's surgery - when do we use the method?

  • with typical, not pre-operated Pilonidal Sinus: Rare
  • for acne inversa: very rare
  • in case of recurrence after radical surgery, if minimally invasive surgery has not been successful

Pro

  • Even large defects can be closed
  • Very good recovery rates: Karydakis itself indicates a recurrence rate of 1%, a complication rate of 8.5% and a follow-up rate of 95% for 6545 patients operated on in 24 years!
  • Low recurrence rate (0 - 6 %) due to lateral scar and flattening of a deep gluteal fold

Contra

  • Technically demanding operation, experienced surgeon required 
  • Even with optimal OP technique 8 - 23 % haematomas (bruises) and wound healing disorders
  • Seroma formation possible (fluid accumulation under the scar)
  • Visible scar
  • Changed body contour
Studies on Karydaki's surgery
Author
Year
Quantity
% Follow up
Years Follow up
% Recurrence
% Complication
Petersen
2006
97
100
0,8
not reported
21

Modification of the Karydakis-OP: CLEFT LIFT to BASCOM

Plastic reconstruction

Our evaluation:
4/5

This technique is similar to the Karydakis operation in terms of the incision and the concept of lateral wound closure.  

This technique focuses on the entry point for hair and bacteria. The fistula is not necessarily excised to its depth, but only unroofed and "cleaned out". The mobilized tissue, the "flap" comprises only the skin and a thin layer of subcutaneous tissue and is therefore thinner and easier to suture. 

Descriptions of the technique in different variants can be found at Bascom and Favuzza, among others. From my point of view it is not conclusively clarified whether the fistula capsule does not represent a reservoir of firmly ingrown hairs and bacterial colonization which should better be removed.

Studies on Cleft Lift OP
Author
Year
Quantity
% Follow up
Years Follow up
% Recurrence
% Complication
Bascom
2002
31
87
1,67
0
9,6

Closure by rotational flaps: LIMBERG - OP

Plastic reconstruction

Our evaluation:
2/5

This technique goes back to the Russian oral surgeon Alexander A. Limberg who published a technique for closing a diamond (rhombus) shaped defect in Russian in 1948 and in English in 1966. In 1984 this technique was published by A.S. G. Azab first used in Egypt to close a coccyx fistula wound. The description of the Limberg operation below follows this publication.

Apart from Karydakis surgery, Limberg plastic surgery is the most frequently used procedure with plastic wound closure. Excellent results have been reported. Unfortunately, in our consultation hours we often see patients who have had complicated recurrences despite (or because of?) an extremely extensive operation.

Schematic drawing Limberg OP Completed suture line after Limberg OP

Before: Planning of the lobes - plastic to Limberg with rhomboid cut

After: Course of the skin suture at Limberg Plastik (the suture lies in the midline!)

Operation Limberg OP

  • General or spinal anaesthesia (spinal anaesthesia), in-patient treatment and abdominal positioning 
  • Cut-out and rotational lobes are rhombus-shaped (i.e. all sides have the same length, unlike the "rhomboid")
  • The respective opposite internal angles are 60° and 120°.
  • The rue containing the fistula is cut out down to the periosteum of the coccyx and the gluteal fascia.
  • A suction drainage is inserted.
  • The pedunculated rhombus flap is relocated to the midline wound and sutured in 2 layers.
  • The donor site of the flap is closed by a diagonal suture.
  • For 10 days, the patient is positioned on the side only .  
  • Then the skin threads are removed.
  • Shaving and showering was recommended. 
  • If the course is uncomplicated, healing is then achieved. 

Often the Limberg plastic is performed in the manner shown above. The positioning of the sutures, as for example in the publication of Bozkurt is extremely unfavourable. Of all things, the acute-angled portions of the rhombus, which are in any case prone to wound healing disorders, lie in the problematic midline. Furthermore, we frequently observe that a kind of new gluteal fold forms in the middle of the lobe, which predisposes especially for new "pits".

So if this technique is used at all, sufficient displacement to the side must be provided, as schematically shown in the pictures below(Wysocki 2019). Even if this technique is done correctly, one is not sure about these real recurrences.

Type IV A recurrence after Limberg surgery because of sinus pilonidalis
Type IV A recurrence after Limberg OP
New pits to Limberg Flap in the new centre line
New pits to Limberg Flap in the new centre line
Before: Here the flap plastic was correctly applied with a wide skin bridge in the midline
Schematic drawing Limberg OP after completion of the suture
After: completion of the operation, an acute angle of the incision in the midline could be avoided

Limberg OP - when do we use the method?

  • Never, because there are better alternatives in almost all situations

Pro

  • Even large defects can be closed

  • In principle possible at any localization

  • Good primary cure rates

Contra

  • Unfavourable cosmetic result with deformed body contour

  • Frequent recurrences (type IV a) when used in the midline

  • Often formation of numerous "pits" in the new midline with type II a recurrences. Therefore laser epilation is highly recommended if Limberg surgery has already been performed.

FAQ Pilonidal Sinus - OP

Good times - bad times: At Pilonidal Sinus , symptoms are often not present all the time. But - the fistula never heals by itself. Periods without symptoms do occur. If the fistula is only discovered by chance, without the patient having symptoms (bland form of progression), one can wait and see.

How long you are sick after surgery depends on 3 factors:

  • the size of the fistula
  • the type of surgery
  • the nature of the professional or sporting load

After abscess cleavage, the patient is often ready to return to work the following day, after pit picking and sinusectomy often after 1 - 2 weeks. Conventional radical surgery often results in downtime of several months.

Yes, with our pit picking technique, the fistula is surgically removed via the small openings. This "excision" of a Pilonidal Sinus belongs to the services of the statutory health insurance in Germany.