What is a pilonidal cyst. How is a pilonidal cyst treated surgically. What are the risks and complications of pilonidal cyst surgery. How can you prepare for pilonidal cyst surgery. What is the recovery process after pilonidal cyst surgery. How can you prevent pilonidal cysts from recurring.

Understanding Pilonidal Cysts: Causes and Symptoms

A pilonidal cyst is a pocket that forms around a hair follicle in the crease between the buttocks. This condition can be uncomfortable and potentially lead to more serious complications if left untreated. The area may appear as a small pit or pore in the skin, often containing a dark spot or hair. When infected, it’s referred to as a pilonidal abscess.

Common symptoms of a pilonidal cyst include:

• Pain or tenderness in the tailbone area
• Swelling near the top of the buttocks crease
• Drainage of pus or blood from an opening in the skin
• Fever, if the cyst becomes infected

The exact cause of pilonidal cysts is not fully understood, but factors that may contribute to their development include:

• Ingrown hairs
• Prolonged sitting or friction in the affected area
• Excessive body hair
• Obesity
• Family history

Surgical Options for Pilonidal Cyst Treatment

When a pilonidal cyst becomes infected or recurrent, surgical intervention is often necessary. There are several surgical options available, each with its own benefits and considerations.

Incision and Drainage

This is the most common treatment for an infected pilonidal cyst. The procedure is relatively simple and can be performed in a healthcare provider’s office under local anesthesia. During the procedure:

1. The skin is numbed with local anesthesia
2. A small incision is made in the cyst to drain fluid and pus
3. The wound is packed with gauze and left open to heal

Recovery time for incision and drainage typically takes up to 4 weeks, with regular gauze changes required during this period.

Pilonidal Cystectomy

For recurrent or problematic pilonidal cysts, a more extensive surgical procedure called pilonidal cystectomy may be recommended. This outpatient procedure involves:

1. Administration of general or regional anesthesia
2. Removal of the affected skin, pores, and underlying tissue containing hair follicles
3. Packing the wound with gauze or inserting a drainage tube, depending on the extent of tissue removal

While pilonidal cystectomy is more thorough than incision and drainage, there is still a chance of recurrence.

Non-Surgical Treatment Options for Pilonidal Cysts

For pilonidal cysts that are not causing symptoms or are in the early stages, non-surgical treatments may be considered. These include:

• Shaving or laser hair removal in the affected area
• Injection of surgical glue into the cyst
• Improved hygiene practices
• Weight management

It’s important to note that non-surgical treatments may not be effective for infected or recurrent pilonidal cysts, and surgical intervention may still be necessary in these cases.

Risks and Complications of Pilonidal Cyst Surgery

While pilonidal cyst surgery is generally safe, it’s essential to be aware of potential risks and complications. These may include:

• Bleeding
• Infection
• Delayed wound healing
• Recurrence of the pilonidal cyst
• Scarring
• Chronic pain in the surgical area

Is pilonidal cyst surgery always successful? While surgical treatment is often effective, it’s important to note that pilonidal cysts can recur in about 50% of cases, even after initial surgery. This emphasizes the importance of proper post-operative care and preventive measures.

Preparing for Pilonidal Cyst Surgery

Proper preparation is key to ensuring a successful surgery and recovery. Here are some important steps to take before your procedure:

1. Discuss your medical history with your healthcare provider, including any existing conditions like diabetes or heart problems
2. Inform your doctor about all medications, vitamins, and supplements you’re taking
3. Stop smoking several weeks before surgery to promote better healing
4. Follow your doctor’s instructions regarding food and drink restrictions before surgery
5. Arrange for transportation to and from the surgical facility
6. Prepare your home for a comfortable recovery period

Your healthcare provider may also advise you to temporarily stop taking certain medications, such as blood thinners, prior to surgery. Always follow their specific instructions regarding medication management.

Post-Surgical Care and Recovery

The recovery process after pilonidal cyst surgery is crucial for proper healing and preventing recurrence. Here are some key aspects of post-surgical care:

• Keep the wound area clean and dry
• Change dressings as instructed by your healthcare provider
• Take pain medications as prescribed
• Avoid sitting for prolonged periods
• Use a donut-shaped cushion when sitting to reduce pressure on the surgical site
• Attend all follow-up appointments with your healthcare provider

How long does it take to recover from pilonidal cyst surgery? Recovery time can vary depending on the type of surgery performed and individual healing factors. Generally, patients can expect to return to normal activities within 2-4 weeks, although complete healing may take several months.

Preventing Recurrence of Pilonidal Cysts

While it’s not always possible to prevent pilonidal cysts from recurring, there are several measures you can take to reduce the risk:

• Maintain good hygiene in the affected area
• Keep the area dry and clean
• Lose weight if you’re overweight or obese
• Avoid prolonged sitting
• Wear loose-fitting clothing
• Consider regular hair removal in the affected area

Can regular hair removal prevent pilonidal cysts? While not a guaranteed prevention method, regular hair removal in the buttocks area may help reduce the risk of pilonidal cyst formation by minimizing the presence of ingrown hairs.

