Pilonidal Cyst

Pilonidal cyst is a chronic recurrent disease that can occur in many different areas of the body (hands, navel, etc.), but most is found in the sacrococcygeal area. It used to be considered a congenital disease. But, today, it is widely accepted as an acquired disorder, where the entrapment of hairs in a deep and hairy intergluteal cleft under stressful conditions (e.g. Jeep drivers), leads to abscess formation and chronic fistula formation. Pilonidal disease can present as a simple cyst, an acute abscess with or without cellulitis, or a chronic draining sinus. The most common clinical manifestation is a painful inflammatory mass in the sacrococcygeal region with accompanying mild cellulitis with frequent pits. The disease rarely extends to the anus. In case of abscess formation (the cause of which is polymicrobial), drainage through an eccentric incision and cleansing of all hairs is required. Changes twice a day and shaving of the area are required for 3 months – this will treat the disease in the 60-70% of patients. In rare cases, the chronic recurrent disease leads to the development of carcinoma (squamous cell carcinona) requiring wide en bloc excision with fascia and biopsy of the swollen lymph nodes followed by subsequent radiotherapy. The prognosis is poor.

Elective surgical treatment

Wide excision. Wide excision of the cyst with 5 mm margins up to the sacrococcygeal fascia and either primary suture repair (with recurrence rate of 40%) or closure at a later date (2 months).

Marsupialization. Insertion of a probe through the main duct, opening and communication of all cavities as well as cleansing creating a shallow wound that heals more easily. Stitches of marsupialization are applied on the periphery. It has similar healing rates to the wide excision.

 Techniques without excision. They consist of careful removal of hairs and fibers from the pores without excision. Long-term follow-up (monitoring) is required.

Phenol injection into the cyst. It has a high recurrence rate and is associated with a lot of pain.

Simple excision of the cyst. The simple excision of the pilonidal cyst is an elective surgery. In this case, we remove the pilonidal cyst alone without other tissue either through a median incision (A) that remains open or through a lateral incision (B) which is then closed. The lateral incision has the advantage of being easier to heal, but it is not always easy, especially in complicated disease.

Excision of the pilonidal cyst and closure with flap reconstruction. The main problem is necrosis and the flap’s infection.

Karydakis Flap Technique (KFT). Eccentric ellipsoidal incision, removal of the cyst and all pores up to the sacrococcygeal fascia, mobilization of a flap on one side and closure of the wound, thus making the intergluteal fold shallower with placement of a closed drain (with 1% rate of recurrence). Karydakis flap procedure is a safe treatment alternative for the surgical treatment of sacrococcygeal pilonidal sinus disease because of associated low complication rate, short length of hospital stay and healing duration, and high patient satisfaction rate. The main complication of this technique is hematoma.

Karydakis Sliding Flap. (A) The sinus is excised to the sacrococcygeal fascia, with the incision made off the midline (Inset). (B) A full-thickness flap is raised on one side. (C) The flap is slide to opposite side and wound closed, remaining off the midline.

Cleft Closure (Bascom Surgery).

Cleft closure. (A) Lines of buttock contact are marked, and the buttocks are then taped apart. (B) The unhealed wound is excised in a triangular shape off the midline. The skin flap is raised out to the previously marked line on the side where less skin was removed and then tapes are released. The skin flap is positioned and excess skin trimmed. (C) A closed suction drain is placed in subcutaneous tissue before skin closure.

 Local flaps (Z-flap, Rhomboid flap, V-Y flap).

Z-plasty closure after midline excision. (A) After sinus excision, limbs of the Z are marked at a 30-degree angle to the long axis of the wound. (B) Full-thickness flaps are raised and transposed. (C) The wound is closed.

Rhomboid Flap. The pilonidal sinus is excised in a diamond shape. (A) Rhomboid flap is incised as shown, including skin and subcutaneous tissue. (B) The flap is rotated into place and secured. The donor site is closed primarily

V-Y advancement flaps. This can be performed unilaterally (A) or bilaterally (B), depending on the defect size after sinus excision. Donor sites are closed primarily. Unfortunately, the degree of mobility of a V-Y advancement flap is dependent on the laxity of the underlying subcutaneous tissue. This is an important disadvantage of traditional V-Y advancement flap and limits its use.

The recurrence is mainly due to infection and incomplete initial technique. Some similar surgery can be performed; however special treatment may be required for deep wounds that fail to close, such as with flap transposition of a gluteus maximus flap.

Gluteus maximus rotational flap. After sinus excision, the flap is rotated into place as shown

The injection of fibrin glue and use of VAC appears to reduce recurrences and postoperative hospitalization time, while the use of drains or antibiotics administration does not affect the progression of the disease.