What are the surgical options?
There are many surgical options for the treatment of pilonidal sinus disease. The main principle is to attempt the simplest option(s) first as most pilonidal sinuses will heal with simpler surgical options that are associated with less pain, less complications, quicker recovery and less scarring.
- This involves excision of the secondary fistula and cleaning the track (curettage) towards the midline pits. It does not involve excising the midline pits and does not remove the whole sinus track.
- The wound is left open and dressed daily until it closes. It can take 4-6 weeks to close but pain is well tolerated and you can return to work soon after surgery.
- This may be enough in up to 80-90% of patients. However, recurrence can occur if more hair falls into the pilonidal sinus. We advise patients to have the hair removed once the wound closes to minimize the chance of recurrence.
- This is a day procedure and is usually done under a general anaesthetic. It can, however, be done under local anaesthetic if required.
- This is where a limited excision of the secondary fistula is performed followed by insertion of a small camera into the sinus to clean it under vision removing all of the hair. It results in up to 95% success and can be repeated. It is a day procedure, is well tolerated and you can return to work soon after surgery.
- Daily dressings are required but due to the small size of the defect may only be required for 2-4 weeks.
- The procedure is usually done under general anaesthetic but can be done under local anaesthetic if required. It is done as a day procedure.
- The endoscopic equipment is not widely available and may not be covered by private health funds.
- If simple excision or endoscopic treatment fail, the next surgical step is to perform a marsupialization. This involves opening the whole track up and excising the top and sides of the track without removing the base. The skin is then sutured to the base making the sinus shallow. The sinus then heals up from inside out.
- Healing can take from 4-6 weeks and depends on the depth and length of the sinus. It is important to keep the hair as it heals.
- Daily packing is required.
- The procedure is usually performed under a general anaesthetic as a day procedure
- If simple excision and marsupialization fail, or if the patient prefers not having an open wound, a wide excision and flap repair can be performed.
- The most common type of repair is called a modified Karyadakis flap repair – named after a Greek surgeon who described the procedure during the second world war.
- This is done under a general anaesthetic in the prone position (lying face down on the anaesthetic table).
- It involves a large excision of the sinus down to the sacral fascia (the layer on top of the back bone). A flap is then brought from the opposite side towards the side of the disease to get rid of the normal midline natal cleft. The scar is thus off centre on purpose. It is also skewed away from the anus on purpose to ensure the bottom of the scar is as far away from the anus as possible to allow healing.
- The procedure is associated with a wound breakdown rate of 10-20%. However, once completely healed recurrence is only about 4-5%.
- It is done as a day procedure but may require a drain which is removed within a week.
- It is the most painful of the pilonidal procedures and thus is associated with the slowest recovery.
- Expect at least two weeks off work.
- If non-dissolving sutures are used to close the wound, they are removed two weeks after surgery.
- This is where the sinus is removed completely down to the sacral fascia (the layer covering the back bone). It is then left open to heal from inside out.
- This ends up being a large defect which can take 2-3 months to completely close. If flap procedures fail or break down, they are treated in the same way as this defect.
- A vacuum dressing may be used to speed up healing.
- This is a day procedure and is performed under general anaesthesia.
What are the risks of surgery?
Surgical procedural risks can be divided into anaesthetic and surgical risks.
Anaesthetic risks are usually discussed with the patient by the anaesthetic team.
Surgical risks specific to pilonidal sinus surgery include:
- Infection – of the wound. This is more of a problem when the wound is closed and is most common at the bottom end of the wound near the anus.
- Wound breakdown – This occurs in 10-20% of flap repairs and may be limited to a small part of the wound or involve the entire length of the wound. It is treated with regular dressings and may require a vacuum dressing to speed up the healing process.
- Bleeding – There is a small risk of haematoma formation following a flap repair which can result in wound infection and breakdown.
- Seroma – Inflammatory fluid can collect underneath the wound following a flap repair. This can result in wound infection and breakdown.
- Recurrence – The sinus can recur especially if the risk factors are not eliminated. It is therefore more common if the natal cleft is not flattened, the hair is not removed and you continue to allow the area to sweat and continue to sit down excessively long times.
- Take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).
- Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.
- Stronger pain killers such as opioid anaelgesics (Endone, Codeine) should be taken sparingly as they can cause constipation which results in more straining.
The skin may be closed with dissolving sutures or non-dissolving sutures.
If non-dissolving sutures are used, these are usually removed after 14 days.
A waterproof dressing is used which stays on for 7 days.
If the dressing is wet, it is important to report this to your nurse or doctor as it needs to be changed. If this happens after you leave hospital, you need to see your local doctor or contact us.
After 7 days, when this dressing is removed, it is okay for the sutures to be exposed to air and to have a shower without covering the wound.
You cannot go for a swim or soak the wound in a bathtub for at least 2 weeks or until after your follow up wound review.
If dissolving sutures are used, the wound is dressed with Dermabond glue which is waterproof. The glue feels hard which is normal. It sheds off over the 2-3 weeks.
You may have a drain following a flap repair.
This is removed when the output reaches a certain colour and volume and is usually under a week.
You may go home with a drain which is usually monitored by the Hospital In The Home (HITH) nursing service. If this is not a free service through your private health fund, we will discuss alternative arrangements prior to your discharge.
Most patients go home the same day but you may be admitted overnight following a flap repair particularly if a drain is used.
A wound review by your surgeon or local doctor is advisable 1-2 weeks after surgery.
The appointment is usually made for you before leaving the hospital.