Our operations for pilonidal cyst

The experience of over 20 years of surgery flows into the surgical treatment of our patients.

The minimally invasive therapy is always preferred by us.

There are various options for the treatment of pilonidal cyst (pilonidal sinus). The common factor is that so far only surgical therapy is available as a cure. Conservative therapy, even with the administration of antibiotics, is not possible. The surgical method depends very much on the severity of the findings.

This condition usually occurs with a collection of pus (abscess) and immediate surgical repair is required. An abscess is always an emergency indication. Smaller abscesses of up to 5 cm can usually be opened well on an outpatient basis under local anesthesia.

It is important to cut out some of the skin to ensure good drainage. Only a small incision under icing is not sufficient. Larger abscesses should be operated on in the hospital under general anesthesia, especially if they are located near the anus.

This often results in very large defects that heal slowly over 3-6 months. This is a great physical and psychological burden for the mostly young patients.

Here you can see the openings where hairs grow into the depth. These so-called pits can be operated on in a small, painless operation, the pit picking well outpatient. Small wound defects remain that cause little pain and usually heal within 7-14 days. This procedure is purely outpatient, so no hospitalization is necessary.

In these findings, the pit picking procedure reaches its limits, as there are cavities and scars at the end of the canals that have to be excised. A combination here would be pit picking with sinusectomy, in which the scars and the scar cavity are removed with several small incisions.

In the case of recurrent pilonidal cyst without acute inflammation, plastic surgery according to Karydakis, for example, can be performed. In this case, the skin and the subcutaneous fatty tissue are completely removed and followed by a plastic surgery with shifting of the midline to the side in order to close the defect. The wound can be completely sutured closed in the process. This operation is always inpatient.

During pit picking, small hair channels are removed from the skin with a punch. These are believed to be the entry points for hairs into the subcutaneous fatty tissue, leading to the dreaded chronic inflammation. Therefore, the complete removal of these hairs is also part of the surgery, otherwise the inflammation will reappear, which is called a recurrence. There must be a lot of experience on the part of the surgeon and the procedure must be performed very thoroughly. The diameter of the punch is 3-4mm. 

However, pit picking always includes removal of the abscess cavity present under the pits, where the hair has been deposited. The cavity together with the wall and the hairs must always be removed as well in order to prevent the recurrence of the disease. In this case, the surgical access is always somewhat lateral in order to leave the smallest possible wound in the midline, which heals poorly. 

After the operation, the very small wounds remain open to allow the wound secretion that forms to drain away, allowing the wound to clean itself. There is also the possibility of suture closure, but since there is always the residual risk of renewed inflammation with pus formation and the wounds close within 1-2 weeks without a suture, we prefer open wound healing as a safe option.

It is important to know that the disease can recur and the risk of this is about 20-25%. Unfortunately, the classic generous excision of the lesion is still the "gold standard" in surgery of the pilonidal sinus, as there are fewer recurrences, but it leads to a very long wound treatment.

Therefore, pit picking should always be considered as a therapeutic option if the findings are suitable.

In more extensive findings, a lateral fistula outlet is found above the pits in the midline. Between this fistula outlet and the pits, a rough induration can often be palpated, which corresponds to the 2-5cm long fistula in the subcutaneous fat tissue. 

This fistula structure must be completely removed, which we call sinusectomy. 

During the operation under local anesthesia, the fistula is cut out via the lateral exit (ectomy) after punching out the pits, without opening the overlying skin. This creates a tunnel, so to speak. Importantly, all diseased tissue must be removed to prevent recurrence.

After the procedure, the small wounds remain open so that the secretion that forms can drain away, allowing the wound to clean itself. The larger wound takes about 3-4 weeks to close.

SiLaC® is a safe procedure to treat coccygeal fistulas. Here, the coccygeal fistula is irradiated with a laser beam using a minimally invasive technique. Minimally invasive here means that only a small operation with minimal wounds is necessary. SiLaC means "Sinus Laser ablation of the cystic duct".

The operations are performed under general anesthesia. During the treatment, which takes only a few minutes, a probe is inserted into the inflamed fistula tract. Laser energy is used to precisely obliterate the fistula tissue without damaging or even removing surrounding tissue. Any incisions made to relieve the abscess are significantly smaller.

As the probe is withdrawn, the fistula tissue is slowly and safely destroyed. The existing cavity collapses and eventually scars over. The extremely flexible probe is well suited for use even in slightly tortuous passages and can therefore be used anywhere. 

The small wounds are healed quickly and there is very little secretion of wound fluid in contrast to conventional surgical procedures, where an open wound area remains for several months. There is often swelling in the area of the cavity, which resolves after several weeks and is not painful. Our patients require very little to no pain medication. 

Since 01.06.2021, the costs for minimally invasive laser therapy have been covered in full by many company health insurances as part of integrated care. Patients from other states in Germany can also undergo minimally invasive surgery with us in Berlin. Please contact us to find out whether your BKK is included.

For larger findings that are not infected, plastic surgery can be performed instead of extensive excision. The best known methods are the Karydakis operation and the Limberg plastic.

We recommend surgery only in case of recurrence. A risk is always a wound infection due to the proximity to the anus , so that in many cases the wound must be opened early after 2-5 days and then heal like an excision.

Outpatient surgery is generally not recommended due to the excessive movement of the patient in the freshly sutured buttock area. 

Operation time: 30-60 minutes

Hospital stay: 3-5 days, outpatient surgery is possible according to the findings, but not recommended.

Inability to work: approx. 2-3 weeks

General anesthesia: Usually yes, for smaller findings local anesthesia is also possible.

This operation is a major plastic surgery with a large wound area. Even with careful handling, the wound is subjected to severe stress, so that wound healing problems and infections often occur due to the proximity to the anus.

When the wound opens, the wound area is very large and the healing time is correspondingly long. Therefore, we recommend this operation only in case of very pronounced findings and then only by plastic surgeons.

Operation time: 60-120 minutes

Hospital stay: 3-5 days, inpatient surgery

Inability to work: approx. 2-4 weeks

General anesthesia: yes