Pit picking / sinusectomy: treatment procedure for outpatient surgery
Your comprehensive guide
There are two strategies for treating the pilonidal sinus, each of which has advantages and disadvantages and differs in the procedure.
- Minimally invasive treatment (pit picking/sinusectomy) is a minor surgical procedure that can be performed on an outpatient basis in the practice under local anaesthetic. We offer the "all-in-one" appointment for this, where the operation can take place directly after the examination and consultation. This method is suitable for patients with coccyx fistulas that have not been previously operated on as well as for recurrences, provided there are no major midline defects. A further advantage of minimally invasive surgery is that all conceivable options are kept open in the rare event of a recurrence.
- The lateral displacement of the scar (Karydakis operation) makes hair removal by shaving or laser less important. A separate appointment in an outpatient surgery center under general anesthesia is required for this procedure. This method is too complex for most fistulas that have not been previously operated on. This method is also chosen if a previous surgical procedure has led to a lengthy and frustrating healing process and the patient wants treatment with a quick conclusion. All information on this can be found on our Karydakis surgery page.
Step 1: Diagnosis pilonidal sinus
Step 2: Find appointment
The easiest way to do this is to book an appointment directly here in our online calendar:
- The diagnosis is clear and you want pit picking surgery immediately after the examination and consultation? Then the appointment category "Examination/treatment Pilonidal Sinus All-in-one" is made for you. You book a 2-hour appointment with treatment option - a great relief for all those who want to avoid a second journey and have already seen a specialist.
- If you are not yet sure or would like to consider the decision at your leisure, we recommend that you choose "Special consultation Pilonidal Sinus/Sinus pilonidalis". This will give you a 20-minute appointment for an examination and consultation. We will then arrange an appointment for the operation according to your wishes. Such a consultation appointment is also essential if an operation under general anesthesia is to be planned, either at your request or if medically necessary.
We offer these appointments daily from Monday to Friday. It is almost always possible to find an appointment within 2 weeks. Pre-treatment is usually necessary for acute pain. You can find all the information you need on the Pilonidal abscess page.
When booking an all-in-one appointment, please send us photo documentation of the affected area in accordance with these instructions:
Photo documentation
Overview image
Photo documentation
Detail image
Please note that an examination or treatment for other diagnoses (hemorrhoids, anal fistulas, etc.) is not possible on these dates, as the space and/or personnel conditions are not available.
An appointment requested via our booking system will only be confirmed by the doctor if either the patient has already been examined in our practice or image documentation has been sent in advance.
Step 3: Preparing for the pit picking surgery
Pre-existing conditions: Please let us know if
- significant diseases (heart, lungs, blood coagulation) are known
- Intolerances and allergies to be considered (especially local anesthetics or antibiotics)
- you need to take "blood thinning" medication
- or you require pretreatment (e.g., antibiotics for heart valve disease or Minirin for congenital bleeding tendencies).
Organize a driver/accompanying person: We do not recommend getting behind the wheel yourself for the journey home. Circulatory reactions can never be completely ruled out. Immediately after treatment, you may not be a concentrated participant in road traffic. It is therefore best to organize a driver or a journey by public transport without having to change too often.
Step 4: On the day of surgery
You will find Dr. Hofer / Liebl's practice at Brienner Straße 13 on the 4th floor above Café Luitpold in the center of Munich. The entrance is between the café and the flower store Flor&Decor.
The subway stops directly in front of the building(Odeonsplatz stop), and a parking garage is located behind the Luitpoldblock.
Please note that during rush hour you can expect heavy city traffic and unexpected detours due to numerous roadworks. You should therefore allow sufficient time to avoid stress.
Unlike surgery under general anesthesia, you do not need to be fasting for the sinusectomy. Eat and drink enough. This will prevent circulatory problems, especially on hot summer days.
Diabetics eat their meals and medication as usual.
If possible, we ask to shave the buttocks generously. This facilitates our work and you the dressing changes, if the plaster does not stick in the hair.
You will lie on an extra thick gel mattress with an adjustable head section and adjustable supports for the arms. Before the start of surgery, it is recommended to visit the toilet once again so that it does not "squeeze" afterwards.
This is followed by shaving and local anesthesia. If possible, you can do the shaving already at home, it will save some time.
Typically, the procedure takes between 30 and 60 minutes.
Local anesthetics have been used in medicine since 1884 and block the conduction of excitation in the nerves. As a result, they enable pain-free surgery with normal consciousness. Many patients fear that local anesthetics (local anesthesia) are not sufficiently effective. It is therefore important to emphasize that the effectiveness and safety of tumescent anesthesia have been proven by numerous studies, including one by Prof. Bussen at the University of Würzburg.
We can take this fear away from you. Tumescent anesthesia (tumescence lat. = swelling), developed in 1985 by plastic surgeon Dr. Jeffrey A. Klein in the USA and since then successfully used in various medical specialties, offers many advantages.
- even large areas can be reliably anesthetized
- the tendency to bleeding and bruising is reduced
- the anesthetic has an antibacterial effect and prevents infections
- the long duration of action ensures freedom from pain even after surgery
- it is a safe procedure, which stresses the organism less than general anesthesia
What types of procedures can be responsibly performed in this outpatient setting?
