Treatment procedure at the PILONIDAL SINUS CENTER Munich

Sinus Pilonidalis Surgery Part 1

Pit picking under local anesthesia

Surgery of the Pilonidal Sinus (sinus pilonidalis): treatment procedure

A comprehensive overview from registration to post-surgery care

There are basically two strategies available for the treatment of the pilonidal sinus, each of which has its specific advantages and disadvantages and differs in the course of treatment.

  • Minimally invasive treatment , as the name suggests, is a minor surgical procedure that can be performed on an outpatient basis in our office under local anesthesia. For this we offer our " all-in-one" appointment, where the surgery can be performed directly after the examination and consultation. This method is suitable for patients with non-pre-operated coccygeal fistulas as well as for recurrences, provided there are no major midline defects. Another advantage of minimally invasive surgery is that in the rare case of recurrence, both a repeat minimally invasive treatment and other techniques remain possible.
  • Removal of the fistula with primary wound closure requires more surgical effort, but offers the patient the advantage of a closed wound with usually less need for care. The lateral displacement of the scar also makes hair removal by shaving or laser less important. However, this procedure often requires a separate appointment at an outpatient surgery center under general anesthesia to provide optimal conditions. This method is too costly for most fistulas that have not been preoperated on, but is often a very good and effective long-term option for recurrences. It is also chosen when a previous surgical procedure has resulted in a protracted and frustrating healing process and the patient desires treatment with rapid completion.

Step 1: Diagnosis pilonidal sinus

Is it a Pilonidal Sinus at all ?

You have already been to the doctor and the diagnosis of Pilonidal Sinus is confirmed? Then you can skip this step.

Otherwise, see our Symptoms page for what the typical symptoms are, and our Pictures page for what a Pilonidal Sinus looks like. 

markus winkler afW1hht0NSs unsplash
Look closely and find pits (© Markus Winkler Unsplash)

Step 2: Find appointment

The fast way to consultation and treatment with a specialist

The easiest way to do this is to book an appointment directly in our online calendar:

  • The diagnosis is clear and you want surgical treatment directly following 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 trip and have already presented to a specialist.
  • If you are still unsure or want to take your time to consider the decision, we recommend that you select "Special consultation Pilonidal Sinus /Sinus pilonidalis". This will give you a 20-minute appointment for examination and consultation. We will then make an appointment for the operation according to your wishes. Such a consultation appointment is also essential if surgery under general anesthesia is to be scheduled, either at your request or if medically necessary.

We need this information from you (for all-in-one):

Please note that examination or treatment for other diagnoses (hemorrhoids, anal fistulas, etc.) is not possible on these dates due to lack of space and/or personnel.

An appointment requested via our booking system will only be confirmed by the physician if either the patient has already been examined in our practice or image documentation has been submitted in advance and the online questionnaire ("Access to Ondasys") has been completed.

Pit picking surgery outpatient practice Liebl Hofer Munich
Info flyer for outpatient pit picking / sinusectomy surgery

Step 3: Preparation for the appointment

Here is what you should do before the appointment

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 driver / escort: We do not recommend getting behind the wheel yourself for the ride home. Circulatory reactions can never be completely ruled out. Immediately after treatment, you may also not be a focused participant in road traffic. It is therefore best to organize a driver or travel by public transport without changing trains too often.

Step 4: On the day of surgery

This is important for a perfect treatment process
Directions to the proctology practice

You will find us at Brienner Straße 13 on the 4th floor above Café Luitpold, the entrance is between the café and the Flor&Decor flower store.

The subway stops directly in front of the building(Odeonsplatz stop), and a parking garage is located behind the Luitpoldblock.

Please expect intense city traffic especially during rush hour and unexpected routing due to numerous construction sites. Therefore, plan enough time, this will help avoid stress.

You do not need to be fasting for surgery under local anesthesia:

You do not need to be fasting for the procedure, unlike surgery under general anesthesia. Eat and drink enough. This will help 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.

48101 pinotrend hydraulic 01 f54004 lime f90000 silver gray.jpg

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.

