Pilonidal Cyst Packing After Drainage
Wound packing after pilonidal cyst drainage is not recommended based on current evidence, as it increases pain and healthcare costs without improving healing time or reducing recurrence rates. 1, 2
Evidence Against Routine Packing
The World Journal of Emergency Surgery guidelines explicitly state that no recommendation can be made regarding the use of packing after drainage of an anorectal abscess (which includes pilonidal disease), based on available literature. 1 The evidence shows:
- A Cochrane review found it "unclear whether using internal dressings (packing) for the healing of perianal abscess cavities influences time to healing, wound pain, development of fistulae, abscess recurrence, or other outcomes." 1, 2
- A multi-center observational study of 141 patients concluded that packing is costly and painful and does not add benefit to the healing process. 1, 2
- Packing causes increased pain during dressing changes and higher healthcare expenses due to prolonged use. 1, 2
Recommended Alternative Approach
Instead of packing, place a catheter or drain into the abscess cavity that drains into an external dressing, with a small stab incision under local anesthetic, and leave it in place until drainage stops. 1
For primary closure cases specifically:
- A drain can be placed at the base of the wound with its tip brought out laterally (at least 5 cm from the suture line). 3
- The cavity can be flushed with antiseptic solution followed by sterile saline on postoperative days 2,4, and 6. 3
- The drain is removed on day 8 or 9. 3
Optimal Wound Management Strategy
For wounds healing by secondary intention after pilonidal cyst excision:
- Rinse the wound with clean water or antimicrobial solution. 4
- Apply appropriate mechanical or autolytic debridement as needed. 4
- Use sterile dressings changed regularly. 4
- Consider closed incision negative pressure therapy (ciNPT) for primary closure cases, which significantly reduces healing time (23.8 days vs. 57.9 days), decreases pain, and shortens hospital stay compared to gauze dressings. 5
Critical Pitfalls to Avoid
- Do not pack the wound routinely - this is an outdated practice that causes unnecessary pain without benefit. 1, 2
- Do not allow premature skin closure - the wound must heal from the inside out (secondary intention). 6
- Ensure adequate initial drainage - inadequate drainage is the primary cause of the high recurrence rate (15-44%). 2, 6
- Avoid probing for fistulas if none is obvious, as this causes iatrogenic complications. 1, 2
Expected Outcomes
- Average healing time for secondary intention healing is approximately 76 days with appropriate wound care. 4
- With primary closure and ciNPT, healing can occur in as little as 23.8 days. 5
- Recurrence rates remain significant (15-44%), emphasizing the importance of complete initial drainage rather than packing. 2, 6