Minimally invasive surgery for pilonidal disease
In recent years, the field of minimal treatments for pilonidal disease has expanded, offering advanced alternatives to traditional wide excision surgery. These treatments are characterized by minimal damage to healthy tissue, faster recovery, and improved aesthetic results.
Main Minimal Treatment Methods:
1. Mini-surgery with Trephine (Trephine/Punch Operation)
The minimal method for treating pilonidal disease was published in 2008. The treatment involves using thin perforators (trephines, punches) for separate punctate excision of each of the skin openings and the channels leading from them to the subcutaneous cavities and cleaning the cavities of hair and inflammatory content that accumulated in them. This treatment removes in a targeted manner the disease factors (openings, channels and hair), without the need for wide and unnecessary excision of surrounding healthy tissue. Due to the minimal tissue excision, no aesthetic damage is caused and compared to traditional wide excision, recovery with the minimal method is incomparably faster and easier. The procedure is possible under local anesthesia, without the need for hospitalization, and the average healing time is 2-4 weeks. In case of disease recurrence (about 20%), the same treatment can be repeated.
Additional names for the minimal method: Lord & Millar operation, Bascom "pit picking" operation, Gips "trephine/punch" operation.
The picture shows the punching tools (trephines), used to remove each pit and subcutaneous tracts.
Excision of a pilonidal pit using a 4mm trephine and extracting hairs from the sinus.
2. Video-Assisted Endoscopic Treatment
A minimally invasive technique published in 2014, combining punctate excision technology of openings using trephine with endoscopy for visualization of the pilonidal cavity. Endoscopes are thin tubes with a camera and light at their ends. The endoscope is inserted into the subcutaneous pilonidal cavity and allows removal of hair and debris from the cavity under direct visual control. Through the endoscope, it is also possible to cauterize the cavity walls using electric current or laser beam.
3. Laser Treatment
A cauterization technique performed without the need for an endoscope. The method includes excision of openings and channels and cavity cleaning as in trephine surgery, insertion of an optical fiber into the pilonidal sac and activation of a laser beam through it to cauterize the sac walls and cause its contraction.
The modern minimal surgeries for pilonidal disease represent a significant advancement in treating this condition. Trephine treatment, as the leading method in the field, offers an effective, safe and convenient solution for patients, with excellent results and minimal impact on quality of life. Endoscopic and laser methods are based on trephine operation and aim to optimize cleaning of the pilonidal cavity. However, they require expensive resources and equipment for their operation, and ongoing medical research is needed to prove their advantages in long-term disease healing.
4. Phenol Injection Treatment
An old treatment based on chemical cauterization to destroy the pilonidal cavity. The treatment is performed by injecting carbolic acid (phenol) into the sac cavity, as a single treatment or as a complement to trephine surgery. The treatment often requires multiple injection sessions and is not widely used by surgeons.
Additional information on trephine surgery
The principle of minimal surgery is based on the special structure of the basic pilonidal unit:
the unit consists of a dermal opening (pit) that leads to a narrow skin-lined canal. The canal extends to an hair containing inflamed subcutaneous pocket.
Pilonidal disease may include one or several units along the natal cleft and the pockets of the units sometimes merge into one cavity.
During surgery, each of the openings and canals is individualy excised with a trephine (punch) and a canal of several millimeters wide is created, denuded of skin lining. The wider canal enables effective cleaning of the subcutaneous cavity and allows continued drainage from the cavity for several days until it shrinks and disappears along with the opening in the skin.
Cross section along the bottom of the natal cleft illustrating the excision of pits and tracts and cleaning of the underlying cavity.
Minimal procedures using trephines with complete healing within few weeks.
