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.
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10%, personal still unpublished results).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).
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15 days AFTER surgery |
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"SYNOTOMY" OR "UNROOFING" PROCEDURE WITH DEBRIDEMENT FOR PILONIDAL DISEASE
The "synotomy" or "unroofing" procedure accompanied by debridement for the treatment of pilonidal disease is a minimally invasive procedure and is a valid alternative to the Bascom-Gips procedure and other minimally invasive procedures.
"Synotomy" or "unroofing" with curettage does not involve the sacrifice or loss of tissue, but simply flattens the fistulous tract(s), thus preserving the surrounding tissue.
This procedure is particularly indicated for cases characterized by medial fistulous tracts, where it allows very rapid healing times, comparable to those of other minimally invasive procedures.
In cases of superficial fistulous tracts, "synotomy" or "unroofing" with curettage guarantees very satisfactory results, with a low percentage of recurrence.
Due to these characteristics, "synotomy" is considered a highly effective procedure in the treatment of pilonidal disease and a valid alternative to the Bascom-Gips procedure and other minimally invasive procedures.
More specifically, the "synotomy" or "unroofing" procedure involves passing one or more probes into the fistulous tract(s) and then "flattening" the fistulous tract(s) to access the inflamed area so that careful debridement can be performed with a specific instrument (Volkmann spoon or curette). The surgeon then cleans the cavity, removing hair, debris, and inflamed tissue. The wound, generally not very large, is left open and usually not sutured, allowing for gradual but rather rapid healing, reducing the risk of recurrence. Healing occurs through the formation of new healthy tissue, resulting in spontaneous closure of the wound within 2 to 3 weeks.
Advantages of the procedure:
Minimally invasive:
The incisions are generally small and the wound is not completely closed, reducing postoperative pain.
Low risk of recurrence:
Removing inflamed tissue and hair through curettage reduces the risk of the cyst recurring.
Faster healing:
Although healing occurs by secondary intention, healing times are much shorter than with other techniques, allowing a quicker return to daily activities.
Smaller scarring:
The resulting scars are generally small and less noticeable than with other procedures.
What to expect after the procedure:
Dressings:
Dressings are simple and can be managed by the patient with saline solution or simply using a shower at home.
Follow-up:
The patient is generally reevaluated after one week, one month, two months, and six months.
Recovery:
Physical and work activities can be resumed normally after approximately 2 or 3 weeks, as long as they do not involve the sacrococcygeal region, although medication may be necessary for a longer period.
In summary, the "synotomy" or "unroofing" procedure for pilonidal disease is an effective and minimally invasive procedure that offers numerous advantages in terms of healing, risk of recurrence, and aesthetic impact, allowing a rapid return to normal daily activities. The "synotomy" or "unroofing" procedure with debridement represents a valid alternative to the Bascom-Gips procedure and other minimally invasive procedures for the treatment of pilonidal disease.
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