By SERGIO LARACH, MD, FASCRS, FACS; AMY MORRISON, BS
Surgical management of pilonidal sinus disease more often involves a large, wide, en bloc excision of inflammatory tissue in the presacral area. For simple pilonidal disease, it is possible to perform a more minimally invasive technique to reduce healing time and improve cosmetic outcome.
Pilonidal sinus disease occurs in roughly 70,000 people per year in the United States, however the global incidence is estimated at 20-30 people per 100,000 people globally. It is characterized as an inflammatory disease of the gluteal region, usually appearing as an erythematous, tender area in the gluteal cleft that may or may not contain purulent contents.
Additionally, these lesions might be a source of embarrassment for patients. Pilonidal sinus disease is generally accepted to be an acquired disease, which begins with penetration of hair into the skin, which causes deep pits, tracts, and associated inflammatory reaction.
Risk factors include obesity, hirsutism, those with deep gluteal clefts, and male sex. In fact, males are affected two times more than females.
The disease usually presents in these patients by age 40. Patients often complain of pain, discomfort, and visible purulent drainage in the gluteal area. Treatment of the disease involves complete removal of any associated pits, tracts, hair, and debris, and any treatment decisions balance between excising the diseased area and the lowest rate of morbidity and recurrence.
The most common accepted technique for surgical management of pilonidal disease is wide excision with or without closure. However, minimally invasive techniques are becoming more widely used for certain patients.
The Gips procedure is a minimally invasive technique that is suitable for use in patients with simple disease. The Colorectal Surgery team at the Digestive and Liver Center of Florida has seen success using the Gips procedure on patients with minimal inflammation, and we hope to emphasize the benefits of this technique on simple pilonidal sinus disease as compared to a wide excision.
Wide excision of pilonidal sinus disease involves the removal of any skin, sinuses, inflammatory tissue, tracts, or abscesses en bloc, down to the sacral fascia. It is either left open or closed at either the midline, off-midline, or with a flap. Patients report pain and discomfort for weeks following the surgery, as full healing time is approximately 8 weeks. Although the area of disease is fully removed, a large cosmetic defect is left whether the area is closed or left open They will also require help from a caregiver for dressing changes and care of the area given the location of the wound.
While this technique is applicable for more complex pilonidal disease, for simple pilonidal disease, a more minimally invasive approach can be considered.
The Gips procedure begins with injection of local anesthetic at the affected area. A probe is used to localize the fistulous tracts, and skin trephines are used to remove any pits and tracts until the pilonidal cavity is reached. These small openings allow the removal of the cyst cavity, tracts, and any associated inflammatory tissue. In the post-operative period, patients report minimal pain and discomfort, and they return to work in approximately 1 week.
While debate still exists regarding which surgical technique is superior for treatment of pilonidal sinus disease, at the Digestive and Liver Center of Florida, we are seeing great outcomes with the use of the Gips procedure in patients with simple pilonidal sinus disease. Di Castro et. al detailed that, in a study of 2,347 patients who underwent the Gips procedure, only 102 of patients experienced complications such as bleeding (66 patients), prolonged analgesic use (27 patients), wound infection (19 patients), and reduced local sensation (3 patients). Because there is no skin separation between trephine openings, wound healing time is decreased, and patients can resume normal activities quickly. Out of the 2,347 patients who underwent the Gips procedure, the median time in the hospital was 6 hours, the median time to daily activities was 1 day, and the median time to wound healing was 4 weeks.
In conclusion, along with the benefits of quick recovery and low complication rate, the Gips procedure also may be performed under local anesthesia, reducing cumulative risk of the procedure. Finally, the Gips procedure provides good cosmetic outcome, with minimal scarring, as compared with the traditional en bloc excision which overall produces a longer recovery time and larger, deeper scarring in the presacral area.
Pre-op image of pits and abscess
Image of trephine openings
8 weeks post-op
In June 2021, a 21-year-old male patient presented to the Digestive and Liver Center of Florida Clinic for consultation of a pilonidal cyst. It had been previously treated one year ago with antibiotics but his inflammation in the area waxes and wanes intermittently. Physical exam showed multiple pits, induration, and scarring of his presacral area. He underwent the Gips procedure for removal of his pilonidal cyst. The patient reported minimal pain at two days post-op, and returned to work at 10 days post op.
Sergio Larach, MD, FASCRS, FACS is a colorectal surgeon at the Digestive and Liver Center of Florida. He is devoted to his work allowing him to become a pioneer in performing laparoscopic surgical procedures and co-creator of the TAMIS procedure. Besides taking in patients at DLCFL, he also dedicates his time to educating colorectal surgeons, and future doctors as a Clinical Assistant Professor at University of Central Florida and Florida State University.
Amy Morrison, B.S. is an MD candidate at the University of Central Florida.