PILONIDAL SINUS DISEASE
Pilonidal disease is an ailment that occurs in the lower
part of the back region. It usually affects young,
hairy, plumpy (overweight) males who sweat a lot and
have to sit for long hours. It is most common in the
15-30 age group and rarely has the onset after 40. About
1 per cent of the population is affected by this disease
and males are afflicted about 3 times more than females.
In this disease, a painful wound forms in the midline
about 5-8 cms from the anus in the back region from
which pus keeps oozing out. The wound doesn’t heal
spontaneously because almost always there is a tuft of
hair present at the base of the wound. This happens as
the loose hair over the lower back are drilled,
propelled, and sucked into the pilonidal sinus. This
sucking is caused by friction and the movement of the
buttocks whenever the patient stands or sits.
Pilonidal Sinus with hairs protruding from the Sinus
The wound has the tendency to spread upwards, lower side
or sidewards, thereby extending the disease to the new
area. When pus keeps on forming and somehow is unable to
drain, an abscess might form leading to an acute
swelling and severe pain.
Pilonidal disease is notorious for its recurrent nature
after treatment. However, if properly managed its
recurrence is not very common.
The treatment of pilonidal disease is almost always
surgical. Of the non-surgical techniques, injections of
Phenol or Fibrin Glue may be tried but are usually not
widely used. The goals of the ideal procedure for the
treatment of this disease should be reliable wound
healing with a low risk of recurrence, a short period of
hospitalisation, minimal inconvenience to the patient,
and minimum wound-management problems. Also, treatment
should allow the patient to resume normal daily
activities as quickly as possible.
1. Incision & drainage: This is done in
acute cases when there is an abscess formation. A small
cut is made and the pus collected is drained out. The
cavity is thoroughly cleaned. The rest of the management
of sinus is done at a later date.
2. Excision of the sinus and leaving the wound
open: Excision of a pilonidal sinus means
removing all the affected tissues with at least 5 mm
margin of normal skin. All the tissue right up to the
backbone (prescaral fascia) is removed.
The wound is cleaned by rubbing with a blunt instrument
to remove the hair, granulation tissue and skin debris.
A bunch of hair is usually found at the base of the
wound, which is responsible for non-healing of the
wound. The resulting wound is left open which gets
healed slowly over four-six weeks.
Advantages- Lower recurrence rate as any missed
branch/tract would be see during the dressing period
Disadvantages- A large open wound which takes
much longer time to heal from upto 6 to 24 weeks
depending on the size of the wound. Admission for 2-3
days and bed rest in prone position from 10-14 days.
A patient with Pilonidal Sinus
Wide Excision of Pilonidal Sinus done
Resulting Final Wound left open to heal
3. Excision with primary closure: In this
method, the diseased part is totally removed as
described above. However, the wound is closed so that it
heals much faster. However, a small disadvantage of this
method is that the recurrence could be potentially
slightly higher. This is so because any infection left
behind would not be known as the wound has been closed.
Primary Midline Closure (Stitches in 2 layers)
Final wound after Midline Closure
Different methods have been used to close the wound. It
can be a primary closure (simply closing the wound with
stitches) or making a flap such as Z flap, rhomboid,
limberg, bascom or karydakis flap.
Advantages- The wound heals in shorter time as it is
closed (14 to 20 days)
Disadvantages- It's a bigger operation, hospital
admission required for 2-3 days, technically more
demanding operation, Big wound and scar, slightly higher
risk of recureence
4. Laying Open with Curettage under Local
Anesthesia (LOCULA) operation: In this method,
the pilonidal is incised/ deroofed (simply cut open and
cleaned of all the pus, hair and debris) rather than
excised (removing the sinus with a wide margin). The
benefit is that the resulting wound is much smaller and
healing time and pain is much less than when the wound
is widely excised. This procedure can even be done under
local anaesthesia, it does not require any
hospitalization and the person can resume work with-in
two-three hours of operation.
It has distinct advantages-
High success rate
Low complication rate
Possible under to do this under operation under local
anesthesia as an outpatient procedure
admission/ hospitalization required
to learn and reproduce
Less operating time
Minimal hospital stay
Early/ Immediate return to normal routine and work
Small wound and minimal scar
Preservation of the body contours
13. Low cost
Can be easily done again in case of a failure.
As it has so many advantages, LOCULA procedure has the
potential to become the first line procedure for all
kinds of Pilonidal sinus disease.
term has been coined by Dr Pankaj Garg. Dr Garg was
invited to Boston on 1st June, 2015 by the
AMERICAN Society of Colon Rectum Surgeons (ASCRS), the
biggest society of Colon & Rectal Surgeons in the world
to give presentation on LOCULA procedure.
Pankaj Garg, Paryush Lakhtaria, Vikas Gupta. Lay open
(deroofing) plus curettage (LOCULA) vs excision with
primary closure as the treatment of Pilonidal sinus
disease: A metaanalysis of randomized controlled trails
and a systematic review of lay open (deroofing) plus
curettage procedure for Pilonidal sinus disease.
Presented at the annual conference of AMERICAN Society
of Colon Rectum Surgeons (ASCRS), on 1st June 2015 at
Boston, MA, USA.
Pilonidal Sinus- Before Operation
After LOCULA Operation ( The
resulting wound is quite small)
In spite of all these
methods, there is always a small risk of recurrence of
the disease after the operation. Therefore, certain
precautions need to be taken so that the chances of
recurrence are minimised. These are:
shaving/cleaning of hair 5 cms around the disease site.
This shall be required for at least five years after the
b. Keep the area dry.
Apply powder regularly in the buttock folds two-three
times a day.
c. In case the body
weight is on the higher side, then keeping the weight in
d. In case of any
problem, immediately consult your surgeon.
Artcile published in The Tribune on
Pilonidal Sinus Disease
Single Hole Surgery -
You thought that a Surgery, even keyhole,
always produces a scar. Not any
Gall Stones developing in
the Gall Bladder is quite common. During the last decade,
Laparoscopic Removal of Gall Bladder has become gold
standard for treating Gall stones. But now, its about to
change with Single Hole Laparoscopic Surgery on the
horizon. This scarless surgery is a major advancement. To
know everything about Gall stone disease and its
Inflammation of Appendix known as Appendicitis occurs
commonly in young adults. Now its possible to remove
the offending Appendix with excellent cosmetic results
(no visible scar) and remarkably early recovery by
Single Hole Keyhole Surgery. Know more…
Uterus removal, also
known as Hysterectomy, is one of the commonest
operations done in females. Now, its possible to
remove Uterus or Ovarian Cyst or to do Tubectomy (Sterlization)
operation without any visible scar on the tummy. Know more…
Inguinal hernia in males
is the most common surgery done all over the world.
Now it can be done without any visible scar. Know more…