Patient Education and Consent

All patients should be counseled about proper hygiene to the area. Patients with a significant amount of hair in the area may benefit from hair removal strategies.

For proper healing, patients may need thorough instructions for care and dressing changes. A dressing can be as simple as a dry rolled gauze held in place with tight-fitting underwear or a small amount of tape. A wound care nurse may be consulted for care of complex wounds that require packing the wound or for sponge dressing changes on negative-pressure wound therapy (NPWT) devices.

Patients should minimize any shear stress to the area by not performing any running, twisting, or repetitive motions (eg, biking or horseback riding), friction (eg, motorcycle riding or off-roading), or exercises on the back (eg, situps). Patients should lie on the abdomen or on one side when sleeping.

Equipment

A standard minor surgery set is used for this procedure. An electrocautery device with a smoke evacuator is preferred. An anoscopy set should be available to examine the anus and rectum in cases where the cyst or sinus tracts are close to the anorectal canal. A lacrimal duct probe and a curette set should also be available.

Anesthesia

For very small pilonidal cysts or for drainage of an abscess, the procedure can be performed with local anesthesia using 1% lidocaine mixed with 0.25% bupivacaine and epinephrine. For a simple pilonidal cystectomy, the patient may be offered spinal anesthesia and local anesthesia with monitored anesthesia care. For larger or more complex procedures, local and general anesthesia may be preferred.

Positioning

For most procedures, patients are placed in the prone jackknife position with slight Trendelenburg. If necessary, the patient's buttocks are held spread apart by attaching long pieces of tape from the buttocks to the operating table.

Monitoring & Follow-up

Follow-up depends on the type of procedure performed. If primary closure is attempted, patients generally follow up in 2 weeks, then as needed. If the wound is left open to heal secondarily, then follow-up may have to be more frequent until patients are able to care for the wound themselves. In these cases, daily wound care is often required, including packing the wound with gauze and covering with tape.

Many surgeons recommend using a razor or clippers to remove hair around the natal cleft on a weekly basis as needed after surgery. One study surveyed patients who had a pilonidal cystectomy and had been instructed to use a razor to remove hair.^[8] Over a mean follow-up of 11 years, those who performed razor epilation had a higher recurrence rate, 30.4%, compared with those that did not perform postoperative epilation, at 19.7%. On the basis of this study, the authors recommended against using a razor for epilation postoperatively.

Many small studies have been performed evaluating laser epilation postoperatively. In the 1- to 3-year follow-up periods, there is a significant reduction in recurrence. However, many of these studies used different types of lasers with different treatment schedules. Collectively, these studies suggest that laser epilation prevents recurrent pilonidal disease. Long-term studies may be warranted to further elucidate the role of laser epilation.^{[1, 2, 3]}

Technique

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