Experience with wound healing from 7137 operations on pilonidal sinus

Wound healing after coccyx fistula surgery

(Status: 05.06.2024)

This page is currently being fundamentally revised. You will soon be able to find comprehensive information about your situation here and actively contribute to optimizing your healing time. We apologize for the current restrictions.

Avoid mistakes: The wound will not heal without perfect surgery

Optimal wound healing starts with choosing the right surgical method and an experienced surgeon . The more that is removed during the operation, the greater the challenge for your body to heal - a process that should not be underestimated.

Many patients initially try surgery at their nearest hospital, thinking they will only go to a specialist if they have a problem. This approach can lead to an unexpectedly long recovery time and time off school, work and sport. Our advanced therapies are designed to avoid such problems. Find out about other patients' experiences and reviews before making your decision. A long journey to a specialized facility usually pays off.

Already had surgery? Your checklist for follow-up treatment

Have you had an operation on Pilonidal Sinus and are unsure how to deal with the wound properly? It is understandable that you are confused by the numerous opinions from doctors, friends and on the internet. Our wound healing checklist summarizes what is really important. The success or failure of an operation at Pilonidal Sinus is decided in the first 4 - 6 weeks after the procedure.

Stocktaking: Was the operation performed suitable to heal the fistula?

Was your treatment aimed at removing an Pilonidal Sinus or was an abscess simply split? Even if you feel symptom-free at the moment, a second procedure is usually necessary. Without this procedure, the risk of abscess recurrence remains high.

This was only the first of two steps: Examples of abscess drainage

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This is not how it should look: Examples of incomplete fistula removal

Have you had a complete removal of the Pilonidal Sinus performed? It is important to carefully inspect the entire gluteal fold to ensure that no noticeable openings have been left behind. The presence of such openings can be a clear sign of impending recurrence. If you suspect this, take the initiative immediately and consult a doctor who specializes in this matter.

Unfortunately, this is not uncommon: despite repeated operations under anesthesia, the origin of the fistula remains unnoticed. This means that it cannot heal.

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Basics of wound healing

After an Pilonidal Sinus operation, different priorities need to be set for follow-up treatment depending on the procedure. It is helpful to know what physiological processes take place in the body when a wound heals.

Primary wound healing with closed procedures (midline suture, Karydakis surgery)

In primary wound healing after surgical procedures with wound closure, the wound is sutured, stapled or glued. Healing then goes through four phases:

Coagulation phase (day 1): This is when blood platelets and coagulation factors stick the wound together. The resulting fibrin is the body's own superglue. Antibodies and white blood cells are active in the defense against infection. Cohesion is primarily ensured by the skin sutures, which is why strain should be avoided.
Inflammation phase (day 1 - 4): Messenger substances are released that cause vasodilation, increased blood flow, new blood vessel formation and the attraction of connective tissue cells (fibroblasts). These fibroblasts are true masters in the production of stabilizing fibres. The increased blood circulation can be recognized by the reddish or purple color of the scar. The mechanical stability is still low.
Proliferation phase (day 5-14): The fibroblasts multiply and form procollagen. This protein transforms into tropocollagen and contains larger amounts of the amino acids lysine, glycine and proline. The collagen fibrils formed by cross-linking these proteins give the scar mechanical strength.
Contraction phase (day 15 -): During this phase, the formation and breakdown of collagen fibrils are in balance and the fibers rearrange themselves. The mechanical strength of the scar continues to increase, while the color gradually returns to the normal skin tone. The scar contracts and takes on a more compact structure. The scar is now fully resilient again.

Secondary wound healing in open procedures ("Metzger" method, pit picking, sinusectomy)

Open wound treatment with secondary wound healing is usually chosen for an Pilonidal Sinus operation. Here too, the healing process goes through the stages mentioned. Between phases 2 and 3, the wound must first fill up before it can consolidate in phases 3 and 4. This takes place in the granulation phase (proliferative phase): New blood vessels (angiogenesis) form to supply the tissue with nutrients and oxygen. Fibroblasts migrate into the wound and produce collagen, which serves as a scaffold for the new tissue. Granulation tissue is formed, which consists of newly formed blood vessels, collagen and other connective tissue components. The wound fills with this tissue from the bottom up. Mechanical resilience is ensured at all times.