Living with Pilonidal Disease: Long-Term Management

For some individuals, pilonidal disease can be a chronic condition requiring ongoing management. Long-term strategies for living with pilonidal disease include:

1. Regular follow-up appointments with your healthcare provider
2. Maintaining a healthy lifestyle, including proper nutrition and exercise
3. Being vigilant for signs of recurrence
4. Considering alternative treatments for recurrent cases, such as Bascom’s procedure or Karydakis flap surgery
5. Joining support groups or online communities for individuals with pilonidal disease

Is it possible to completely cure pilonidal disease? While many patients experience successful treatment and long-term relief, complete eradication of pilonidal disease is not always guaranteed. Some individuals may require multiple treatments or ongoing management to control symptoms and prevent recurrence.

Emerging Treatments and Research

The field of pilonidal cyst treatment continues to evolve, with researchers exploring new techniques and approaches. Some promising areas of research include:

• Minimally invasive procedures
• Biological therapies to promote healing
• Advanced wound closure techniques
• Genetic studies to better understand predisposition to pilonidal disease

These ongoing research efforts may lead to more effective treatments and improved outcomes for individuals suffering from pilonidal cysts in the future.

The Importance of Early Intervention

Early detection and treatment of pilonidal cysts can significantly improve outcomes and reduce the risk of complications. If you notice any signs or symptoms of a pilonidal cyst, it’s crucial to consult with a healthcare provider promptly. Early intervention may allow for less invasive treatment options and a quicker recovery.

Psychological Impact of Pilonidal Disease

Living with pilonidal disease can have psychological effects on some individuals, including:

• Embarrassment or self-consciousness
• Anxiety about recurrence
• Depression related to chronic pain or discomfort
• Social isolation due to symptoms or treatment requirements

It’s important to address these psychological aspects as part of a comprehensive treatment plan. Mental health support, such as counseling or support groups, can be beneficial for individuals struggling with the emotional impact of pilonidal disease.

The Role of Nutrition in Pilonidal Cyst Management

While there is no specific diet that can prevent or cure pilonidal cysts, maintaining a healthy diet can support overall health and potentially aid in recovery. Consider the following nutritional strategies:

• Stay hydrated to support skin health and wound healing
• Consume adequate protein to support tissue repair
• Include foods rich in vitamins A and C, which are important for skin health
• Maintain a balanced diet to support a healthy immune system

Always consult with a healthcare provider or registered dietitian before making significant changes to your diet, especially if you have other health conditions or are preparing for surgery.

The Impact of Lifestyle Factors on Pilonidal Disease

Certain lifestyle factors can influence the development and recurrence of pilonidal cysts. Consider the following lifestyle modifications:

1. Maintain good posture to reduce pressure on the tailbone area
2. Take regular breaks from sitting, especially if your job requires prolonged periods of sitting
3. Practice good hygiene, including thorough cleaning of the affected area during showers
4. Wear breathable, loose-fitting clothing to reduce friction and moisture in the area
5. Engage in regular physical activity to promote overall health and maintain a healthy weight

By incorporating these lifestyle changes, you may be able to reduce your risk of developing pilonidal cysts or experiencing recurrence after treatment.

The Role of Genetics in Pilonidal Disease

Recent research has suggested that genetic factors may play a role in the development of pilonidal disease. While the exact genetic mechanisms are not yet fully understood, studies have shown that individuals with a family history of pilonidal cysts may be at higher risk of developing the condition.

This genetic component highlights the importance of discussing your family medical history with your healthcare provider. If you have a family history of pilonidal disease, you may benefit from more frequent check-ups and early intervention strategies.

Alternative and Complementary Therapies

While surgical intervention remains the primary treatment for severe or recurrent pilonidal cysts, some individuals may explore alternative or complementary therapies to manage symptoms or support healing. These may include:

• Herbal remedies with potential anti-inflammatory properties
• Acupuncture for pain management
• Topical applications of tea tree oil or other natural antiseptics
• Stress-reduction techniques such as meditation or yoga

It’s important to note that the effectiveness of these alternative therapies for pilonidal disease has not been extensively studied. Always consult with your healthcare provider before trying any alternative treatments, especially if you’re considering them as a substitute for conventional medical care.

The Future of Pilonidal Cyst Treatment

As medical technology and understanding of pilonidal disease continue to advance, new treatment options may become available. Some areas of ongoing research and development include:

• Advanced imaging techniques for more accurate diagnosis and treatment planning
• Robotic-assisted surgical procedures for increased precision
• Stem cell therapies to promote tissue regeneration and healing
• Personalized treatment approaches based on genetic and lifestyle factors

While these advancements are promising, it’s important to remember that current surgical techniques, when performed by experienced professionals, remain effective for many patients. As research progresses, we may see improvements in treatment outcomes and reduced recurrence rates for pilonidal disease.

Surgery for pilonidal cyst: MedlinePlus Medical Encyclopedia

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A pilonidal cyst is a pocket that forms around a hair follicle in the crease between the buttocks. The area may look like a small pit or pore in the skin that contains a dark spot or hair. Sometimes the cyst can become infected, and this is called a pilonidal abscess.

