Background

Pilonidal cystectomy is the surgical removal of a pilonidal cyst or tracts extending from a sinus. It may range from a simple procedure that involves excision of a small amount of tissue to a very complex procedure that may include allowing the wound to heal secondarily or rotating adjacent tissues into the defect after excision.

Risk factors that have been attributed to developing a pilonidal cyst include the following:

Increased friction or abrasion in the area
Increased hair
Deep natal cleft

A pilonidal cyst is believed to be an acquired condition caused by the presence of hair in involuted epithelial tissue in the natal cleft. Some clinicians have theorized that this condition is a congenital one, but it is more generally accepted that the presence of hair in the natal cleft causes a foreign body–like reaction that leads to inflammation and possibly infection.

Medical management may reduce the severity of disease. Proper hygiene is paramount. Local hair control by laser epilation has been shown to be an effective therapy that decreases recurrence.^{[1, 2, 3]} Lifestyle changes to reduce repetitive trauma or friction to the area have also been encouraged. Rare cases of squamous cell carcinoma have been reported in the pilonidal sinuses, which are similar to carcinomas arising in chronically inflamed areas.^[4] Thus, pilonidal cysts that are not amenable to medical management should lead to surgical referral for further evaluation.^{[5, 6]}

Indications

Pilonidal cystectomy is indicated for any patient who has pain or discomfort from the presence of the pilonidal cyst. Occasionally, a pilonidal sinus is encountered on physical examination that is not causing any deficits. Surgery may be deferred in these instances.

Contraindications

The pilonidal cyst may become infected. Closure after pilonidal cystectomy is contraindicated in any patient with an active infection. In these cases, antibiotics should be prescribed and the procedure deferred until the infection has been cleared. In certain cases, drainage of an abscess is performed and a formal cystectomy is deferred until the infection has cleared.