Follow-up treatment in detail

Effective aftercare and wound care

Remove the hair around the wound in an approximately 2 cm wide seam by shaving, depilatory cream, waxing or plucking. Particularly important is the area 3 cm below the deepest wound point, an area that you can see by pulling the buttocks slightly apart.
In addition, showering once or twice a day is essential to remove wound secretions and minimize the bacterial load. A clean skin surface harbors 10,000 times less bacteria and promotes faster and safer healing. Focus all your attention on these two points to optimally support the healing process!
Wound irrigation with sterile solutions (physiological NaCL solution, antiseptics) corresponds to the official recommendation of the RKI, but in our view is not absolutely necessary. The sinusectomy procedure does not leave a poorly drained abscess cavity, but a largely "clean" wound cavity due to careful removal of the fistula capsule.

Instructions for proper wound cleansing and care
Use of special wound dressings and bandages
Tips for avoiding infections
Hair Removal

When the hair is removed, the fistula will heal.

1965 Peter H. Lord and Douglas M. Millar, pit picking inventors

Diet and lifestyle

- Nutrition tips to support wound healing (e.g. high-protein diet, vitamins)
- Importance of sufficient fluid intake
- Smoking cessation and its influence on healing

Pain control

- Pain management and suitable painkillers
- Alternative methods of pain relief (e.g. cooling, relaxation techniques)

Activity adjustments

- Recommendations for physical rest and movement restrictions
- Tips for returning to everyday life and sporting activities

Hygiene and clothing

- Suitable clothing and underwear to minimize friction and pressure
- Hygiene measures in everyday life to keep the wound clean

Warning signs and complications

- Recognizing signs of wound infection or other complications
- When to see a doctor

Scar care and cosmetic aspects

- Methods for reducing scarring
- Use of scar ointments and creams

Psychological support

- Dealing with emotional and psychological stress after surgery
- Support through self-help groups or psychological counseling

Long-term prognosis and relapse prevention

- Long-term prognosis and options for preventing recurrence
- Tips for preventing recurrence of fistulas (e.g. hair removal in the affected region)

Testimonials and patient forums

- Exchange experiences and tips with other affected people
- Access to online forums and self-help groups

You can safely omit these measures

Antibiotics can be helpful in the short term, especially after complete closure of the wound. The first dose is typically administered during induction of anesthesia, either as an infusion or as a tablet on the morning of the operation. However, the continuation of this treatment over a longer period of time is controversial among experts. Preventive antibiotic administration to avoid wound infections should generally not last longer than three days.
Tamponades often prove to be painful and ineffective. After removal of a fistula, the wound is usually relatively clean and should not be kept open artificially. This differs from the treatment of an abscess, where it may be necessary to ensure the drainage of pus for a few days.
The removal of hypergranulations, also known as "wild flesh", with cauterization (silver nitrate) or mechanically is counterproductive. These growths are an indication of obstacles to healing caused by ingrown or loose hairs and are therefore a side effect and not the cause of the problem.

The wound is not healing or has reopened?

Don't leave your wound healing to chance - act now!

Plan B for stagnant wound healing: Despite inconspicuous ultrasound findings and optimal care, it can happen that a wound does not heal. If no healing progress is visible over a period of one to two months, you have to face reality: Further surgery may be necessary. Consideration may be given to re-cleaning the wound or performing a Karydakis plasty.

Do not delay the decision to undergo plastic reconstructive surgery unnecessarily. Delays only lead to loss of time and disappointed hopes. You should also not be overly afraid of the procedure. If it is performed by an experienced surgeon, it can be an effective and permanent solution to your wound healing problem.

Sport after coccygeal fistula surgery

When is it allowed to return to physical work, sports and sex after the operation?

Sport is a real health booster - even for patients after an operation! The fast-track concept of surgical rehabilitation builds on precisely this.

We have learned that bed rest, plaster casts and food restriction are not beneficial, but can actually be detrimental (keyword: inactive atrophy and catabolic metabolic states).

