Sinus pilonidal surgery: Our surgical methods

Treatment procedure at the Pilonidal Sinus Center Munich

Pilonidal sinus Operation

Everything you need to know about your treatment with us

This page is under construction and should soon make it easier for you to see the surgical techniques we use.

sinus pilonidalis operation

How to get rid of your Pilonidal Sinus

From the decision to have an intervention to the end of the healing period

The basic concept of our treatment is an individual approach that fits the patient's findings and requirements. Nevertheless, in the many years that we have now been focusing on Pilonidal Sinus , some helpful standards have emerged. In the following, we would like to explain when which operation offers the greatest chances of recovery and how the course of treatment can be expected for the individual variants of sinus pilonidalis surgery.

Step 1: Diagnosis pilonidal sinus

Our specialists take care of you personally

You have already been to the doctor and the diagnosis is certain? 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.

Symptoms

Clinical pictures

Step 2: Request appointment

You do not need a referral

The easiest way is to fill in our Contact form form and use the option to upload pictures. A specialist will check the information and create a treatment plan. You will receive three mails (check your SPAM folder if necessary!)

a general info mail: This is basically adapted to your situation and contains helpful documents on the treatment process in the attachment.
a link to an online questionnaire (see picture, Ondasys portal)
a proposed appointment, if you have not yet requested an online appointment.
You have acute pain? Then sometimes you don't have much time and the abscess must be relieved first. If you inquire by mail, write an appropriate keyword (e.g., "emergency," "pain") in the subject line so that your inquiry stands out among the numerous perhaps less urgent concerns.

You have already decided to have the operation with us? Then you can also make an appointment directly. Our online calendar offers a choice:

Examination / treatment Pilonidal Sinus "All-in-one": With this you book an appointment of 2 hours. If desired, the operation under local anesthesia can take place directly at this appointment. This option is particularly suitable for patients who want to avoid a second further journey and had already presented to the specialist at home.
Special consultation Pilonidal Sinus / Sinus pilonidalis: This is a 20-minute appointment for examination and consultation. This can be followed by an appointment for surgery. This category of appointments is intended for patients for whom the diagnosis is uncertain, who still need time to think about it, or for whom surgery under general anesthesia is necessary or desired.

Contact

Photo

Please note that examination or treatment for other proctology diagnoses 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.

Step 3: Before the appointment

Preparation for the day of surgery

Pre-existing conditions: Please inform us of any significant medical conditions (heart, lung, blood clotting), intolerances and allergies, especially if you are taking "blood thinning" medications, have a known intolerance to local anesthetics or other medications, or require pretreatment (e.g., antibiotics for heart valve disease or Minirin for congenital bleeding tendencies).
Plan enough time for the journey. You will find us at Brienner Straße 13 on the 4th floor above Café Luitpold. The subway stops directly in front of the building, a parking garage is located behind the Luitpoldblock. Please expect intense city traffic.
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

You do not need to be fasting for the procedure, eat and drink enough.
After examination and ultrasound, the doctor explains the treatment plan.
If the appointment is scheduled accordingly, the treatment can follow directly. In this case, you explicitly waive your right to a reflection period and second opinion.
The procedure is performed in the prone position and takes between 20 and 90 minutes. Visit the toilet again before the start of the operation.
This is followed by shaving and local anesthesia. If possible, you can do the shaving already at home, it will save some time.
Injection of the physiologically buffered drug causes only slight discomfort. After 10 min, the area is completely anesthetized. We also test this again before starting the treatment. Local anesthesia does not affect alertness, muscle strength or bowel function.
The next step is the optional laser treatment. The "pits" are inactivated and the hair density in the critical region is reduced.
Then the actual procedure takes place.
After completion of the operation and dressing, slowly stand up from the treatment couch so that the circulation remains stable.
You will receive a bottle of water, a pastry and a pain pill and recover in the waiting room.
After a dressing check and circulation check, you can leave the practice.
If you need a certificate regarding disability or for school, please let us know.

Do not be afraid of pain!

