Perioperative management - Excision of pilonidal sinus with secondary healing

• Chronic pilonidal sinus
• Acute abscessing pilonidal sinus

• An asymptomatic, non-irritated pilonidal sinus does not require further therapy. The patient should be informed that a chronic or acutely abscessing infection may occur. If these patients are monitored, they are not asymptomatic over time but have mild symptoms and will eventually undergo surgery sooner or later.
• A radical excision in the abscess stage is uncertain and is associated with a high recurrence rate (up to 41%), as it is often performed as an emergency and then by inexperienced individuals. Additionally, with complete excision, the wound often becomes unnecessarily large due to swelling. Therefore, initially only unroofing of the abscess for effective drainage. Radical excision is performed in the infection-free stage after 7–10 days.

In the case of suspected diagnosis of a pilonidal sinus, risk factors such as excessive body hair, increased sweat secretion, obesity, and reduced personal hygiene should first be considered. Then, it is necessary to distinguish between:

• a non-irritated pore
• an acutely abscessing form
• a chronically secreting form

Ultrasound, CT, or MRI are dispensable.

In the case of a non-irritated porus, the patient is informed about the course of the condition, particularly that spontaneous healing is not possible, and that very rarely a malignant transformation may occur (see above). The patient is scheduled for annual follow-up examinations.

In the case of the acutely abscessing form, the typical signs of a soft tissue abscess with local redness, warmth, and swelling can usually be detected paramedian to the anal cleft. The acutely abscessing form requires immediate therapy, and initially, a surgical abscess drainage should be performed with a 1-2 cm incision. The wound should allow adequate drainage, and definitive surgical treatment should generally occur after seven to ten days.

• Recurrence
• Local wound healing problems
• Bleeding
• Cosmetically disturbing changes in the gluteal region
• Impairment of skin sensitivity
• Longer, possibly several months of healing duration