Pilonidal Sinus Surgery

Overview

What is it? A pilonidal cyst is an abnormal pocket of the skin, usually on the top of the buttocks containing hair and skin debris. A pilonidal sinus is a small hole or tunnel at the skin in the same area which communicates with the cyst.
Why it happens: Pilonidal cysts develop when hair in-grows and becomes embedded in the skin.
Frequency: It is more frequent in young men. People who sit for prolonged periods of time, such as professional drivers, are predisposed to the development of pilonidal cysts. Obesity, inactive lifestyle and excess of hair in the area are also risk factors for developing a pilonidal cyst. The problem has a tendency to reoccur, sometimes even after surgery.

Symptoms

If not infected, pilonidal cysts may be entirely asymptomatic. When infected, pilonidal cysts present as a swollen mass (abscess) which can be very painful. The surrounding skin is most of the times red and hot. There may be pus, purulent discharge or blood discharging through a skin opening. The pus often has a foul smell.

Diagnosis

In most cases, a careful medical history and a physical examination will diagnose the pilonidal cyst and will identify the presence of communicating sinuses. Rarely, it may be required to have an MRI scan of the area to find out what is the size of the cyst.

Treatment

Management depends on the acute or chronic nature and the exact type of the symptoms. Cysts that are entirely asymptomatic do not warrant surgery in the first instance.
Acute presentation (infected pilonidal cyst) – This happens when the cyst becomes infected. The management consists of a procedure called incision and drainage.
Under anaesthesia you will get a cut to allow the accumulated pus and debris to come out. You will almost certainly be prescribed antibiotics for a few days after to control the inflammation.
Chronic and recurrent pilonidal cyst – Once the acute inflammation settles (or in cases where previous surgery has failed and the cyst has recurred) a definitive treatment is required. This consists of a more extensive procedure that removes the cyst entirely. There are different options to achieve this goal:
Open technique – in this approach the surgical wound is left open and packed with a wound dressing to allow time to heal from the inside out. It is associated with a lower risk of recurrence and infection however; it results in a longer recovery period and requires wound dressings and regular repacking at the initial post-operative stages (roughly for 10-14 days after surgery).
Close technique – in this approach the wound is closed primarily at the end of surgery (or half – closed in a slightly different version). It offers speedier recovery and has relatively straightforward wound care requirements. This technique is restricted by the size of the pilonidal cyst. This is because big cysts with multiple sinuses, once completely excised, leave a wide wound area which may be difficult to close with stiches. It has also been associated with higher recurrence rates, particularly when the area is hairy or when the occupation/lifestyle of the patient is not favourable.

Follow Up

If you had surgery for pilonidal cyst
  • Pilonidal cyst surgery is usually completed as a day case procedure and you should be able to go home the day of your surgery.
  • It is important to follow all of your doctor’s instructions, take any medication prescribed regularly and keep your follow-up appointments.
  • Getting out of bed and walking is an important part of recovery and helps prevent complications.
  • Wound care is very important after pilonidal surgery. You will receive detailed instructions about how to look after your wound and also a detailed plan of follow up appointments. During these appointments the healing of your wound will be assessed and you will receive advice on further steps.
  • Depending on the type of surgery you had, you may have a drain in place. This is a small silicon tube that sits deep inside the wound and is clearing the wound from blood and skin debris. It should be handled with care. Advice on when the drain will come out and other drain- related instructions are given on a case by case basis.
  • You may have difficulty sitting on a chair for a few days after pilonidal surgery. This is something that may last up to 1 week.
  • Do not drive before you feel safe to emergency break – check with your insurance company for any small prints in your policy.
If you have a pilonidal cyst that has been infected or a recurrent pilonidal cyst
  • Removing hairs from the area around the cyst can prevent cysts from forming or recurring.
  • Good hygiene and keeping your lower back clean and dry may also help prevent further infections. When cleaning the area try to use mild soap and water. Rinse the area well to remove any soap residue.
  • Take frequent breaks if your job requires sitting for long periods.
  • Avoid tight clothing.
  • Laser hair removal from the area may reduce the risk of recurrence.
Seek immediate medical attention if
  • You noticed a swollen, painful area around your tailbone with or without a purulent discharge.
  • You have signs of systemic infection (fast heart rate, high temperature, tachypnea)
  • You have had previous surgery for a pilonidal cyst and now you feel that similar symptoms are recurring.
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