An infected pilonidal cyst or abscess requires surgical drainage. It will not heal with antibiotic medicines. If you continue to have infections, the pilonidal cyst can be removed by surgery.

There are several types of surgery.

Incision and drainage — This is the most common treatment for an infected cyst. It is a simple procedure done in the health care provider’s office.

• Local anesthesia is used to numb the skin.
• A cut is made in the cyst to drain fluid and pus. The hole is packed with gauze and left open.
• Afterward, it can take up to 4 weeks for the cyst to heal. The gauze has to be changed often during this time.

Pilonidal cystectomy — If you keep having problems with a pilonidal cyst, it can be removed surgically. This procedure is done as an outpatient procedure, so you will not need to spend the night in the hospital.

• You may be given medicine (general anesthesia) that keeps you asleep and pain-free. Or, you may be given medicine (regional anesthesia) that numbs you from the waist down. In rare cases, you may only be given local numbing medicine.
• A cut is made to remove the skin with the pores and the underlying tissue with the hair follicles.
• Depending on how much tissue is removed, the area may or may not be packed with gauze. Sometimes a tube is placed to drain fluid that collects after surgery. The tube is removed at a later time when the fluid stops draining.

It may be hard to remove the entire cyst, so there is a chance that it will come back.

Surgery is needed to drain and remove a pilonidal cyst that does not heal.

• Your provider may recommend this procedure if you have pilonidal disease that is causing pain or infection.
• A pilonidal cyst that is not causing symptoms does not need treatment.

Non-surgical treatment may be used if the area is not infected:

• Shaving or laser removal of hair around the cyst
• Injection of surgical glue into the cyst

Pilonidal cyst resection is generally safe. Ask your provider about these complications:

• Bleeding
• Infection
• Taking a long time for the area to heal
• Having the pilonidal cyst come back

Meet with your provider to make sure medical problems, such as diabetes, high blood pressure, and heart or lung problems are in good control.

Tell your provider:

• What medicines, vitamins, and other supplements you are taking, even ones you bought without a prescription.
• If you are or could be pregnant.
• If you have been drinking a lot of alcohol, more than 1 or 2 drinks a day.
• If you are a smoker, stop smoking several weeks before the surgery. Your provider can help.
• You may be asked to temporarily stop taking blood thinners, such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), vitamin E, clopidogrel (Plavix), warfarin (Coumadin), and any other medicines like these.
• Ask your provider which medicines you should take on the day of your surgery.

On the day of the surgery:

• Follow instructions about whether you need to stop eating or drinking before surgery.
• Take the medicines your provider told you to take with a small sip of water.
• Follow instructions on when to arrive at the hospital. Be sure to arrive on time.

After the procedure:

• You can go home after the procedure.
• The wound will be covered with a bandage.
• You will get pain medicines.
• It is very important to keep the area around the wound clean.
• Your provider will show you how to care for your wound.
• After it heals, shaving the hair in the wound area may help prevent pilonidal disease from coming back.

Pilonidal cysts come back in about one half of the people who have surgery the first time. Even after a second surgery, it may come back.

Pilonidal abscess; Pilonidal dimple; Pilonidal disease; Pilonidal cyst; Pilonidal sinus

Hyman N, Umanskiy K. Anus. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 21st ed. St Louis, MO: Elsevier; 2022:chap 53.

Johnson EK, Vogel JD, Cowan ML, et al. The American Society of Colon and Rectal Surgeons’ clinical practice guidelines for the management of pilonidal disease. Dis Colon Rectum. 2019;62(2):146-157. PMID: 30640830 pubmed.ncbi.nlm.nih.gov/30640830/.

Wells K, Pendola M. Pilonidal disease and perianal hidradenitis. In: Yeo CJ, ed. Shackelford’s Surgery of the Alimentary Tract. 8th ed. Philadelphia, PA: Elsevier Saunders; 2019:chap 153.

Updated by: Debra G. Wechter, MD, FACS, General Surgery Practice Specializing in Breast Cancer, Virginia Mason Medical Center, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

CSA Surgical Center – Pilonidal Cyst Removal

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Pilonidal cysts develop in the crease of the buttocks along the tailbone. These cysts contain hair and skin debris. The cyst resembles a large pimple and may become painful, inflamed and even infected. Pilonidal cysts usually occur in people younger than 40 and are more common in men than women.

Indications: 

Surgical removal or drainage of a pilonidal cyst is indicated if it is large, painful, or becomes infected.

Pre-Op Evaluation and Prep: 

Patients will have a physical exam by the surgeon to discuss symptoms and determine if surgery is needed. Routine blood work is usually not needed but may be ordered prior to surgery based on the patient’s age and the presence of any existing medical problems.

You may be instructed to stop taking some medications before surgery. Make sure your surgeon knows all the prescription and over-the-counter medications you take, including natural or nutritional supplements. For more information related to preparation for surgery click here.

