Pilonidal Cystectomy

Acute Management.

Patients presenting acutely with new-onset disease may have a painful fluctuant abscess or a draining infected sinus. Both can be managed with simple office treatment, with more definitive procedures reserved for patients who suffer from a recurrence. Abscess can be drained in the office or emergency department using local anesthesia. Typically, the fluctuance extends to either side of the midline cleft, and incision and drainage down to the subcutaneous tissues off the midline provide for the best drainage and fastest healing. For abscesses and sinuses, hair should be removed from the wound and local skin should be shaved weekly to prevent the reintroduction of hair. Whereas short-term razor epilation is advised, long-term razor epilation is not advised; there is no proven efficacy in nonsurgical cases and, when performed as a long-term adjunct to surgery, it increases rates of recurrence. Laser depilation can also be used to accomplish effective long-lasting hair removal, especially if repeated. Ideally, these patients should be seen weekly in the office for wound care until there is complete healing. Most do not require further care; those who do can be treated as described in the following section.

Surgical Management.

For patients who have recurring infections, definitive operative management is warranted. Numerous procedures have been described in the literature, ranging from simple incision and drainage to complex plastic flaps for cleft obliteration.

Comparative studies in this field are rare. Most reports have been limited to a single surgical approach, with only a few prospective randomized trials available in the current literature. In one comparative trial, the complex V-Y advancement flap was found not to be superior to simple primary suture methods. In another trial, the Bascom cleft closure was found to offer more predictable healing than the Bascom simple surgery. The development of a classification scheme for pilonidal disease may help with future comparative studies because there are likely numerous patient factors that contribute to the causes and/or failures of a given procedure.

The simplest approach for chronic pilonidal disease is the ambulatory technique of midline excision and primary suture. This approach was studied in 103 patients at a single institution, with excellent long-term follow-up. Patients with chronic disease or acute but not inflamed disease were treated with 3 days of preoperative oral antibiotics and the surgery was performed under local anesthesia. Methylene blue was injected into the sinus or pit, which stained the tissue to be excised. Suture closure included incorporation of the deep sacral fascia and a vacuum drain. Three patients experienced a recurrence; otherwise, wound healing occurred between 10 and 16 days postoperatively. For primary closure, the omission of wound drainage was associated with a higher frequency of minor and major wound infections and wound dehiscence.

An alternative to simple excision plus closure is marsupialization. In this procedure, the areas of midline pits and sinuses are removed and the wound reduced in size by suturing the wound edges to the fibrous base of the wound. This can reduce wound healing times and may be effective at removing extensive sinus tracts, but requires frequent office visits for meticulous wound care over several weeks. This approach is appealing because of its low rate of reinfection and wound breakdown.

Several more complicated approaches to pilonidal disease have been described, including rhomboid excision, Limberg flaps, and oblique excisions with bilateral gluteus maximus fascia advancement flaps, Bascom's cleft closure, and V-Y advancement flaps. The Bascom closure and oblique excision are premised on the need to create an off-midline closure to facilitate healing. In most practices, the complex flap closures are reserved for patients with refractory disease for whom simple measures have failed.