FAQ – Surgery

“Is surgery the only option?”

To a degree, yes. But today this SHOULD NOT MEAN wide and deep excision, there are conservative techniques that are much better and remove much less tissue. For early cases, a simple Pit Picking might be all that is required, or a lancing followed up by Pit Picking. Pilonidals will not be cured by Herb Compotes, Colloidal Silver Concoctions, Tea Tree Oil or any other potion. Some people have a mild enough case that they can live with their Pilonidal.

“Should I get surgery or not?”

We can’t answer that for you. Since Pilonidals range from mild to severely aggressive, what we suggest is that you read through the entire site very carefully and then make a decision knowing the facts. You can visit 4 surgeons and get 4 different answers as to what to do, so it’s up to you to find the most competent doctor you can and make the choice. You might never have a major flare up and be able to go through life with no problems, that is possible. You can choose to take a wait and see approach, but you need to understand that if you start experiencing inflammations, infection, new sinus openings, drainage, or any other indications of an active problem it’s time to do something. That something might be just a lancing and Pit Picking, but action needs to be taken when you are experiencing infection.

“I’m freaking out! All I see on the forums here are problems!”

The forums are not an appropriate yardstick to measure Pilonidal surgery by. People seek out community message boards for both social reasons and for support. Some people really like helping other people out and answering questions, some people need a lot of support and find common experience in other patients. Think it like computer tech support. Nobody ever posts on a tech support forum when their computer is fine and everything is going great – they post when they need help. The Pilonidal forums are a lot like that. For every one person experiencing a problem there are 50 out there doing just fine and healing nicely.

“What is a lancing?”

A lancing (aka Incision & Drainage) is where the doctor cuts open the top of the cyst (usually under local anesthesia) and suctions out the pus/hair inside. Usually, the top is left open and stuffed with gauze (packing) but some surgeons don’t like packing and just leave it open to heal — both methods can work. The gauze is repacked daily and healing is complete within about 2 weeks. Lancing, by itself, only works approx 40% of the time, those odds increase dramatically if the pit are excised approximately 10 days after the lancing when the swelling has gone down.

“How is a lancing different from excision (full removal)?”

With a lancing, the abscess is just cleaned out but the deep tissues are left intact. Full excision means removal of the abscess area all the tissue around it. There are newer techniques that leave the deep tissue intact and brush the abscess cavity and sinuses out, then remove the “pits”. It is well worth your time to find a surgeon that does this less invasive technique first and save more invasive surgery as a second choice. You can always go forward to a more extensive surgery, you can’t go backward from excision.

“What is the difference between open healing and closed healing?”

Open healing (aka, healing from the bottom up, healing by secondary intention) involves leaving the wound open – no stitches. The wound heals by filling itself in from the bottom. Average healing time is about 8 weeks. With open healing you the wound at least twice a day for 8 weeks; it is a long, tedious process but it’s also the one with the highest cure rate. The infection/recurrence rate for open healing is 5% – 10%.

Closed healing (aka, stitches, sutures, primary closure, healing by first intention) involves stitching the wound closed after surgery. Average healing time is less than 4 weeks. The drawback is that the infection rate goes up to 20% and if you do get an infection the remedy is to re-open the wound and let it heal from the bottom up. However, there is a new technique that is showing great promise. It involves using a closed-suction drain and flushing the wound with antiseptic solution – the drain is removed after about 9 days and the infection rate drops to about the same as with Open Healing.

“What about the anesthesia?”

Excision surgery is best done under MAC (managed care anesthesia) which is very heavy sedation with local anesthesia or a Spinal Block. You do also have the option of having General Anesthesia. You may think that you would prefer to be awake during your surgery but with this operation you will be face down, looking at the shoes of your medical team, while you are in the “jack knife” position bent at the waist with your rear end stuck in air.

If this is your first surgery or you are very nervous you can ask for a sedative in your IV – this is a post from the message board:

“a surgical nurse suggested that I ask the anesthesiologist for Versed which she called the “happy to go with you” drug. He was happy to give it to me in my IV. I was scared and crying before I got the drug, but afterwards, I was giggling and happy as a clam. Wheel me away whoo hoo! Anyway… I was glad to get something to help me relax. No matter what anyone says, surgery is scary!“

Also read the “Anesthesia” page….

“Why a Colon & Rectal Surgeon?”

Pilonidal Disease is officially classified by the medical establishment as being a disease of the colon & rectum, even though it affects neither. This is a somewhat logical classification since Pilonidal can be confused with Anal Fistula and the general proximity to anus. More realistically, Pilonidal is really a skin problem and more of a dermatology issue than a colon & rectal one. The only doctors whom you can expect to have a brochure in their waiting room on this disease are Colon & Rectal Surgeons. Almost all of the major research and articles on this disease have been done/written by Colon & Rectal specialists.

However, if your general surgeon can discuss the various techniques and explain them to you, then you can feel more confident that they’ve done their homework. Ask any surgeon who you are considering to explain the difference between open healing and closed. Ask them to explain Marsupializaton, Flap Surgery, and Follicular Occlusion. If your surgeon can’t explain these things to you then find another doctor who is up on the current treatments and surgeries.

A small number of people are truly born with an obvious sinus opening, this is technically called a Sacral Dimple and is not actually related to Pilonidal Disease as discussed on this site. If you are not one of those people (just ask your mom, she’ll remember if you had a hole in your bottom at birth) and your doctor is adamant that Pilonidal Disease is something you were born with, this should be a big red flag that it’s time for you to find another doctor.

FAQ – Surgery

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