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How to Choose Surgery for Pilonidal Sinus?

The decision on the type of surgery is based on the extent of the disease

and the patient's preferences.

This page covers choosing between types of surgery.

For conservative treatment or abscess treatment read the relevant pages.

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1. Extent of the disease

During the examination, the consulting physician identifies the characteristics of the disease and classifies its extent according to the following grading:

• Mild: a few isolated pilonidal openings, with a single fistula or no fistula.

• Intermediate: multiple pilonidal openings and fistulas.

• Complex: multiple openings and fistulas extending in different directions, previous surgeries, open wounds that do not heal, or distortion of the gluteal cleft tissue.

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What surgical associations around the world recommend:

  • Mild grade: Minimally invasive surgery as the first choice.

  • Intermediate grade: This is a “Gray area”, the medical literature tends to recommend wide excision. In the author's opinion, minimally invasive surgery is also possible, although a higher risk of recurrence has been reported.

  • Complex grade: Off-midline flap surgery, for example Karydakis, Bascom 2 or a rhomboid flap.

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For all grades, it is recommended to avoid midline wide excision, because of its high rate of complications and recurrence.

The effectiveness of these recommendations in choosing the type of surgery has not yet been proven in controlled medical studies.​​​

2. Patient preferences: To enable an informed choice, the physician should explain the grade of the disease and the surgery they recommend. The patient will choose based on the physician's explanations, the complexity of the disease, and personal needs:

  • The ability to return to activity, work, or studies.

  • Ease of recovery.

  • The likelihood of recurrence.

  • The aesthetic effect of the surgery on the appearance of the area.

Questions worth asking the surgeon:

• Why do you recommend this surgery in my case?

• What alternatives exist, and why are they less suitable?

• What should I expect in terms of recovery, wound care and return to activity?

• What is known about recurrence rates with the proposed method?

• What would the next option be if the surgery fails or the disease recurs?

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The main differences between the types of surgery are 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.

  • 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%.

​* (After open midline wide excision, recovery takes months).

Minimally invasive surgery:

  • 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%.

Author’s notes:

1. There is still no single agreed-upon classification for grading the complexity of pilonidal disease in the medical community.

2. In most proposed classifications of disease complexity, recurrent disease after surgery is by default defined as complex disease, for which wide excision is recommended. However, in most cases of recurrence after minimally invasive surgery, repeat minimally invasive surgery is still possible, without the need for wide excision.

3. Today, most surgeons around the world were trained in, and have experience with, traditional midline wide excision, and recommend it regardless of disease complexity. It is important to consult a surgeon who is also experienced in minimally invasive surgery and flap procedures, and who can recommend the most suitable treatment according to the complexity of the disease.

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