Management of Pilonidal Sinus
For uncomplicated pilonidal sinus disease, surgical excision with off-midline primary closure is the recommended approach, as it significantly reduces recurrence rates, accelerates healing, and minimizes complications compared to midline closure or open healing techniques. 1
Initial Assessment and Patient Selection
When evaluating a patient with pilonidal sinus, identify key risk factors that will guide surgical planning:
- Body mass index and weight: Patients with BMI >27 or weight >90 kg have higher infection rates 2, 3
- Smoking status: Active smoking is an independent risk factor for wound infection (p=0.027) and should prompt preoperative cessation 2
- Disease extent: Exclude pilonidal abscess requiring immediate drainage and extensive gluteal involvement 3
- Previous surgical history: Document prior treatments, as 25% of patients present after failed procedures 3
Surgical Management Strategy
For Acute Pilonidal Abscess
- Perform incision and drainage immediately 1
- Critical step: Excise the pilonidal pit at the time of abscess drainage to reduce the 40% risk of subsequent chronic sinus formation 4
For Chronic Pilonidal Sinus
Primary surgical approach should be asymmetric (off-midline) excision with primary closure, as this technique demonstrates:
- 80% lower recurrence rate compared to midline closure (Peto OR 4.95; 95% CI 2.18-11.24 for midline vs off-midline) 1
- 79% lower infection rate (RR 4.70; 95% CI 1.93-11.45 for midline vs off-midline) 1
- 89% fewer wound complications (RR 8.94; 95% CI 2.10-38.02 for midline vs off-midline) 1
Surgical Technique Specifications
The procedure should include 3, 5:
- Eccentric elliptical excision of affected tissue (not wide en-bloc excision)
- Mobilization of the flap to the sacrococcygeal fascia
- Suturing the flap edge to the lateral wound margin to flatten the natal cleft
- Suction drain placement (not Penrose drains, which increase collection rates) 3
- Subcuticular skin closure for optimal cosmetic results 3
Alternative Approach: Open Healing vs Primary Closure
While off-midline closure is superior to midline closure, the choice between any primary closure versus open healing involves trade-offs 1:
Open healing advantages:
Primary closure advantages:
However, when primary closure is chosen, off-midline technique must be used to avoid the unacceptably high failure rates of midline closure 1
Risk-Stratified Management
High-Risk Patients (Obese or Smokers)
For patients with BMI >27 or active smoking 2:
- Strongly recommend preoperative weight loss and smoking cessation
- Consider simple laid-open procedure if risk modification not achievable
- Infection rates are "unacceptably high" with primary closure in this population 2
Standard-Risk Patients (Non-obese, Non-smokers)
- Proceed with off-midline excision and primary closure 2, 3
- Expected outcomes: 1.8% infection rate, 0.9% recurrence, mean healing time 13.2 days 3
Minimal Disease Management
For patients with minimal symptoms or single acute abscess 5:
- Simple removal of midline skin pits (the primary cause) with lateral drainage
- Avoid wide excision, which lacks rational basis 5, 4
- Perform as day-case surgery with rapid return to work 5
Postoperative Care
Expected recovery parameters 3:
- Hospital stay: 2-3 days
- Return to normal activity: 12-13 days
- Follow-up duration: minimum 6 months to assess for recurrence
Critical Pitfalls to Avoid
- Never perform midline primary closure: This technique has 4-5 times higher recurrence and infection rates 1
- Abandon en-bloc excision with secondary healing: This outdated approach should be replaced with asymmetric closure techniques 4
- Do not use Penrose drains: Suction drains eliminate fluid collections that occur in 7% of cases with passive drainage 3
- Do not proceed with primary closure in unmodified high-risk patients: Active smokers and obese patients require risk reduction first 2