Procedure:

Pilonidal cyst removal will be performed under general anesthesia. The surgeon will make an incision on the skin near the cyst. The sac enclosing the cyst is removed and the pocket is cleaned. The skin may be packed with gauze, sutured closed or left open to drain.

Recovery:

This varies from patient to patient. Many patients return to desk type work the next day. You will probably not have any lifting restrictions. It is rare for patients to need extended time off of work.

While recovery instructions may be tailored to individualize a plan of care based upon your specific needs, these instructions are common following cyst removal surgery:

• You will need to arrange for a ride home the day of your surgery and we recommend someone stay with you for the first 24 hours at home.
• When you leave the facility after surgery, we will want you to go home and rest. Avoid making any other plans on the day of your surgery. Starting the following day, you can increase your activity as you feel up to it.
• Avoid fried foods, milk products and citrus juices for around one day after your surgery. Suggestions for foods to eat include soup, sandwich, pasta, potatoes, toast, and applesauce.  
• Care instructions at the surgical site including dressings and bathing will depend upon the exact location of the cyst and closure of the incision. You will receive more detailed instructions specific to your procedure.
• Although you will likely feel completely numb for several hours after the procedure, you will likely be given a prescription for pain medication following your surgery. The recovery nurse will discuss a pain control plan following surgery specific to you and your needs including activities like ice applied over incisions and a medication regimen. Often times we will recommend taking Tylenol and Advil (same as Motrin, Ibuprofen) or Aleve in addition to the narcotic pain medication.
• It is often suggested to start taking a stool softener and Miralax the day following your procedure. You will want to continue this regimen as long as you are taking narcotic pain medications.

For additional information for after surgery preparation click here.

To Schedule an Appointment

To find out more about Pilonidal Cyst Removal services offered at CSA Surgical Center in Columbia, Missouri please call Columbia Surgical Associates at 573-443-8773 and schedule an appointment.

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Coccyx cyst removal – excision of the epithelial coccygeal passage

What is an epithelial coccygeal passage?

Epithelial coccygeal tract (ECC, coccyx cyst, coccyx dermoid cyst, coccyx dermoid fistula, pilonidal sinus/coccyx cyst, pilonidal disease, sacrococcygeal epithelial dips) is a few millimeters wide canal (or cavity) lined with skin. It refers to inflammatory diseases of the skin and subcutaneous tissue of the intergluteal fold and sacrococcygeal region. This channel is located in the area between the buttocks, above the external opening of the anus (rectum), it goes deep into the skin and ends blindly in the soft tissues. Opens, such a fistulous tract is usually on the skin with one or more chiseled holes and, sometimes, contains a tuft of hair. These holes can go unnoticed for a long time, as they often do not have any unpleasant symptoms and only in the event of inflammation they attract attention.

Important! If there are painless holes in the intergluteal fold without any additional symptoms, the disease is called asymptomatic ECC (Figure 1). This form of ECX does not need surgical treatment and requires only careful observance of elementary hygiene rules by the patient himself and periodic examinations by a proctologist.

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With the development of an inflammatory reaction, which is usually preceded by blockage of the external opening, the epithelial coccygeal tract first manifests itself as a painful induration on the skin in the region of the intergluteal fold (it is important to know that sometimes, especially with a long absence of adequate treatment, fistulous tracts can acquire bizarre shapes and appear outside the specified area (Fig. 2)

Figure 2. A rare form of ECC with multiple fistulas in the perianal region (arrows indicate multiple secondary fistula openings resulting from a long-term chronic form of the disease)

Important! The occurrence of such a form is possible with untimely and / or inadequate surgical treatment.

In the absence of adequate treatment, pain increases and the induration turns into a full-fledged abscess (abscess). Further, there are usually three options for the development of the disease:

• the abscess continues to grow and forces you to consult a doctor on an emergency basis;
• the abscess spontaneously drains on its own into the existing fistulous tract, which is manifested by the outflow of pus in the region of the intergluteal fold. At the same time, pain and body temperature gradually decrease, and the patient may regard this as a cure, and in the future do not consult a doctor;
• the skin over the abscess is destroyed by an acute inflammatory process and the abscess spontaneously “breaks” out. After emptying the purulent focus, pain decreases sharply, body temperature returns to normal.

In the last two cases, a significant relief of the condition leads many patients to the idea that there is no need for further treatment. However, despite the fact that in most cases the skin wound heals over time, the very cause of the inflammatory process – a purulent cavity with elements of an embedded hair – remains in the soft tissues, and prerequisites are created for a new accumulation of purulent discharge and the process is repeated. Important! In any of the variants of the course of the disease, it is necessary to contact a proctologist as soon as possible to assess the need for further treatment and exclude more serious diseases in this area.

Why is ECC formed?