In the "Metzger method" and pit picking, the process of secondary wound healing is used, which corresponds to the natural mechanism for healing an injury, whereby the wound slowly fills with granulation tissue to finally reach the skin level. The skin then gradually begins to grow over the wound from both sides at a rate of about 1 mm per week. Only when the wound is completely closed will it stop oozing. It does not "air dry". With this type of wound healing, the progress achieved remains stable at all times, and physical rest offers no additional benefits, but if secondary wound healing is disturbed, usually caused by hair in the context of coccyx fistulas, the granulation tissue remains unstable, proliferates beyond the boundaries of the wound ("wild flesh") and can bleed at the slightest touch. Normally, even in this case, a delicate layer of skin forms over this tissue. Nevertheless, the scar remains unstable, regardless of how much you protect yourself. Only when the disturbing factor, namely the hair, is removed can a firm and bleeding-free scar form.

Green = recommended

Open wound treatment: sport allowed without restrictions Closed wound treatment: Sport after 2 weeks

Which sports are problematic? Which are recommended?

When choosing sports with a view to potentially relieving or stressing the coccyx region, it is important to distinguish between activities that can put pressure or impact loads on the coccyx and those that avoid this. Here are some considerations:Sports that can put pressure on the coccyx:Cycling: Sitting on a tight saddle for long periods of time can put pressure on the tailbone.Horseback riding: The movements and pressure of the saddle when riding can put pressure on the coccyx.Rowing: The sitting position when rowing can put pressure on the coccyx, especially during intense or prolonged exercise.Contact sports: sports such as soccer, rugby or martial arts carry the risk of direct impact or injury to the coccyxUnproblematic sports:Swimming: Swimming is generally very easy on the joints and does not place any direct stress on the coccyx.Hiking: Hiking or brisk walking is a low-impact activity that does not directly stress the coccyx.Yoga: Many yoga exercises can help strengthen and stretch the muscles around the coccyx without stressing the coccyx. However, certain positions that put pressure on the coccyx should be avoided.Pilates: Similar to yoga, Pilates can help to strengthen the core muscles and improve flexibility without putting strain on the coccyx.Cross-trainer: Cardio training on a cross-trainer minimizes the strain on the coccyx and other joints.Fitness - training on strength equipment: Strength training on machines leads to a selective load on individual muscle groups and can therefore be used in a very targeted manner.it is important to listen to your own body and to avoid or adapt activities in the event of pain or discomfort in the coccyx area. In general, shear forces and frictional loads under pressure, i.e. when sitting or lying down, appear to be a decisive factor.

Literature: Coccygeal fistula and sports

What science says

Diao, J., Liu, J., Wang, S., Chang, M., Wang, X., Guo, B., Yu, Q., Yan, F., Su, Y., & Wang, Y. (2019). Sweat gland organoids contribute to cutaneous wound healing and sweat gland regeneration. Cell death & disease, 10(3), 238Doll, D., Brengelmann, I., Schober, P., Ommer, A., Bosche, F., Papalois, A., Petersen, S., Wilhelm, D., Jongen, J., & Luedi, M. (2021). Rethinking the causes of pilonidal sinus disease: a matched cohort study. Scientific Reports, 11(1)Karydakis,G.E. (1992). Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust. N. Z. J. Surg. 62, 385-389 Kawanishi, M., Kami, K., Nishimura, Y., Minami, K., Senba, E., Umemoto, Y., Kinoshita, T., & Tajima, F. (2022). Exercise-induced increase in M2 macrophages accelerates wound healing in young mice. Physiological Reports, 10(19)Pinho, E., Soares, G., Henriques, M., & Grootveld, M. (2015). Antibacterial Activity of Textiles for Wound Treatment. The AATCC Journal of Research (AJOR), 2(5), 1Yndriago, L., & Izeta, A. (2017). Shh... Sweat gland in progress! Experimental Dermatology, 26(6), 548-549.

DR. BERNHARD HOFER &AMP; FLORIAN LIEBL

Specialists in Visceral Surgery and Proctology - PartG mbB

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