Intelligent OP techniques

Pit picking, sinusectomy, laser surgery (SiLaC)

My proven methods to take the horror out of Pilonidal Sinus surgery

How to get rid of your Pilonidal Sinus

while avoiding hospital, general anesthesia and long downtime.

The Pilonidal Sinus is a harmless disease. Many problems only arise due to overly extensive operations and neglect of the aftercare. We know all the current surgical techniques and can advise you comprehensively about the advantages and disadvantages.

On this page you will learn everything about our preferred techniques based on Bascom I (pit picking) and Bascom II (cleft lift) surgery. These methods have become our standard because they combine low invasiveness with excellent long-term results and can also be performed on an outpatient basis.

New and simple: Pit Picking - A Simple Treatment

Peter Lord, England 1965

Why does this chapter begin with a publication by the surgeon Peter Lord 1965 in the British Journal of Surgery on a new, "simple treatment" for Pilonidal Sinus?

He founded a new era of Pilonidal Sinus surgery because he was the first to recognize the importance of the Pits and the deposition of hair in the fistula tract.

He called the cutting out of the pits "pit picking" and recommended a round brush for cleaning the fistula canal. 

In addition, Lord stressed the importance of hair removal in the aftercare. He recommended electro-epilation or shaving, lasers for hair removal did not exist at that time.

Excerpt from the original publication of Pit Picking by Peter Lord
Original publication of the Pit Picking by Peter Lord
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

Dr. John Bascom, USA 1983

Initially, this "Lord-Millar-Procedure" received little attention. Only John Bascom (Oregon, U.S.A.) ensured the worldwide dissemination of this advanced technique, which he called "follicle removal". With great commitment he supported surgeons worldwide in learning this technique.

I have been successfully using the pit picking technique since 2004. With the experience of over 4400 operations, I have continuously improved the technique. Expertise and technological progress (magnifying glasses, 4MHz radio frequency surgery, laser surgery and fine instruments from plastic surgery, ENT and maxillofacial surgery) allow today to treat almost every Pilonidal Sinus minimally invasive. You will also benefit from this therapy principle in the case of recurrence, if a relapse has occurred 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:
3.5/5

According to the original description by Lord and Bascom, the pits are cut out as skin cylinders the size of a grain of rice during this procedure. We use biopsy punches of 2 - 4 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 1 - 2 cm long at the side to allow secretions to drain out, the relief incision. The removal of the foreign body eliminates the inflammatory irritation and the fistula can heal. Wounds and fistula tract close without suture through scar tissue.

Conclusion Pit Picking "classic"

Gentle and effective method
  • for little scarred and not pre-operated coccygeal fistulas
  • especially in adolescents < 14 years

Pro

  • smallest possible intervention
  • ambulatory
  • short treatment duration 10 - 30 min
  • short healing time 2 - 3 weeks
  • Healing rate up to 70% 
  • replayable
  • all other techniques remain possible

Contra

  • not practicable for severely scarred fistulas
  • Cleaning hair sometimes incomplete
  • hardened fistula strand may remain
  • 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 the surgical technique in 2004 following John Bascom's instructions for simple coccygeal 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, as were many other surgeons, that major surgery was inevitable for recurrence after pit picking. My recommendation for recurrence was cleft lift surgery.

Many patients wanted to know whether one could not make another attempt with Pit Picking. It turned out that a renewed pit picking is indeed successful in many cases. Since then, new developments in medical technology have enabled the Bascom method to be constantly refined.

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

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

Our evaluation:
3.5/5
FiLaC SiLaC for coccygeal fistula Schematic drawing

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.

Conclusion FiLaC / SiLaC

FiLaC offers advantages with
  • 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" excision of the fistula tract

Our evaluation:
5/5
Sinusectomy Minimal tubular fistulectomy scaled 1
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.

Pit Segment
Sinusectomy is the method of choice for most non-preoperated coccygeal fistulas and also many recurrent fistulas.

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

FAQ Pit Picking and Variations

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 discovered only by chance, without the patient having symptoms (bland course form), one can wait. Pit picking as the smallest possible intervention is also justified in the bland form. 

After pit picking and sinusectomy, you may basically do everything you feel able to do from the day after the operation. The healing process is not affected by stress. 

Mild to moderate pain while sitting in the office or car can justify an inability to work, rarely longer than 2 weeks.

After Pit Picking, you may immediately resume sitting and sleeping on your back. Wound pain is to be expected in decreasing intensity for 2 - 3 weeks.

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.

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

Our recommendation traffic light

Green = recommended
Yellow = suitable under certain circumstances
Red = not recommended or not available

In no case should the following presentation serve as a guide for an uncritical self-treatment. To the best of our knowledge, the recommendations are based on our own experience and selected publications. They do not represent a systematic analysis of available studies. In any case, consult a specialist experienced in wound treatment before use.