For a long time the mechanism of the disease remained a mystery to doctors, but in the 50s of the last century, an explanation was found why this disease develops, and it still surprises both young doctors and patients. The intergluteal fold has several features: it is prone to sweating, most of the time it is squeezed by underwear and outerwear, and is difficult to reach for self-examination. When walking between the reduced buttocks, a kind of “pumping” effect occurs. The hair that has fallen into the intergluteal fold, under the influence of this effect, is introduced into the thickness of the skin, then into the subcutaneous tissue, where an infected cavity is formed (Fig. 3). This predisposes to the development of a local inflammatory process in the intergluteal fold, which facilitates the possibility of hair penetration into the thickness of the skin.

a)

b)

c)

Scheme of buttocks movement during walking with the formation of the effect of a vacuum pump

b. Photograph of the initial stage of hair penetration into the skin of the intergluteal fold

c. Scheme of the development of the inflammatory process (the arrow indicates the abscess)

What are the main symptoms of the disease? How does ECC manifest itself?

In about half of the cases, the disease is asymptomatic for a long time. The only manifestation may be the presence of one or more holes or dimples in the skin of the intergluteal fold, from which a tuft of hair is sometimes visible.

Important! The absence of other symptoms is often the reason for the late detection of the disease, or its detection as an incidental finding during examinations for other problems.

Microorganisms from the surface of the skin or from the anus enter the lumen of the skin canal formed earlier by the introduction of a hair, which inevitably leads to the development of chronic, recurrent (repeating) inflammation and the formation of an abscess.

• When inflammation of the ECC most often occurs the following symptoms:
• Pain in sacrum and coccyx;
• Redness and thickening of the skin in the region of the intergluteal fold or slightly to the side of it;
• Bloody or purulent discharge from the orifices of the epithelial coccygeal duct;
• Fever;
• The appearance of additional (secondary) holes along or near the intergluteal crease;
• Discharge from additionally formed holes;
• General weakness;
• Inability to conduct normal physical and labor activity (Fig. 4).

Figure 4. Abscess of the epithelial coccygeal tract (arrows indicate the primary holes located in the intergluteal fold. The area of ​​the suspected abscess is limited by the orange line)

Who is at risk of developing ECC?

The disease is 4 times more common in men than women. ECC belongs to a group of rare diseases and is detected in only 26 out of 100,000 people. Basically, young people of working age from 15 to 30 years old get sick. According to statistics, ECX is most often found in Arabs and Caucasian peoples, less often in African Americans.

Risk factors for developing ECC are:

• excessive body hair
• overweight
• insufficient attention to the hygiene of the coccyx area
• sedentary lifestyle
• wearing tight and tight clothing (pants, skirts)

What is a recurrence of the disease and how to avoid it?

Another form of the disease is the recurrence (re-development) of the epithelial coccygeal tract, which occurs after some time (from 1 year or more) after the previous radical surgical treatment of the epithelial coccygeal tract.

Important! The risk group for recurrence of ECC includes both patients who have previously undergone insufficient surgical intervention, and patients who have developed a violation of the postoperative wound healing process.

In case of ECC recurrence, repeated surgical treatment is indicated, which in turn becomes more complicated due to the development of a cicatricial process in the intervention area, the hospitalization period increases, and the cosmetic effect worsens.

How to diagnose ECC?

The diagnosis of epithelial coccygeal passage is established after comparing the data obtained from the patient and his examination with the results of instrumental methods of examination. You will need to tell the specialist in detail about when the first complaints appeared, what changes you noticed in this area before the moment of treatment, to remember whether there were episodes of suppuration and spontaneous opening of the ECX. The doctor will definitely examine the intergluteal fold and the adjacent gluteal region. In some cases, with a common process or an atypical course of the disease, a digital examination of the rectum may be necessary. Treat this simple study with understanding, because it is important for us that the diagnosis is established correctly.

Instrumental studies are of great help to doctors in establishing a diagnosis and determining the extent of the process, especially for the abscessing course of ECC and recurrent forms of the disease.

Instrumental methods include:

1. Ultrasound of the soft tissues of the sacrococcygeal region. This diagnostic method allows you to assess the size, prevalence of the process, the presence of a connection between purulent cavities, identify deeply located abscesses, which cannot be determined by examining and feeling this area. Ultrasound allows the surgeon to pre-determine the scope of the surgical intervention, to plan the technique for closing the skin defect after removal of the ECC (Fig. 5).

Figure 5. Ultrasound picture of the epithelial coccygeal tract in the projection of the intergluteal fold (ultrasound examination of soft tissues, directly under the skin, in the thickness of the subcutaneous fat, there is an inhomogeneous formation measuring 25×32 mm with even, clear contours with inclusions)

2. Fistulography — introduction of a contrast agent into the formed course and X-ray examination. This method allows you to determine the direction of purulent passages, their connection with the primary course, and allows the surgeon to plan the operation in more detail.

In some complex cases, additional examinations may be necessary: ​​

• Anoscopy – examination of the anal canal with an anoscope – a special optical device for painless examination of the final section of the digestive tract. This study allows you to visually assess the mucous membrane of the rectum and anal canal. Anoscopy in most cases is necessary for the differential diagnosis of ECC with diseases of the anal canal and rectum.
• MRI (magnetic resonance imaging) of the pelvic organs is a study that allows you to obtain a detailed image of the area of ​​interest in various projections, in particular the small pelvis and the sacrum. This method is more expensive than ultrasound, but it allows accurate diagnosis in complex cases of ECC, with relapses of the disease, and the presence of comorbidities.