Tumescent anesthesia

This local anesthetic works reliably

Local anesthetics have been used in medicine since 1884 and switch off excitation conduction in nerves by blocking sodium channels. In this way, they enable painless surgery without influencing consciousness. Many patients come in with concerns that local anesthesia (local anesthetic) may not be effective enough. Those who have had bad experiences in the past, for example when an abscess was split, no longer have confidence.

We can take away this fear. As with all medical procedures, local anesthesia must be performed correctly. We rely on the so-called tumescent anesthesia. In this procedure, a large volume of diluted local anesthetic is injected into the subcutaneous tissue through an extremely thin cannula using a special dosing pump. The subcutaneous tissue absorbs the solution like a sponge. This is where the term tumescence (lat. = swelling) comes from. Due to the dilution and the admixture of bicarbonate, the drug works better and the application is more pleasant than anesthesia with a conventional syringe. The admixture of vasoconstrictor drugs enables a bleeding-free operation with an optimal overview. If necessary, antibiotics can also be added, achieving higher effective concentrations at the desired site.

The method was developed by the American plastic surgeon Dr. Jeffrey A. Klein in 1985. Subsequently, other specialties also discovered this elegant technique for themselves. Operations for varicose veins, for example, are now very often performed with tumescent anesthesia. At the University of Würzburg, a large study by Prof. Dr. Bussen showed that the method can also be used very well for many other proctological operations. Numerous studies prove the effectiveness and safety of this procedure.

Advantages of tumescent anesthesia

Even large areas can be reliably anesthetized
the tendency to bleeding and bruising is reduced
the anesthetic has an antibacterial effect and thus prevents infections
the long duration of action ensures freedom from pain even after surgery
safe procedure, which stresses the organism less than a general 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.

With small fistula and favourable localisation

Simple sinusectomy

Often the wound can be closed by suturing

We want to avoid the large wounds as in the "butcher's method". The actual fistula rarely has a diameter greater than 1 cm. This "tube", which is surrounded by the fistula capsule, can be removed sparingly but completely by dissecting exactly along the border of the fistula capsule. The surgical optics with focused light source and the 4 MHz radio frequency technique help us to do this.

Closure of the wound by suturing or gluing is possible with good prospects of success (approx. 80% remain closed and free of infection) if

there was no acute infection (for this reason, in the case of an abscess, we would always first relieve the infection and then remove the fistula only after healing)
the tissue defect could be kept small
the wound is not too far in the depth of the fold of the buttocks near the anus
ideally, laser epilation has taken place to prevent hair from growing into the wound.

We use two different techniques for this:

Wound bonding with Dermabond ®: The wound edges are brought together and coated with the "super glue", a varnish-like film is formed, which closes the wound and protects it from external influences. From the stability, this method is sufficient for everyday activity, sports should be refrained from for 2 weeks, and also not necessarily to fall into an armchair with a swing.
Suture in "inverting mattresssuture technique": In this suture technique, the suture is made in such a way that the wound edges lie against each other like two lips. This bead does not look nice at first, but it has 3 decisive advantages over a standard suture: the larger contact area with better mechanical stability, better blood circulation and a redirection of the disturbing hair growth away from the wound.

Product presentation Dermabond®, manufacturer video from Ethicon

And what if the wound opens up again?

Then the wound will be treated openly. As always, the most important measure is then the weekly shave, which we are happy to perform in our wound consultation if necessary.

The standard for most fistulas

Pit picking and sinusectomy

Avoid large wound in the midline

pit picking

The vast majority of fistulas that have not been preoperated on are between 3 and 10 cm long and 0.5 cm to 1.5 cm in diameter. Especially in the middle and lower third of the gluteal fissure, it is crucial to keep the wounds as small as possible in the midline. Our concept for this is to "pick" the "pits" with biopsy punches. Such a punch removes a circular piece of skin around the entry port of the fistula of a precisely defined diameter of 2 to 4 mm.

Laser vaporization

In the case of a large number of closely spaced "pits", removal with the punch as described would result in a larger wound overall. In these cases, the "pits" can be "vaporized" with the laser, which only removes a diameter of about 1 mm.

Microdissection

Another alternative is the excision of a narrow skin spindle of 1 mm width with the radiofrequency microdissection needle. These wounds can also be sutured or glued as described above.