PILONIDAL SINUS (PILONIAL PILON)
Pilonidal Sinus (cyst, infection, pilonidal sinus) is a sinus or abscess that occurs in the intergluteal space (the area between the two hips) and contains hair. Although the exact cause is not known, it is thought that this gap creates a vacuum while sitting and pulls the hair into the midline pits. These hairs that grow inward are later infected and the disease manifests itself as an abscess in the coccyx.
What are the Types of Pilonidal Sinus
It is important to know the Clinical Classification of this disease to determine the treatment. There are 5 types.
Type I: Those with a silent point — There have been vague complaints in the coccyx. There are still no complaints. There are only one or a few holes the size of a pinhead. Only follow- up is sufficient. No intervention is required
Type II: Those who cannot sit — Abscessed beginning (acute pilonidal cyst abscess). There have been no complaints before. There is pain, swelling and redness in the coccyx, which has developed in the last few days, usually 5-6 centimeters above the anus, and is a few centimeters in diameter. The patient has difficulty sitting. Antibiotics are rarely effective. The pain cannot be relieved despite painkillers. Urgent surgery is required.
Type III: Those with constant discharge — Long-term discharge (chronic pilonidal sinus). This is the most common clinical picture. Discharge is in the foreground. It may have started after a previous abscess or without any abscess symptoms. Pain and redness are rare. The patient often sees inflammatory soiling in their underwear. Inflammatory holes usually start 5-6 centimeters above the anus in the hollow between the buttocks and tend to spread upwards. Sometimes hair is seen growing out of these holes. Holes may also be seen a few centimeters to the side of the midline in those who have had the disease for a long time. This is a sign that the disease is progressing. Surgery is required for planned permanent treatment.
Type IV: Those Who Cannot Sit Down After Their Discharge Stops — After a long period of discharge, the discharge stops and an abscess develops (chronic pilonidal sinus abscess). During the course of the chronic disease, an abscess similar to the one at the beginning develops as a result of the blockage of the openings that drain the inflammation. There are abscesses that extend beyond the coccyx region. Emergency surgery is required, 2-stage treatment should be preferred..
Type VI: Those Who Had Surgery and Recovered — These are patients who develop an abscess and discharge again after a complaint-free period of at least 3 months after surgery.
WHAT IS DONE IN THE TREATMENT OF HAIRY TUMBLER
If the pilonidal sinus has abscessed, it is necessary to open the abscess surgically. Since these abscesses are usually superficial, the procedure can be performed in the office, clinic or emergency room.
Surgery is the only valid method for the treatment of Chronic Pilonidal Sinus. Simple non-surgical applications such as scraping the area, freezing it, burning it with laser beams or electric knives, and applying various chemical substances such as Polyphenol can be performed. However, the recurrence rate of these methods is higher than surgical intervention.
It can be applied to patients who do not accept surgery.
WHAT ARE THE METHODS OF HAIRY TUBE SURGERY?
Microsinusectomy
Opening the fistula and scraping it
Complete removal of the cyst and primary closure
Complete removal of the cyst and leaving it open
Complete removal of the cyst and flap applications
Cleft-Lift application
MICROSINUSECTOMY
It is a treatment method performed with local anesthesia and does not require hospitalization. There is no need for general anesthesia at all. It only takes 10 minutes. The sinus there is removed with a very small incision of 2 cm. However, the length and area of this incision is quite large in other operations. In fact, in some surgical techniques, the tissue is shifted and there is a large suture area, which causes you to live with a large surgical scar afterwards. In the microsinusectomy method, since there is a very small incision after the operation, a barely visible scar remains.
Complete removal of the cyst and flap applications (patch shifting)
One of the types of surgery that may be suitable for most cases of chronic pilonidal sinus with long-term discharge is the type of surgery in which the with a patch. First, the diseased tissue is completely removed. A tongue- shaped patch tissue (flap) is prepared from the adjacent hip tissues in the midline, including the skin and subcutaneous tissue. The surgery (excision + flap) is completed by turning the patch to the side and stitching it to the space left after the wound removal. When considered in terms of long-term results, it is a successful surgical technique.
Complete removal of the cyst and leaving it open
Excision of the diseased area and leaving the wound open as it is; It is a short and easy procedure. However, the wound healing period can take up to 6-8 weeks. The recurrence rate of the disease is 5-10%. Since it is a laborious treatment method for the patient, it is not preferred unless necessary.
Complete removal of the cyst and primary closure
The method in which the diseased area is removed and the wound lips are stitched together (excision + primary repair) is a less preferred type of surgery. Rarely, it is only suitable for minor inflammations. The surgery time is 20 minutes. The wound healing period is 10-15 days, but the recurrence rate of the disease is 20-30%.
CLEFT LIFT TECHNIQUE
The Cleft Lift technique is the asymmetric ellipse-shaped removal of the affected skin, Pilonidal Sinus and lateral openings by preserving the fatty tissue in the coccyx and flattening the space between the two buttocks by filling the removed space with a thick piece of skin.
It is a reliable, easy-to-perform, low- recurrence, and non-stressful operation method for type 4 cases where one or more sinus openings are outside the coccyx region and in recurrence cases. Patients who have this operation stay in the hospital for 1 day and can start working within 7-10 days.
WHICH SURGERY FOR WHICH PATIENT?
As in all surgical procedures, the aim in Pilonidal Sinus surgery is to choose an operation method that is simple, painless, effective, provides early return to work and has the least recurrence. There is no single method that meets all these conditions. The important thing is to choose the appropriate method for the patient.
For example, microsinusectomy seems to be the best method among all methods. However, this operation may be suitable for a very small portion of pilonidal sinus patients, such as 5-10%. It can only be considered as a simple option in the early stages of the disease, when the hollow between the buttocks is small and the hair density is low. There is a misconception on social media that it can be applied to every patient. The vast majority of patients present with a large area of chronically inflamed tissue. It is obvious that removing only a 1-2 cm diameter piece of tissue will not provide a permanent cure for most patients and that recurrences will be high.
The types of surgery that may be appropriate for most cases of chronic pilonidal sinus with wide sinus openings are wide removal of the wound and repair with a patch (flap) and cleft-lift surgery.
Cleft-Lift should be the operation that will be chosen more frequently in patients with recurrence and long-term treatment.