Intelligent OP techniques

Pit picking, sinusectomy, laser surgery (SiLaC)

New and yet proven: Methods that take the horror out of the Pilonidal Sinus surgery

Get rid of Pilonidal Sinus

while avoiding hospital, general anesthesia and long downtime.

A Pilonidal Sinus (sinus pilonidalis) is harmless. Many problems only arise due to too extensive an operation and neglect of the aftercare.

We are familiar with all common operations for the pilonidal sinus and can provide you with professional advice. Our preferred methods are based on the Bascom I (pit picking) and Bascom II (cleft lift) techniques. These gentle methods provide excellent functional and cosmetic treatment results.

Your advantages through this treatment concept are:

  • 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
  • Faster work and sport ability
  • Preservation of the normal body contour, more inconspicuous scars
Pit Picking Method Info Flyer
Download PDF free of charge now: Pilonidal Sinus OP - Everything you need to know about treatment with Dr. Hofer

Although a pilonidal sinus is usually not dangerous, the associated symptoms can limit life enormously. Large rotational lobe procedures are ... overkill for milder conditions and ... lead to a complex wound that usually makes the situation worse than the original disease.

Johnson, Eric K. "Expert Commentary on Pilonidal Disease: Management and Definitive Treatment." Diseases of the Colon & Rectum 61.7 (2018): 777-779. Cleveland Clinic, Cleveland, Ohio, U.S.A.

The "simple" method: Pit Picking - A Simple Treatment

Peter Lord M.D., England 1965

The English surgeon Peter Lord published a new treatment method in the British Journal of Surgery in 1965. This operation at Pilonidal Sinus , called pit picking, is so simple and effective that it is hard to believe.

He was the first to recognise the crucial importance of the ingrown hairs. With his technique of removing the affected hair roots, he developed an alternative to the usual radical surgery and thus founded a new era in the treatment of Pilonidal Sinus. He recommended a round brush for cleaning the fistula canal. 

In addition, Lord stressed the importance of hair removal for 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
First release of 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

Pit Picking = Follicle removal

John Bascom M.D., USA 1983

At first, the groundbreaking "Lord Millar Procedure" received surprisingly little attention. It was not until John Bascom (Oregon, U.S.A.) ensured the worldwide dissemination of the advanced technique, which he called "follicle removal". With great commitment, he supported surgeons worldwide in learning this technique.

With the experience of over 4500 operations, I have constantly developed the technique. Expertise and technological progress (magnifying glasses, 4MHz radiofrequency surgery, laser surgery and the best instruments from different specialities such as aesthetic surgery, ENT and maxillofacial surgery) make it possible to treat almost every Pilonidal Sinus in a minimally invasive way. The pit picking principle can also be applied to recurrence (relapse) after conventional surgery: Identification of the entry point, removal of the fistula via this already existing opening and prevention of the re-growth of hair by shaving and laser epilation.

Pit Picking "Classic": LORD - BASCOM - OP

Our evaluation:
3.5/5

According to the description by Lord and Bascom, this procedure involves cutting out the pits as skin cylinders the size of a grain of rice. We use dermatological biopsy punches of 2 - 4 mm for this. The trapped hairs are pulled out with a fine clamp and the fistula tract is cleaned out, leaving the fistula capsule intact. Some surgeons also make a longitudinal incision 1 - 2 cm long at the side to allow secretions to drain out, the relief incision. Removal of the foreign body eliminates the cause of the chronic inflammation and the fistula can heal. Skin sutures are not necessary and might even interfere with healing.

Conclusion Pit Picking "classic"

You can't go wrong with this. Gentle and effective method.
  • with little scarring of the Pilonidal Sinus
  • for not pre-operated coccygeal fistulas
  • gute Alternative bei jungen Patienten < 14 Jahre

Pro

  • smallest possible intervention
  • ambulatory
  • short treatment duration 10 - 30 min
  • short healing time 2 - 3 weeks
  • Healing rate up to 70% 
  • Repeatable, alternatives remain possible

Contra

  • Less promising with heavily scarred fistulas
  • Cleaning of the fistula tract sometimes incomplete
  • Recurrence rate up to 30
  • Hardened fistula tract often noticeable despite healing of the openings
Scientific research on pit picking

FAQ Pit Picking and Variations

By definition, the pit-picking operation can only be performed if "pits", also called primary fistula or porus, are found, i.e. primarily in the case of a pilonidal fistula that has not yet been operated on. However, such a "pit" can also have been overlooked during the initial operation or have newly developed and thus cause a relapse (recurrence). And finally, the basic idea of pit-picking, the healing of the fistula by eliminating a port of entry, can also be implemented in the frequent type IV pilonidal fistulas.

This procedure is currently offered exclusively by specialised specialists, predominantly from the field of general and visceral surgery, but also dermatology. When choosing a doctor, the question should also be allowed as to how often the colleague performs such minimally invasive procedures.

The classic pit picking operation can always be performed under local anaesthesia. General anaesthesia would only be preferred in exceptional cases with very young or particularly anxious patients.

Yes, you do not need to stay in hospital for this operation.

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.

Yes, if the surgeon has experience with local anaesthesia and takes some time, there is no pain during the operation. We use the so-called tumescent anaesthesia, which can also be used to reliably anaesthetise large surgical areas.

The "picking of the pits" (sparingly cutting out the enlarged hair roots) and cleaning of the fistula tract sometimes takes only 10-15 minutes. If the fistula tract is also to be treated with laser (SiLaC) or removed (sinusectomy), surgery times of between 30 and 60 minutes can be expected.

 Yes, you may assume any position that is comfortable for you. Especially directly after the operation, this is even helpful, as gentle compression has a preventive effect against post-operative bleeding.

Serious complications are not to be expected. Postoperative bleeding is possible on the day of surgery, but very rarely requires medical hemostasis. Wound healing disorders, wound infections and the recurrence of a fistula after healing (recurrence) affect about 10 % of patients (with pit picking and sinusectomy) to 30 % (with pit picking alone).

After pit picking and sinusectomy, all activities are generally permitted from the day following the operation. Healing 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.

Yes, physical activity has no negative influence on wound healing.

There are many opinions on the subject of bathing and showering. The official guidelines of the Robert Koch Institute would advise against it and recommend the use of a bacteria filter (e.g. Germlyser® D) when showering. However, we have never seen any negative consequences when our patients shower with water of drinking quality or go swimming in the sea, lake or swimming pool (Europe).

The most common problem after all operations at Pilonidal Sinus is the penetration of hair into the wound. Care should therefore be taken to shave the area around the wound. Loose, broken hairs from the head should also always be removed immediately. For long-term prognosis, laser epilation offers advantages. 

It has proved useful to place a dressing of folded or rolled 10 x 10 ES compresses in the fold of the buttocks and to fix it with a tape strip, for example Fixomull®. For smaller wounds, a ready-made plaster or a commercially available panty liner that absorbs the wound secretion is sometimes sufficient. Elaborate dressing material (silver, alginate, hydrocolloid) is only occasionally useful if there are problems during the healing process.

If the course is normal, this is not absolutely necessary. You can find an overview of ointments and antiseptics on our page on conservative treatment.

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

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" peeling 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
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.