Additional studies will help specialists to distinguish complex rectal fistulas from neoplasms of the sacrum and soft tissues of the sacrococcygeal region, disorders of embryonic development, if ultrasound is not enough to establish a diagnosis (Fig. 6).

Figure 6. MRI image of a complicated epithelial coccygeal tract (MRI in the lateral projection shows a change in the subcutaneous fat layer at the level of the sacrum and coccyx with the formation of a cavity)

How to distinguish ECC from other diseases?

Some other diseases may have manifestations similar to ECC, which requires differential diagnosis.

Furuncle

Furuncle is an inflammation of the soft tissues around the hair follicle. First, there is a thickening and redness of the tissue around the hair. Then a white rod is formed, around which a zone of hyperemia is preserved. An ECX abscess may look like a furuncle, however, the presence of primary holes in the intergluteal crease will be a distinctive feature (Fig. 7).

Figure 7. ECX with developing abscess (the arrow indicates the primary opening. The area of ​​the forming abscess is limited by the orange line)

Rectal fistula

anus (on the perianal skin). In the presence of an internal fistulous opening, which is located in the anal canal, it can be determined using a digital examination of the rectum or with fistulography. With ECX, there is no connection between the passage and the rectum, which is confirmed by probing and or MRI, and during external examination, the primary openings of the coccygeal passage are visible.

Presacral teratoma

Presacral teratomas may have a so-called embryonic tract that opens on the skin near the anus in the form of an epithelized funnel. Presacral teratomas are located between the posterior wall of the rectum and the anterior surface of the sacrum, which can be established by digital examination. At the same time, the epithelial coccygeal passage is located under the skin on the back surface of the sacrum and coccyx. MRI should be the definitive method for accurately diagnosing such cases.

Infected wound

A simple infected wound in the area of ​​interest may occur if the patient has had trauma to the sacrococcygeal region, surgery for a rectal fistula, or excision of the epithelial coccygeal tract. In this situation, the presence of primary ECX openings, data on the course of the disease, and the availability of information about any interventions in this area are also of fundamental importance.

Is it always necessary to treat ECC?

The form of the disease is the determining factor in the choice of treatment for ECC. Accidentally detected asymptomatic form of the disease does not require immediate urgent surgical treatment. In order to prevent the development of acute inflammation of the pilonidal cyst in the asymptomatic form of the disease, it is necessary to carry out daily hygiene measures, avoid traumatic effects on the ECX area and wear tight and narrow clothes, remove hair (using periodic shaving or epilation) in the area of ​​the intergluteal furrow and buttocks. However, such preventive measures do not guarantee the absence of ECC complications.

At the initial stages of ECC abscess formation (stage of infiltration), when the first symptoms are just beginning to appear (increasing pain in the sacrum and coccyx, swelling of tissues in the area of ​​the intergluteal fold, a slight increase in temperature), it is possible to stop the inflammatory process with the use of antibiotics and removal of the invading hair tuft.

Important! Even if the symptoms are not pronounced and develop slowly, it is necessary to consult a specialist as soon as possible to rule out more dangerous diseases and plan treatment correctly!

Treatment should only be carried out by an experienced specialist, as it is not always easy to find the line between an abscess (this condition requires mandatory surgical treatment!) and the so-called infiltrate, when surgical treatment is ineffective. Sometimes visual inspection and palpation is not enough to determine the stage of the inflammatory process. Then an ultrasound examination of soft tissues comes to the aid of a specialist, which allows you to determine further treatment tactics.

Important! In all more severe cases, with other forms of the disease, surgical treatment is indicated.

In the event of an acute ECC abscess, urgent surgical treatment is indicated, which is aimed primarily at evacuating pus and speeding up the relief of the patient’s condition.

How to get rid of ECX forever?

The main radical method of treatment of ECC – that is, a method aimed at the complete removal of the source of the inflammatory process, is surgical. Depending on the prevalence of the disease, various types of surgical interventions are performed. There are over 50 different techniques for the treatment of ECC. Such a large number of possible methods of surgical treatment is due to the fact that at present there is no optimal method that could be called the “gold standard” of treatment for all patients with ECC. In each case, the choice of surgical technique should be individual: several factors should be taken into account – the clinical picture of the disease, the stage of the disease and the extent of the lesion, the possibility of temporary limitation of physical activity in the postoperative period.

Important! After some surgeries, it will be necessary to strictly avoid sitting for 2-3 weeks in order for the wound to heal properly. This must be taken into account when coordinating the method of surgical treatment with the doctor. The doctor can always suggest several alternative methods.

A specialist who owns and uses several of the most effective methods in his practice will help you choose the best way.

What operation is performed in the event of an abscess (acute suppuration) of ECX?

In the event of an acute ECX abscess, in most cases, two consecutive operations will be required. Treatment of a purulent focus of ECX should be carried out in a specialized coloproctological hospital. Its main goal is to ensure the full evacuation of purulent contents, stop inflammation in the surrounding soft tissues, and prevent the further spread of the purulent process.

