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A Pilonidal Sinus (sinus pilonidalis) in itself is basically harmless. However, many problems can result from too extensive surgery and neglect of the follow-up treatment. We want to avoid this at all costs.
You are in good hands with us, because we are familiar with all common surgical techniques for sinus pilonidalis and are ready to assist you with professional advice. Our minimally invasive method is based on the Lord -Bascom I (pit picking) technique. Since 2004, we have continuously developed these gentle procedures and can now achieve excellent functional and aesthetic results.
The advantages of our treatment concept are:
On this page we explain the variants of pit picking surgery from the pathophysiological and surgical point of view. On the page about the treatment procedure in our practice you will learn about the practical aspects.
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.
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.
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.
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.
Pro
Contra
Laser surgery (SiLaC - Sinus Laser Ablation of the Cyst)
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.
Pro
Contra
Author | Year | Quantity | % Follow up | Years Follow up | % Recurrence | % Complication |
|---|---|---|---|---|---|---|
Dessily | 219 | 200 | 77,5 | 10,44 | 14,9 | 15,0 |
"Pit Picking 2.0" Minimally invasive "tubular" excision of the fistula tract
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.
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.
Pro
Contra
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
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.
You would like to get more detailed information about how a treatment with us could proceed? We have answered frequent questions right here in the FAQ and our chat can often help as well (click on the icon with the two speech bubbles on the bottom right!).
Otherwise, we have built a new page that describes the entire treatment process in detail.
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.
In classic pit-picking as described by Lord and Bascom, the fistula tube is not removed, but only cleaned of the trapped hairs. By removing this inflammatory stimulus, the tissue may normalise to a certain extent in the course of the procedure, but the hardening does not usually disappear completely. This is another reason why we combine pit-picking with sinusectomy, i.e. peeling out the fistula tract under the skin.
In principle, this risk can indeed not be completely ruled out if no histological examination can be carried out. Malignant coccygeal fistulas are fortunately extremely rare and usually conspicuous by other findings.
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.
Private patients and self-payers should expect to pay between 700 and 1200 € for outpatient treatment under local anesthesia. The costs depend on the complexity of the fistula and the time required. For an overview of reimbursement, please see our Treatment Costs page.
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 impaired by sport or occupation.
Mild to moderate pain while sitting in the office or car can justify an inability to work, rarely longer than 2 weeks.
The time it takes for all wounds to heal naturally depends very much on the initial findings. On average, you should expect 6 weeks. If the wounds have not healed after 8 weeks, a check-up with us is recommended.
Externally, all wounds should be closed, and the color of the scars should no longer be purple but skin-colored to white. Slight hardening in the former course of the fistula is normal, more severe swelling is suspicious of a problem. Significant pain should no longer be present. The best assessment allows an ultrasound examination.
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.
Specialists in Visceral Surgery and Proctology - PartG mbB
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