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Pilonidal cysts and sinuses should be completely excised or exteriorized (Figure 3A and 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 3B). 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 operation to avoid excessive staining of the operative area, which may occur if the injection is done at the time of operation.

Light general anesthesia is satisfactory. The patient's position requires that special care be taken to maintain an unobstructed airway. 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 1).

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 2). This spreads the intergluteal fold for better visualization of the operative area. A routine skin preparation follows after the skin is carefully shaved.

An ovoid incision is made around the opening of the sinus tract about 1 cm away from either side (Figure 4). Firm pressure and outward ...

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