Important! Even such a simple step as opening an ECX abscess can significantly complicate the second (main) surgical intervention if simple rules are not followed.

The incision should be small and as close as possible to the midline (gluteal crease). During the second operation, the scar from the previously performed incision will need to be removed as a single block with the main volume of ECX tissue. The larger the primary scar, the more tissue will need to be removed during the second operation. At the same time, too small an incision should not be made, since the key to a successful recovery is adequate drainage of the purulent-inflammatory focus (Fig. 8).

a)

b)

the place of the greatest fluctuation and the evacuation of the purulent discharge with the taking of material for the determination of the microorganism, causing inflammation.

Properly performed opening of the abscess leads to the disappearance of pain, temperature and improved well-being. However, the final inflammatory processes (changes in the surrounding tissues) after the first stage of the surgical intervention (opening and draining the ECC abscess) usually subside within 1-2 weeks.

After the successful completion of the first stage of surgical treatment, which will be accompanied by a decrease in the manifestations of acute inflammation and, in fact, be a “symptomatic operation”, it is no less important to carry out the second stage – a radical operation aimed at complete removal of the pilonidal cyst with the affected area of ​​the skin and subcutaneous adipose tissue and subsequent plastic stage to achieve a good cosmetic result.

Important! In acute inflammation, it is the two-stage treatment that is the most effective and quickly leads to the restoration of working capacity. Despite the improvement in the condition after opening and draining the ECC abscess, it is extremely necessary to perform a second radical operation, since each subsequent inflammation will involve more and more unchanged tissues in the process!

With a small size of the purulent focus and a high level of professionalism of the surgeon, one-stage radical treatment of acute ECC is sometimes possible.

Long-term inflammatory changes lead to a persistent pain syndrome and long periods of disability, impaired quality of life, complications and relapses after the second stage of surgical treatment, complicate the performance of a radical operation. It is optimal to perform the second (radical) operation 3-4 weeks after opening and draining the ECC abscess.

What operations are performed for chronic and recurrent forms of ECC?

Currently, there are a large number of different radical operations for the removal of ECC, each of which has its own advantages and disadvantages. All types of surgical interventions can be divided into 2 large groups:

1. Minimally invasive techniques.
2. Radical surgical treatment with closed wound closure.

Minimally invasive procedures

Minimally invasive procedures include, for example, synsuectomy and laser destruction of the ECC. The advantage of these techniques is that after their implementation there is no significant limitation of physical activity, it is possible to return to work on the same day after the surgical intervention. The disadvantage is: the possibility of performing only with small sizes of ECX (the choice of volume and the possibility of performing is determined by the doctor after the performed ultrasound).

a) Sinusectomy

If the patient has only primary passages, as well as in the absence of streaks and additional passages or branches, according to additional examination methods, it is possible to perform a minimally invasive operation – sinusectomy. This operation involves a very economical excision of the epithelial passages with a scalpel, leaving skin bridges between the primary passages. This allows you to return to work as quickly as possible, having received an excellent cosmetic result (Fig. 9).).

a)

b)

Figure 9:

after 3 weeks after sinusectomy

b) Laser ablation of ECX ( diode laser)

The essence of the operation is to process the primary strokes of the ECX using a laser. This allows you to destroy the ECC moves and prevent the development of complications of this disease. For the operation, a laser with a certain wavelength is used in continuous mode. During the ECX, the laser beam is delivered using an LED (Fig. 10). The laser power can be from 1.5 to 3 watts. The total duration of work is from 5 to 25 minutes and depends on the stage of the disease, the length of the coccygeal passage. Due to the ability to concentrate its action only on the affected tissues, the procedure is minimally invasive, accompanied by minimal pain. In addition, the laser has a coagulating property, thereby minimizing the possibility of bleeding from the affected vessels.

Figure 10. Laser ablation of ECX passages

Radical surgical excision with tight suturing of the wound

This operation, perhaps the most common in Russia, involves a more extensive excision epithelial sinus/stroke with defect plasty with local tissues. There are many opinions about how effective and safe this operation is. In the hands of an experienced surgeon, as a rule, the probability of recurrence in this type of intervention does not exceed 3-5% and is easily tolerated by patients. The main disadvantage of this technology is the need to limit mobility and exclude sitting after surgery for a period of several days to several weeks.

The type of surgical intervention is finally determined after examination and obtaining the results of ultrasound of the soft tissues of the sacrococcygeal region and, if necessary, additional examination methods.