Periprocedure

Odili J, Gault D. Laser depilation of the natal cleft--an aid to healing the pilonidal sinus. Ann R Coll Surg Engl. 2002 Jan. 84 (1):29-32. [QxMD MEDLINE Link]. [Full Text].
Jain V, Jain A. Use of lasers for the management of refractory cases of hidradenitis suppurativa and pilonidal sinus. J Cutan Aesthet Surg. 2012 Jul. 5 (3):190-2. [QxMD MEDLINE Link]. [Full Text].
Benedetto AV, Lewis AT. Pilonidal sinus disease treated by depilation using an 800 nm diode laser and review of the literature. Dermatol Surg. 2005 May. 31 (5):587-91. [QxMD MEDLINE Link].
Velitchklov N, Vezdarova M, Losanoff J, Kjossev K, Katrov E. A fatal case of carcinoma arising from a pilonidal sinus tract. Ulster Med J. 2001 May. 70 (1):61-3. [QxMD MEDLINE Link]. [Full Text].
Humphries AE, Duncan JE. Evaluation and management of pilonidal disease. Surg Clin North Am. 2010 Feb. 90 (1):113-24, Table of Contents. [QxMD MEDLINE Link].
Bascom J. Pilonidal disease: origin from follicles of hairs and results of follicle removal as treatment. Surgery. 1980 May. 87 (5):567-72. [QxMD MEDLINE Link].
Petersen S, Wietelmann K, Evers T, Hüser N, Matevossian E, Doll D. Long-term effects of postoperative razor epilation in pilonidal sinus disease. Dis Colon Rectum. 2009 Jan. 52 (1):131-4. [QxMD MEDLINE Link].
McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis. BMJ. 2008 Apr 19. 336 (7649):868-71. [QxMD MEDLINE Link]. [Full Text].
Neşşar G, Kayaalp C, Seven C. Elliptical rotation flap for pilonidal sinus. Am J Surg. 2004 Feb. 187 (2):300-3. [QxMD MEDLINE Link].
Mentes O, Bagci M, Bilgin T, Coskun I, Ozgul O, Ozdemir M. Management of pilonidal sinus disease with oblique excision and primary closure: results of 493 patients. Dis Colon Rectum. 2006 Jan. 49 (1):104-8. [QxMD MEDLINE Link].
Giarratano G, Toscana C, Shalaby M, Buonomo O, Petrella G, Sileri P. Endoscopic Pilonidal Sinus Treatment: Long-Term Results of a Prospective Series. JSLS. 2017 Jul-Sep. 21 (3):[QxMD MEDLINE Link]. [Full Text].
Giordano P, Schembari E, Keshishian K, Leo CA. Negative pressure-assisted endoscopic pilonidal sinus treatment. Tech Coloproctol. 2021 Mar 23. [QxMD MEDLINE Link].
Azhough R, Azari Y, Taher S, Jalali P. Endoscopic pilonidal sinus treatment: A minimally invasive surgical technique. Asian J Endosc Surg. 2020 Nov 12. [QxMD MEDLINE Link].
Kalaiselvan R, Bathla S, Allen W, Liyanage A, Rajaganeshan R. Minimally invasive techniques in the management of pilonidal disease. Int J Colorectal Dis. 2019 Apr. 34 (4):561-568. [QxMD MEDLINE Link].
Kalaiselvan R, Liyanage A, Rajaganeshan R. Short-term outcomes of endoscopic pilonidal sinus treatment. Ann R Coll Surg Engl. 2019 Aug 5. 1-4. [QxMD MEDLINE Link].
Dragoni F, Moretti S, Cannarozzo G, Campolmi P. Treatment of recurrent pilonidal cysts with nd-YAG laser: report of our experience. J Dermatolog Treat. 2018 Feb. 29 (1):65-67. [QxMD MEDLINE Link].
Suárez Valladares MJ, Rodríguez Prieto MA. Neodymium-doped yttrium aluminium garnet laser to treat primary pilonidal cysts: an alternative treatment. Br J Dermatol. 2018 Feb. 178 (2):e127-e128. [QxMD MEDLINE Link].
Harju J, Söderlund F, Yrjönen A, Santos A, Hermunen K. Pilonidal Disease Treatment By Radial Laser Surgery (FilaC™): The First Finnish Experience. Scand J Surg. 2020 Dec 21. 1457496920975610. [QxMD MEDLINE Link].
[Guideline] Johnson EK, Vogel JD, Cowan ML, Feingold DL, Steele SR, Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons' Clinical Practice Guidelines for the Management of Pilonidal Disease. Dis Colon Rectum. 2019 Feb. 62 (2):146-157. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Iesalnieks I, Ommer A, Herold A, Doll D. German National Guideline on the management of pilonidal disease: update 2020. Langenbecks Arch Surg. 2021 May 5. [QxMD MEDLINE Link]. [Full Text].
Mahdy T. Surgical treatment of the pilonidal disease: primary closure or flap reconstruction after excision. Dis Colon Rectum. 2008 Dec. 51 (12):1816-22. [QxMD MEDLINE Link].
Gabor S, de Lima Favaro M, Pimentel Pedroso RF, Duarte BHF, Novo R, Iamarino AP, et al. Pilonidal Cyst Excision: Primary Midline Closure with versus without Closed Incision Negative Pressure Therapy. Plast Reconstr Surg Glob Open. 2021 Mar. 9 (3):e3473. [QxMD MEDLINE Link].
Karydakis GE. New approach to the problem of pilonidal sinus. Lancet. 1973 Dec 22. 2 (7843):1414-5. [QxMD MEDLINE Link].
Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z J Surg. 1992 May. 62 (5):385-9. [QxMD MEDLINE Link].
Ekici U, Ferhatoglu MF. The effects of skin closure by using mattress sutures or intracutaneous absorbable sutures after the Karydakis flap surgery because of sacrococcygeal pilonidal sinus. A comparative analysis. Ann Ital Chir. 2019. 90:474-479. [QxMD MEDLINE Link].
Favuzza J, Brand M, Francescatti A, Orkin B. Cleft lift procedure for pilonidal disease: technique and perioperative management. Tech Coloproctol. 2015 Aug. 19 (8):477-82. [QxMD MEDLINE Link].
Bascom J, Bascom T. Failed pilonidal surgery: new paradigm and new operation leading to cures. Arch Surg. 2002 Oct. 137 (10):1146-50; discussion 1151. [QxMD MEDLINE Link].
Bascom J, Bascom T. Utility of the cleft lift procedure in refractory pilonidal disease. Am J Surg. 2007 May. 193 (5):606-9; discussion 609. [QxMD MEDLINE Link].
Emile SH, Khan SM, Barsom SH, Wexner SD. Karydakis procedure versus Limberg flap for treatment of pilonidal sinus: an updated meta-analysis of randomized controlled trials. Int J Colorectal Dis. 2021 Apr 10. [QxMD MEDLINE Link].