What are the surgical options for a patient with pilonidal sinus disease?

Surgical Options for Pilonidal Sinus Disease

For pilonidal sinus disease, the primary surgical choice is excision with off-midline closure when primary closure is desired, as this approach demonstrates superior outcomes compared to midline closure or open healing techniques. 1

Primary Surgical Approaches

Excision with Off-Midline Closure (Preferred for Primary Closure)

• Off-midline closure techniques show significantly lower recurrence rates (Peto OR 4.95; 95% CI 2.18 to 11.24 favoring off-midline), lower infection rates (RR 4.70; 95% CI 1.93 to 11.45), and fewer complications (RR 8.94; 95% CI 2.10 to 38.02) compared to midline primary closure. 1
• This should be the standard management when primary closure is the desired surgical option. 1
• Particularly beneficial for hirsute patients with extensive primary disease, deep natal clefts, or recurrent disease with unhealed midline wounds. 2

Excision with Open Healing (Secondary Intention)

• Open healing demonstrates a 58% lower risk of recurrence compared to primary closure (RR 0.42; 95% CI 0.26 to 0.66). 1
• Healing is slower than primary closure, but infection rates are similar between the two approaches. 1
• Patients return to work approximately 10 days later compared to primary closure (WMD 10.48 days; 95% CI 5.75 to 15.21 days). 1

Simple Pit Excision with Lateral Drainage

• Removal of midline skin pits (the primary cause) with lateral drainage of abscess and sinus is effective for most patients without requiring wide excision. 2
• This conservative approach can be performed as day-case surgery with minimal community care requirements and rapid return to work. 2
• Avoids debilitating complications associated with more extensive surgical treatments. 2

Marsupialization

• Involves excision followed by suturing the wound edges to the base, creating a pouch that heals from the inside out. 3, 4
• In one series, marsupialization was performed in 31.82% of 110 patients with healing times ranging from 4 to 21 weeks. 3
• Minimizes premature skin closure and promotes complete healing from the inside out. 4

Specialized Techniques

Excision with Primary Closure and Antiseptic Drain Flushing

• Involves placing a 12F suction drain at the wound base with tip brought out laterally (at least 5 cm from suture line). 5
• Cavity flushed with antiseptic solution on postoperative days 2,4, and 6; drain removed days 8-9. 5
• In 243 patients, this technique achieved 100% primary intention healing with zero recurrences over 5-15 years follow-up. 5
• Can be performed on day hospital basis in most cases. 5

Minor/Limited Excision

• Less extensive excisions allow discharge within 23 hours and return to daily activities within 5 days. 3
• Healing time ranges from 2-5 weeks (compared to 4-21 weeks for more extensive procedures). 3
• Individual approach tailored to disease extent provides fastest and most comfortable results. 3

Management of Acute Pilonidal Abscess

• Acutely infected pilonidal abscess requires urgent simple incision and drainage, which should not be viewed as definitive treatment. 4
• Definitive treatment of chronic disease should be planned after acute infection resolves. 4

Critical Surgical Principles

• All infected tissue and sinus tracts must be excised through elliptical incision. 4
• Beveling of skin edges serves to minimize premature skin closure and promote complete healing from inside out. 4
• Weekly postoperative follow-up is strongly encouraged to assess progress and promote proper wound healing. 4

Common Pitfall to Avoid

Midline primary closure should be avoided as it demonstrates the worst outcomes with highest recurrence rates, infection rates, and complications compared to all other techniques. 1 When primary closure is chosen, off-midline techniques are mandatory for optimal outcomes.