Main modern modifications of radical treatment of ECC:

1. Excision of ECC with repositioning of skin-fascio-muscular flaps

Our clinic has developed an original technique (patent), which involves the creation of fascio-muscular flaps to close the postoperative wound. The essence of the technique is to move your own soft tissues and create a strong fascial frame (fascia is a strong shell that covers the muscles of our body) in the area of ​​intervention, which reduces the mobility of the wound edges, accelerating healing. It is the tension and excessive load on the postoperative wound that is the main factor in the unsatisfactory results of treatment. This technique allows to achieve the fastest possible recovery of the patient with minimal skin incisions, low complication rate and good cosmetic results, since the postoperative scar is located in the intergluteal fold and remains almost invisible after the operation (Fig. 11).

a) b)

c)

Figure 11:

008 b) view of the wound after excision of the ECX followed by plasty with skin-fascial flaps ( single interrupted sutures were placed on the wound The postoperative scar is located in the intergluteal groove, which provides a good cosmetic effect)

c) view of the postoperative scar 3 weeks after the operation

2. Surgery to excise ECC with Karydakis plasty

In 1976, the army surgeon G.E. Karydakis proposed an operation technique for the radical treatment of the epithelial coccygeal passage. The essence of the operation was that the radical excision of all affected tissues comes from an incision somewhat displaced from the midline, located next to the intergluteal sulcus. The operation is accompanied by a small percentage of relapses and postoperative complications. However, its disadvantage is the presence of a postoperative scar outside the gluteal groove, which provides the worst cosmetic defect (Fig. 12).

Figure 12. Scheme of the operation for excision of the ECX with plasty according to Karidakis

3. The operation for excision of the ECX with plasty according to Bascom

American surgeon John Bascom proposed two types of surgery for different stages of the disease: in the presence of acute inflammation ECX – Bascom I and for the radial treatment of the disease – Bascom II. The radical operation proposed by the author is one of the most controversial in the treatment of ECC. The technique involves the removal of only minor areas of the skin (with the preservation of subcutaneous tissue) containing the primary openings of the ECX. Excision of a large pilonidal cyst, if present, is performed from an incision made away from the median fold.

Figure 13. Scheme of the operation for excision of ECC with plastic according to Bascom

4. Marsupilization

skin and subcutaneous – fatty tissue, followed by suturing of the skin edges to the bottom of the wound. However, at present, this technique is practically not used due to the long rehabilitation period and unsatisfactory cosmetic results (Fig. 14).

Skin grafting after radical surgical treatment of ECC

The main problem of wound healing after excision of ECC is the presence of a wide soft tissue defect. The subcutaneous tissue in the sacrum is tightly fixed to the underlying aponeurosis and fascia, therefore, when the defect is closed by the remaining soft tissues, tension is created, which is accompanied in the postoperative period by a high risk of wound dehiscence and prolonged healing.

The problem of closure of the resulting defect with local tissues with plastic skin flaps is especially important in chronic and recurrent forms of the disease.

There are various forms and types of skin-subcutaneous flaps (Z, V-Y-shaped, Limberg-flap) to close the defect that has arisen after the removal of ECX. The possibility and necessity of using one or another type of plasty is determined by the doctor based on the examination data, the characteristics of the operation, the volume of tissues removed, and the patient’s wishes.

Figure 14. Options for closing a postoperative wound defect after excision of the ECC:

a) Limberg plasty

b) Z-shaped plastic

Epithelial coccygeal passage | TS Clinic — Krasnodar

Epithelial coccygeal tract, or pilonidal cyst (translated from Latin as “nest with hair”), is an anomaly localized in the space between the buttocks.

The cyst looks like a painful lump, the skin over it is reddened, often in the area of ​​the lump there are one or more holes with purulent discharge. Most often, the disease is diagnosed in people from 16 to 25 years old, while men are subject to its development 4 times more often than women.

Pilonidal cysts were first mentioned in medical circles during World War II, when several thousand US troops were found to have symptoms of the disease. Due to the fact that many patients often had to drive off-road vehicles on bad roads, the disease was called “jeep disease”.

Symptoms

In some cases, a pilonidal cyst can proceed without any noticeable signs and be detected only during external examination – in the intergluteal fold, a depression or hole in the skin (sometimes several holes) with a diameter of 1-2 mm is clearly visible. But when an infection enters, inflammation begins, which brings the patient a lot of suffering.

Patients with pilonidal cyst complain of:

• reddening of the skin
• the appearance of edematous areas in the area of ​​the sacrum and coccyx
• temperature rise
• exit of purulent exudate from holes in the skin.

Why is a pilonidal cyst dangerous?

In an uninfected state, a pilonidal cyst does not pose a health risk and causes little or no discomfort to a person. But, unfortunately, with suppuration, the cyst often turns into a chronic (fistulous) form and worries regularly. A timely diagnosis allows you to prescribe adequate treatment and completely save the patient from this obsessive problem!

Treatment of a pilonidal cyst

Treatment of a pilonidal cyst requires surgery.

At the time of exacerbation, the first stage is the opening of the abscess, then, in a calm (non-acute) period, the cystic cavity is removed with all fistulous passages and streaks under general anesthesia.

In order for the operation to give the necessary results, the patient should carefully follow a number of rules:

• do not take a sitting position in the first 3 weeks after the operation, but lie down on your back very carefully
• do not engage in sports or heavy physical labor for a month
• carry out hygiene procedures only after removing the threads, using special tools for this
• after hygiene procedures, the operation site should dry naturally
• visit a doctor every 7-14 days to control the process of tissue regeneration.