Pilonidal Cystectomy - Preparation, Procedure and Recovery Time

Introduction

Pilonidal disease is common among all age groups. It is a soft tissue disease that occurs in the crease of the buttocks and is believed to be acquired. When there is a fluid-filled inside the sac, it becomes a cyst that can be symptomatic or asymptomatic. If there is no pain or discomfort, then it might not need any treatment. If the cyst becomes infected by a bacterial infection, then surgical treatment is the most effective option for quick relief.

The occurrence of pilonidal disease is estimated to be 26 cases in every one lakh people and affects men two times more than women. The cause of this disease is unknown, and it is believed that it occurs because of trapped hair follicles in a sac under the skin.

What Is a Pilonidal Cyst?

It is a fluid-filled sac-like structure present in the skin. A cyst (sac-like structure) may be filled with fluid, semi-solid, or gas materials. The word pilonidal means nest of hair. It is said that pilonidal cyst is an acquired disease, while some think that it has been present since birth.

What Are the Other Common Names of Pilonidal Cyst?

It is also called pilonidal cyst disease, intergluteal pilonidal disease, or pilonidal sinus. During world war II, it was commonly seen in soldiers and was called jeep driver’s disease or jeep disease.

What Is Pilonidal Cystectomy?

It is a surgical procedure to remove the pilonidal cyst from the tailbone-a small bone at the bottom or base of the spine.

What Is the Pilonidal Cyst Position?

The pilonidal cyst is located in the crease of the buttocks.

Who Can Get Pilonidal Cyst?

A pilonidal cyst can occur in anyone. Those who are at higher risk of getting pilonidal cyst are:

• Men are more likely to develop a pilonidal cyst than women.

• Those of age between 20-40 years.

• Truck drivers and others who have sitting jobs.

• Overweight people.

• Those who wear tight clothes.

• Those who have rough or thick body hair.

What Causes Pilonidal Cyst?

The cause of pilonidal cyst is unknown, but there are a few possible causes, such as:

• Pits or depressions in the skin at the base of the spine. These are hair follicles.

• Follicular occlusion - a group of diseases in which the hair follicles become blocked and rupture, causing skin inflammation. This may occur due to frictional forces.

• Hair from surrounding skin may collect in the pit and create an opening.

• Bacterial entry into the pit may cause infection.

What Are the Symptoms of Pilonidal Cysts?

• Pain in one side of the grooves is present at the top of the buttocks.

• Swelling.

• Skin inflammation.

• Pus formation.

• Pus drainage or bleeding.

• Pain.

• Fever.

• Nausea.

How to Diagnose Pilonidal Cyst?

1. Physical Examination: The affected area may appear red and swollen. Midline pits in the superior gluteal cleft may be present.

2. Biopsy: If required, a biopsy may be performed to examine the cyst under the microscope. The histopathological examination may show the following:

• The lining of the cyst is made of vascular pyogenic granulation tissue.

• Free granulation and scar tissue.

3. Imaging Test: Ultrasound or computed tomography are rarely performed when the diagnosis is unclear. It helps to know the extent of the disease.

4. Methylene Blue: It is used to assess the extent of pilonidal sinus.

What Is a Pilonidal Cystectomy Procedure?

The treatment of pilonidal cyst can be surgical or non-surgical. In most patients, surgical treatment is done.

Surgical Treatment:

1. Laser Epilation: It is done when there is no abscess. Epilation can be done in the form of waxing or shaving the hair on the affected area. Laser epilation uses a laser to remove the hair. It is important to remove the hair from the affected area because it reduces the chances of cyst recurrence.

2. Incision and Drainage: It is done when there is an infection or abscess.

3. Pilonidal Cystectomy: It is performed to remove the cyst.

• The patient will lie down with buttocks elevated.

• Local anesthesia is given to the patient.

• An incision or cut is made, and the pus drains out.

• The entire cyst can be removed, or sometimes the cyst is left open to drain it completely.

• If there is no infection, then the entire cyst can be removed.

• The cut is then sutured and closed.

4. Other surgical treatments include curettage, unroofing, surgical excision, or aspiration.

5. Skin Flaps: The defects can be closed through flaps. Commonly used flaps are the karydakis flap, rhomboid flap, or Limberg flap.

• Karydakis Flap: The affected area is surgically excised in an ovoid shape; a fasciocutaneous flap is used to close or cover the wound. This flap provides less recovery time, fewer complication rates, and less recurrence rate.

• Limberg Flap or Rhomboid Flap: A surgical excision is done, and a fasciocutaneous flap is used to close the wound, which is of rhomboid shape. This flap provides minor complications; no recurrence, decreased hospital stay, improved wound healing; and less postoperative pain.

• V-Y Advancement Flap and Z-Plasty: These provide tension-free repair and reasonable coverage of the wound. No complications and fast wound healing are reported.

6. Endoscopic Pilonidal Sinus Treatment: It is a less commonly used surgical treatment. It is a minimally invasive video-assisted technique in which the infected tissues are removed by directly viewing them through a camera.

Non-surgical Treatment:

1. Antibiotic Therapy: The prescription of antibiotics is controversial. These can help reduce the infection but cannot heal the cyst.

2. Analgesics: These can help reduce the pain.

3. Antipyretics: These help to subside fever.

What Are the Complications of Pilonidal Cystectomy?

• Allergic reactions due to anesthesia.

• Recurrence of the cyst.

• Recurrence of the infection in the cyst if not removed completely.

• Surgical site infection.

What Is the Differential Diagnosis of Pilonidal Cystectomy?

• Abscess - A condition in which pus is collected that leads to pain. The pus formation occurs due to bacterial infection and can occur in tissues, organs, or spaces between the organs in the human body.

• Hidradenitis Suppurativa - A condition that causes lumps under the skin, especially under the armpits, buttocks, etc.

• Inflammatory Bowel Disease - A condition that leads to the inflammation of the digestive tract.

• Fistula - An abnormal connection between two structures of the body.

• Epidural Abscess - Occurrence of infection between skull bones and brain lining.

What Is the Recovery Time After Pilonidal Cystectomy?

If the incision is closed with a suture, then the healing takes up to four weeks. If the incision is left for secondary intention healing, then it may take several weeks to months.

How to Prepare for Pilonidal Cystectomy?

Before surgery, it is important to follow some instructions:

• Quit smoking at least two weeks before surgery because it delays the healing process. The patient must avoid smoking for up to eight weeks after surgery.

• The patient may take minor pain relievers such as Acetaminophen to avoid excessive bleeding.

• Stop taking Aspirin before surgery because it interferes with the bleeding and may result in excessive or uncontrollable bleeding.

Conclusion

Pilonidal cysts do not have a single treatment modality, and treatment should be decided based on the patient’s condition and underlying cause. Out of all the options available, pilonidal cystectomy is the definitive and best treatment. It includes draining the pus out from the cyst and closing the wound with sutures, flaps, or left open for secondary intention healing. Physical evaluation of the affected area is the only diagnostic method, and therefore it requires a critical and careful examination.