Pilonidal cysts and sinuses should be completely excised or exteriorized (FIGURE 1A, B). Acutely infected sinuses should be incised and drained, followed later by complete excision after the acute infection subsides. The more limited procedure of exteriorization (marsupialization) is effective when the sinus tract is well defined (FIGURE 1B). Regardless of the various surgical approaches, such lesions may recur.
In complicated sinuses with several tracts present, a dye such as methylene blue may be injected for better identification, although if a careful dissection is carried out in a bloodless field, the surgeon can identify the sinus tracts. It is important that this be done several days before the operation to avoid excessive staining of the operative area, which may occur if the injection is done at the time of operation. Preoperative antibiotics are typically not necessary.
Light general anesthesia is satisfactory. The patient’s position requires that special care be taken to maintain an unobstructed airway. The presence of extensive disease may necessitate the use of general or spinal anesthesia. Spinal anesthesia should not be used in the presence of infection near the site of lumbar puncture.
The patient is placed on his or her abdomen with the hips elevated and the table broken in the middle (FIGURE 2).
Two strips of adhesive tape are anchored snugly and symmetrically about 10 cm from the midline at the level of the sinus and pulled down and fastened beneath the table (FIGURE 3). This spreads the intergluteal fold for better visualization of the operative area. A routine skin preparation follows after the skin is carefully shaved. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
An ovoid incision is made around the opening of the sinus tract off the midline about 1 cm away from either side (FIGURE 4). Firm pressure and outward pull make the skin taut and control bleeding.
An Allis forceps is placed at the upper angle of the skin to be removed, and the sinus is cut out en bloc (FIGURE 5). The subcutaneous tissue is excised downward and laterally to the fascia underneath. Great care is taken to protect this fascia from the incision because it offers the only defense against deeper spread of infection (FIGURE 6). Small, pointed hemostats should be used to clamp the bleeding vessels so as to incur the smallest amount of tissue reaction. Electrocoagulation may be used to control bleeding and to keep the amount of buried suture material to a minimum. Some operators prefer to avoid burying any suture material ...