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Product presentation Dermabond®, manufacturer video from Ethicon
Open wound treatment
We usually leave small wounds up to 1 cm open. Conventional suturing is often ineffective in the midline, as shear forces, bacteria and hair regrowth impair healing. Under optimal conditions, however, it is possible to deviate from this principle, with a success rate of around 80 % under the following conditions:
- Good fabric consistency
- Exclusion of an abscess
- Laser epilation before the procedure to reduce hair growth as much as possible in the first two weeks after the procedure
Will the wound be sutured or glued?
Two different techniques are used:
- Wound bonding: The edges of the wound are brought together with a type of "super glue" and sealed together.
- Eversion suture: Eversion suture is a suture technique that provides a larger contact area and better blood flow, and therefore stability, than a standard suture. It also directs the direction of hair growth away from the wound.
Bandage and tamponade
We place a special fleece called a hemostyptic in the wound cavity. This fleece provides additional protection against secondary bleeding, promotes wound healing and dissolves completely as the wound progresses. These materials contain collagen or gelatine of animal origin. If you have any concerns - for example due to a vegan lifestyle - please let us know.
For the outer area we use a thick absorbent dressing. Initially, wounds can often secrete larger amounts of fluid, and the dressing thus prevents stains on clothing.
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- After the surgery is complete and the dressing is applied, slowly stand up from the treatment table to stabilize your circulation.
- We will offer you a bottle of water, a pastry and a pain pill while you recover in the waiting area.
- After a final dressing check and circulation check, you can leave the practice.
- If you need a certificate regarding inability to work or for school, please inform us.
Step 6: On the way home
After the procedure, the local anesthetic usually continues to work for several hours. You can and may therefore assume a normal sitting position in a car or train without pain. A slight pressure on the wound is even desired and reduces the already low risk of post-operative bleeding.
We do not recommend getting behind the wheel of a motor vehicle yourself, as you may still be thinking about the procedure and even mild circulatory reactions can limit your full ability to drive.
You may exercise normally, but on the day of surgery itself, we would advise against long walks and exercise.
If it bleeds once: Pack several compresses or cellulose material on the wound and apply constant pressure for 15 minutes. It can also be helpful to sit on the wound and wait a while. Post-bleeding is not dangerous, in case of doubt contact the practice or the emergency number below.
Step 7: Aftercare
You can remove the large bandage applied after the operation yourself. Afterwards, showering with normal tap water at a pleasant temperature is possible and useful. We have never seen any negative consequences in the past. According to the hygiene guidelines of the Robert Koch Institute (RKI), a terminal bacteria filter ("Legionella filter", e.g. Germlyser D®) would be required, as only sterile fluids are allowed to reach the wound. However, the gluteal fold area is never sterile and washing has been shown to reduce the bacterial count(Federal Center for Health Education).
Everyday activities are allowed as far as possible. Extreme spreading of the buttocks to inspect the wound should be avoided for the first 2 days. Sports are allowed as soon as the wound pain permits.
We recommend wearing tight-fitting underpants with a commercial panty liner. This type of wound care is more comfortable than a glued-on dressing. The wound secretes bloody secretion. The wound pain is more severe on the second day than on the first and subsides over the course of the week. Treatment with ibuprofen as needed is practically always sufficient.
Step 8: Treatment completion and recurrence prophylaxis
The hemostyptic or the tamponade dissolves. Depending on the material used, this looks brownish-pulpy with Tabotamp® and like white foam with Lyostypt®. Slight irritation and swelling are normal in this phase.
Fibrin, a natural "wound adhesive" made from blood components, forms a yellowish coating reminiscent of pus, but this need not worry you.
Ointments or powders are usually not necessary. If wound healing is delayed, we prescribe ointments with metronidazole, mupirocin or iodine (Betaisodona®), which you apply to the wound twice a day.
Once a week, it is essential to shave the edges of the wound with a disposable razor and check the wound for hair that has penetrated. This can be done by us, relatives or the family doctor. In good light and with good vision (possibly a magnifying glass or reading glasses), the wound is examined and hair is removed with tweezers. After the wound has been closed, shaving should be continued for another 2 months.
To promote wound healing, we have several options:
- A low-energy laser treatment ("LLLT, Softlaser") once or twice a week stimulates the self-healing powers via cellular activation.
- Cold plasma (CAP) treatment provides highly effective disinfection while improving microcirculation.
- Laser hair removal treatment is performed every 4-6 weeks and is a preventive measure against relapses (recurrences). The treatment can be performed painlessly under local anesthesia.
DR. BERNHARD HOFER & FLORIAN LIEBL
Specialists in Visceral Surgery and Proctology - PartG mbB
Brienner Str. 13, D-80333 Munich
- info@darmsprechstunde.de
- Monday - Friday: 08.00 - 13.00 and 14.00 - 18.00
- and by arrangement
- Saturday, Sunday, Holiday : closed
- Please also note our instructions in the title of this website and on our telephone announcement.
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