Pilonidal cyst

Pilonidal Disease (PD), also referred to as a pilonidal cyst, sinus, abscess, or sacrococcygeal fistula, is an acquired condition caused by ingrown hair near or on the midline (natal cleft) which gets infected (sacrococcygeal area). Skin and sucutaneous fat are involved, therefore PD can be considered a "dermatological condition".

This happens centrally (medially), often following microtraumas, especially in hairy people (therefore, more often among males) by means of a “sucking” mechanism. Therefore, the American authors call PD “Jeep disease”. From the centre the condition can expand laterally, with fistulous opening(s), track(s) and cyst(s). PD (see figure below) can present as an acute (abscess) o chronic condition.

PD in less severe cases can be controlled by means of thorough hygiene, depilation (temporary) and epilation (conclusive). In most cases, however, surgery is necessary. Surgery, in non-dedicated centres, is performed by means of wide and deep excisions, with severe postoperative pain, neverending painful dressings (up to 3 months), long recovery time. If these wounds are sutured (attempted primary healing) they often dehisce (open), as the wounds are centrally located (forces of traction). Recurrence(s) is always a possibility. However, PD is a truly dermatological condition, and “Wide excision of blocks of fat down to periosteum, an outmoded treatment, now seems equivalent to treating a pimple on the chin by cutting off the patient’s head!” (“Pilonidals: Distilled Wisdom“. Bascom J, Basso L. Italian Society of Colorectal Surgery, 2010). Therefore, in most cases and according to the researches performed by John Bascom since 1980 (“Pilonidal disease: origin from follicles of hairs and results of follicle removal as treatment”. Surgery, 1980; 87: 567-72), it is possible to surgically remove PD by means of targeted removal of the pits, fistula(e) ("fistulectomy") and cyst(s) ("cystectomy") only, leaving alone all the healthy unaffected tissues surrounding the pits.

This “minimal” excision can be completed by means of small trephines or biopsy punches, according to a slight Israeli modification of the original Bascom's technique of 1980 (Moshe Gips et al. Diseases of the Colon & Rectum 2008; 51: 1656-63 – PAPER – VIDEO 1, 2, 3, 4, 5). Possible wider excisions can be performed laterally or by means of a lateral approach (for example, to drain abscesses) where, for mechanical reasons, the wounds primarily quickly heal (“Pilonidals: Distilled Wisdom”. Bascom J, Basso L. Società Italiana di Chirurgia Colorettale, 2010). According to Bascom's original tecnique this “minimal” excision is performed by means of a scalpel (original Bascom’s technique – VIDEO 6). The choice of the mini-invasive procedure is strictly based on the type of PD, as surgery has to be tailored to the patient and not viceversa (“tailored surgery”). If necessary, the minimally invasive procedure can be repeated, as recurrence is always a possibility (<10%, personal still unpublished results). As a rule, work / school / university can be resumed in 3 or 4 days, full recovery occurs within 15-20 days. Sport can be resumed after 7 days (running, jogging, tennis, ski, fencing, gymnastics, aerobic and similar activities) - 20 days (swimming, soccer, rugby, cricket and similar) - 30 days (cycling, rowing, horse riding, and similar activities).

Only in rare and selected cases of several episodes of extremely wide and complicated recurrences, broad excisions can be taken into consideration. These, can be repaired by means of carefully prepared flaps (for instance: “Z” plasty), which heal in a longer but still short time (generally 20 days).