How Do I Choose the Right Treatment?

The choice of treatment type is influenced by two main factors:

The characteristics of the patient's pilonidal disease

and his preferences regarding possible treatment.

1. The characteristics of pilonidal disease are diagnosed by the consulting physician during the patient's examination and include the number of pilonidal openings along the gluteal fossa, the number of inflammatory extensions of the disease (fistulas), types of surgeries performed in the past, the presence of areas of skin loss and open wounds, and deformities of the gluteal fossa tissue due to previous surgeries.

Based on these characteristics, the patient's individual pilonidal disease can be defined according to the following division:

Mild pilonidal disease: single pilonidal openings with a single fistula or no fistula.
Moderate -grade disease : multiple pilonidal openings and fistulas.
Complex pilonidal disease : multiple openings and fistulas in different directions, condition after previous surgeries, areas of skin loss with open wounds, distortion of the buttock tissue.

Notes:

1. There is still no single agreed-upon division in the medical world to classify the complexities of pilonidal disease.

2. In most proposed classifications for disease characteristics, recurrent disease after surgery is defined, by default, as a complex disease that is recommended for treatment by wide resection. It should be remembered, however, that in most cases of recurrent disease after minimal surgery, it is still possible to treat it with repeated minimal surgery, without the need for wide resection.

Important to know: Surgical associations around the world recommend:

1. Prefer minimally invasive surgery as the first choice for treatment of mild pilonidal disease.

2. Avoid wide median resections due to the high rate of surgical complications and disease recurrence.

3. In complex pilonidal disease, a midline-displaced sling surgery (such as "Karidakis", "Bascom 2" or "rhomboid" type) should be preferred.

Website author's note: Moderate grade disease is in the "gray area" in terms of treatment recommendations, with a tendency in the medical literature to recommend treating it with a wide resection. In the website author's opinion, moderate-grade disease can also be treated with minimal surgery, despite the increased possibility of recurrence of the disease at this level.

2. Patient preferences: To make an informed choice of treatment for his illness, the patient needs a rating of his illness by the consulting physician, an explanation from the physician about the type of treatment recommended according to the degree of his illness, and an explanation of the difference between the types of possible surgeries as follows:

Wide excision surgery with a flap:

The surgery is performed under general anesthesia and usually requires hospitalization.
Involves a healing and recovery period of about a month or more (months in open median surgery type).
Significant pain and limitation of activity during the recovery period.
High incidence of surgical site infection and healing disorders.
Recurrence of the disease usually requires extensive repeat surgery.
Scarring and significant cosmetic damage.
The recurrence rate is less than 10%.

Minimal analysis:

The surgery can usually be performed under local anesthesia and does not involve hospitalization.
Quick recovery with return to normal activity within a few days.
Minimal pain level due to the small surgical wounds.
Without seams.
Very low rate of infection after surgery.
Possibility of repeating the same minimal operation in the event of a recurrence of the disease.
No cosmetic damage.
The recurrence rate of the disease is about 20%.

The patient has the right to choose their preferred treatment, taking into account their personal needs in terms of returning to activity, work or school, and taking into account the ease of recovery and the aesthetic implications of the surgery - even if their choice does not exactly match the type of treatment that is appropriate for the severity of their illness.

Note: As of today, most surgeons around the world have been educated and experienced in the traditional surgery of the wide median resection and recommend it regardless of the complexity of the disease. It is important to consult with a surgeon who is also experienced in minimally invasive and flap surgeries and is qualified to recommend the most appropriate treatment, taking into account the complexity of the disease.