Infusion pump for gentle local anesthesia (local anesthesia)
Tumescent pump for gentle local anesthesia (local anesthesia)

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

You will find specialist literature on local anesthesia at the bottom of the page.

Laser for outpatient sinus pilonidalis surgery under local anesthesia
The DIOS blue laser - gentle and effective

What types of procedures can be responsibly performed in this outpatient setting?

Product presentation Dermabond®, manufacturer video from Ethicon

Bulging suture technique to prevent the suture from reopening after Pilonidal Sinus surgery.
Evert "mattress seam" on the model
Avoid secondary bleeding - hemostyptics
Various hemostyptics
Open wound treatment

We usually leave small wounds up to 1 cm open. A conventional wound suture often does not work in the midline, as shear forces, bacteria and regrowing hairs impair healing. Under optimal conditions, this principle can be deviated from with a success rate of approx. 80% under the following conditions:

  • Good fabric consistency
  • Exclusion of an abscess
  • Laser epilation before the procedure to best reduce hair growth in the first 2 weeks after the procedure.
Wound closure

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 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 gelatin of animal origin. If you have any concerns - for example, due to a strict vegan lifestyle - please advise us accordingly.

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.

210709 LSimon 132
  • 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

How to get home safely and comfortably

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

Sinus pilonidal surgery shorten healing time
First day after surgery a sinus pilonidalis - what to consider
The first week after surgery

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

How to ensure the success of treatment
Eighth day after surgery a sinus pilonidalis - what to consider

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 glue" made from blood components, forms yellowish coatings reminiscent of pus, but 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 absolutely necessary to shave the wound edges with a disposable razor and to check the wound for penetrated hairs. This can be done by us, relatives or the family doctor. In good light and good visibility (possibly magnifying glass, reading glasses) the wound is examined, hairs are removed with tweezers. After closing the wound, 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.

Literature on local anesthesia

Boeni, R. (2020). A Combined Prilocaine-Lidocaine Tumescent Solution Has Lower Clinical Side Effects Compared With Lidocaine Only. American Journal of Cosmetic Surgery, 37(3), 114-117.

Bussen, D., Sailer, M., Fuchs, K., & Thiede, A. (2003). Tumescent local anesthesia in proctologic surgery. Der Chirurg, 74(9), 839-843.

Goyal, N. (2021). Tumescent anaesthesia for liposuction surgery-A review. Dermatological Reviews, 2(4), 180-187.

Holt, N. (2017). Tumescent anaesthesia: its applications and well tolerated use in the out-of-operating room setting. Current Opinion in Anesthesiology, 30(4), 518-524.

Piskin, T. (2009). Tumescent Local Anesthesia for Excision and Flap Procedures in Treatment of Pilonidal Disease. Diseases of the Colon & Rectum, 52(10), 1780-1783.

Klein, J. (1987). The tumescent technique for liposuction surgery. The American Journal of Cosmetic Surgery, 4(4), 263-267.

Klein, J., & Langman, L. (2017). Prevention of Surgical Site Infections and Biofilms: Pharmacokinetics of Subcutaneous Cefazolin and Metronidazole in a Tumescent Lidocaine Solution. Plastic and Reconstructive Surgery Global Open, 5(5).

Lindenblatt, N., Belusa, L., Tiefenbach, B., Schareck, W., & Olbrisch, R. (2004). Prilocaine Plasma Levels and Methemoglobinemia in Patients Undergoing Tumescent Liposuction Involving Less Than 2,000 ml. Aesthetic Plastic Surgery, 28(6), 435-440.

Mantripragada, K., Yerke Hansen, P., Vazquez, O., Pires, G., & Becker, H. (2023). Pain Reduction Using Ropivacaine in Tumescent Solution following Lipoaspiration. Plastic & Reconstructive Surgery Global Open, 11(1),

Schöpf, E., et al. (2001) Tumescent local anesthesia: a new local anesthetic procedure. Dtsch Arztebl 2001; 98(9): A-545 / B-459 / C-434.