Pilonidal Sinus Laser Ablation

Pilonidal Disease (PD) is a chronic infection of the hair follicle that results in a painful cysts and sinus formation. The most common place for PD to develop is the coccygeal region, leading to significant discomfort when sitting or wearing tight clothes. The incidence of PD is approximately 26 per 100.000 persons, the most affected group being young men. Other risk factors include excessive body hair, obesity and a sedentary lifestyle. The current treatment for symptomatic PD is surgical excision of the sinus and the cyst, so-called pilonidal cystectomy. Primary closure, with or without tissue transposition, or secondary open healing, are subsequently chosen based on the size, depth and location of the wound.

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The actual excision is very simply performed; the difficulties arise in connection with the disposal of the large resulting wound. Excision is best carried out when the lesion is in a quiescent phase. If there is an actual abscess present with signs of acute inflammation in the surrounding tissues, the correct procedure in the first instance is to drain the abscess by a small incision. The actual excision can then be undertaken more satisfactorily two or three weeks later, when the inflammation has subsided.

Despite a variety of surgical techniques available to reduce recurrence rates, PD operations frequently present with complications such as delayed wound healing, infection and persistent pain and recurrences, often requiring re-interventions. In order to decrease complications and recurrence rates after PD excision, it is desirable to use a less invasive technique that allows patients to recover more quickly and permanently. Our center is the first in the Netherlands to introduce a minimally invasive treatment with a radial laser probe, causing obliteration of sinus tracts. Previous studies examining the use of this laser technique to treat anal fistulas and pilonidal sinus disease have shown promising results.

The operation is performed under locoregional or general anaesthesia. Patients are placed either prone with the sacrococcygeal region elevated by pillows or angulation of the table or in left-side position. After shaving, cleaning and scrubbing of the skin with alcoholic chlorhexidine, double strong tape is placed on the right buttock in order to increase exposure. Local anaesthesia is administered before incision with 20 ml bupivacaine. The sinusoidal pits are enlarged with a biopsy core punch or scalpel. Hair and debris is removed from the sinus tracts with a small surgical spoon. Saline washes are used for debris washout and ropivacaine is injected under the skin around the pits and in the tracts for tissue protective cooling. Subsequently, a radial diode laser probe at 980 nm wavelength is used. The laser energy is 13 Joule. The radial fiber delivers energy homogeneously at 360 degrees. First, a preparatory laser treatment is performed, after which the sinus tracts are cleansed with a surgical spoon again.

During the following definitive procedure, the probe is withdrawn at an approximate speed of 1 cm per two to three seconds, causing the small sinus tracts to shrink and close. If the tract is not closed after a first withdrawal, a second intervention is performed. Large sinus tracts remain open. The injury to the endothelium will cause granulation and subsequent closure. At the end of the procedure, a washout with saline is performed and sterile dressings are applied.In the first postoperative period (two weeks), patients were advised to keep the puncture wounds open with a thin cotton swab to prevent premature closing of the skin and to use analgesia when necessary. One and three week’s postoperative follow-up was conducted in all cases to evaluate pain medication, inspect and open the pits when necessary, and detect possible complications. After the first period, patients were seen six weeks and three months after the operation in order to evaluate wound healing and closure and to detect any persistent sinus activity or early recurrences. Follow-ups were performed after two weeks (focusing on pain and use of analgesics), three months (focusing on wound healing and closing) and after one year (focusing on recurrences).

Our results show that 88% of patients were successfully treated without requiring a re-laser or surgical excision. Two patients have persistent sinusoidal disease after laser intervention and had not undergone total epilation as prescribde. In all of the persistent cases, there was no remaining sinus, but a recessus which were treated with local phenolisation After the second treatments, all sinuses were closed after a mean follow-up of 61 days . There were no cases of true recurrence after successful laser treatment. No cases of wound infection, nore bleeding complications or severe postoperative pain were reported.