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284
Navicular area
Pilonidal abscess
17 Role ofLasers inPilonidal Sinus
17.11 Classication ofPilonidal
Sinus
Tezel proposed a new classication for the pilonidal sinus based on the navicular area’s repre-
a
Navicular area
Lateral edge
b
sentation of symptoms [22]. The diagrammatic
representation of the classication is shown in
Fig. 17.3a–e. A detailed description of Tezel’s
classication and how to manage pilonidal sinus
are shown in Table17.1.
Pits
Tip of the coccyx
Anus
Anus
Lateral edge
Fig. 17.3 (a–e) Tezel’s classication. (a) Type 1: pres-
ence of pit (asymptomatic). (b) Type 2: acute pilonidal
abscess. (c) Type 3: pits restricted in the navicular area
Tip of the coccyx
Anus
with abscess drainage. (d) Type 4: extensive sinus disease
with sinus opening outside the navicular area. (e) Type 5:
recurrent pilonidal sinus disease after surgical treatment
Navicular area
Sinus opening outside
17.11 Classication ofPilonidal Sinus
c
Lateral edge
d
Navicular area
285
Pits with abscess
drainage
Tip of the coccyx
Anus
natal cleft area
Lateral edge
Anus
e
Navicular area
Lateral edge
Sinus opening inside
natal cleft area
Tip of the coccyx
Tip of the coccyx
Anus
Fig. 17.3 (continued)
286
17 Role ofLasers inPilonidal Sinus
Table 17.1 Tezel’s classication of pilonidal sinus
Type of
pilonidal
sinus Presentation
Type 1 Asymptomatic
pit(s) with no
history of drainage
or abscess
Type II Acute pilonidal
abscess
Type III Pit(s) in the
navicular part with
an abscess or prior
drainage history
Type IV A severe condition
in which one or
more sinus openings
are located outside
the navicular region
Type V Recurrent pilonidal
sinus
Surgical
recommendation
• No surgical
intervention
• Removal of local
hair
• Maintain hygiene
• Drainage using a
lateral incision
• Bascom’s
procedure
• Outside of the
navicular region,
the Bascom
treatment is
coupled with
separate excision
of pits
• Bascom
procedure
17.12 Imaging
If the patient has inammatory bowel disease,
anorectal stula, pelvic sepsis, or neoplastic
lesion, an MRI can provide a denitive diagnosis
[23]. MRI ndings in individuals with pilonidal
sinus may sometimes resemble perianal and
deep-seated sepsis or anal stula. However, the
lack of intersphincteric sepsis or any enteric
opening helps distinguish the two entities on
MRI [23].
Table 17.2 Differential diagnosis
Disease Features
Abscess • Pilonidal sinus is associated with
abscesses, but not all abscesses
can be dened as pilonidal
abscesses
• Location of the abscess
Hidradenitis
suppurativa
Fistula-in-Ano • Position of the external opening
Epidural
abscess
Furuncles • Infection of hair follicles that
Sacral
osteomyelitis
Carbuncles • Group of the infected hair
Folliculitis • Inammation of hair follicles
Pyoderma
gangrenosum
• Primary lesions are deep-seated
nodules approximately 0.5–2cm
• On rupturing, the tract is formed
subcutaneously
• The disease often affects the
groin, axillary, perianal, and
perineal regions
• Communication with the anal
canal
• Tract palpation
• Internal opening
• MRI
• Percussion tenderness
• Local or radiating back pain
• Fever
• Worsening of pain during
recumbency
goes deep into the skin
• It may have a small pus pocket
• Infection of the sacrum
• Associated with fever, chills, and
rigors
• X-ray of the spine shows
osteomyelitis
follicles with pus
• Usually associated with diabetes
• Ulcerative lesions
• Associated with other
comorbidities
• The patients are in their late
forties
17.13 Dierential Diagnosis
Pilonidal sinus disease should always be differentiated from other conditions present in the
sacrococcygeal region, as shown in Table17.2.
Some authors believe that the pilonidal sinus
and anal stula can co-exist and communicate. In
a study by Pankaj Garg, 9 individuals out of 1284
had a co-existing stula and pilonidal sinus disease [24]. The pathophysiology explained in his
study was as follows:
• Both these diseases existed independently.
• The pilonidal sinus was a primary condition, but it progressed to the point where it
developed into a stula with an anorectal
opening.
• One of the anal stula tracts traveled posteriorly and opened in the lower back [24].
17.15 Video-Assisted Laser Ablation ofthePilonidal Sinus (VALAPS)
287
17.14 Management ofPilonidal
Sinus Disease
The removal of diseased tissue remains the mainstay of surgical management. In the case of an
asymptomatic pilonidal sinus, hair removal,
either by shaving the area or laser epilation, is
recommended [25]. Incision and drainage are the
rst-line therapies for pilonidal sinus with acute
abscess [25]. Pilonidal sinus without an abscess
can be treated with surgical excision [25]. The
conventional surgical procedures vary from limited or wide excisions of pilonidal sinus followed
by primary closure or healing by secondary
intention. The most commonly used procedure is
the Bascom technique which involves the removal
of midline pits followed by closure along with
draining and curetting of the associated abscess
cavity [26]. Many other procedures, including
Z-Plasty, Rhomboid excision (Limberg ap),
V-Y fasciocutaneous ap, Karydakis procedure,
and advancement aps, have been described [27].
These procedures are associated with large
wounds, pain, discomfort, and a recurrence rate
ranging from 3% to 40% [28]. Phenol installation, sinusotomy, and sinusectomy, which
involves circumferential incision of the pilonidal
sinus, are other management modalities [29, 30].
The ap procedure requires preserving the vitality of the ap tissues [31].
17.14.1 Minimally Invasive
Techniques forPilonidal
Sinus: Newer Surgical
Modalities
treatment (VAAFT), Meinero etal. successfully
tried a similar technique in treating the pilonidal
sinus and named it “Endoscopic pilonidal sinus
treatment (EPSiT) [32].” The principle is, to
destroy the pilonidal sinus tract with monopolar
cautery under direct vision. In Milone’s technique, the pilonidal sinus is treated by removing
a minor elliptical wedge of subcutaneous and
inammatory tissue while the overlying skin
remains intact [29]. The use of the endoscope
provided direct visualization of the tract. Milone
etal. [29] reported faster healing of the pilonidal
sinus tract due to a small elliptical incision 2mm
deep and 5mm wide.
The procedure I do in my practice is a hybrid
procedure combining pit excision, Video endoscopy and Laser ablation.
17.15 Video-Assisted Laser
Ablation ofthePilonidal
Sinus (VALAPS)
VALAPS is a minimally invasive procedure done
under spinal anesthesia. It involves removing hair
and necrotic material from the sinus tract by sharp
curettage under vision followed by laser ablation.
The laser emits controlled energy at 65–80 °C,
whereas in cautery, the energy emitted is 300–
400 °C. Moreover, the conduction pathways in
cautery cannot be controlled. The laser has better
soft-tissue ablation and hemostatic qualities and is
more effective than electrocautery.
17.15.1 Principle
Minimally invasive surgical procedures have
gained popularity in treating pilonidal sinus in
the last decade. Meinero etal. [32] and Milone
etal. [29] developed the concept of endoscopic
treatment for pilonidal sinus. Having succeeded
in stula surgery using video-assisted anal stula
The video endoscope offers direct visibility of
the sinus tract. The laser energy destroys the
sinus epithelium while simultaneously obliterating the tract. The necrotic material and hair are
removed under direct vision, reducing the
chances of recurrence.
288
17 Role ofLasers inPilonidal Sinus
17.15.2 Device forVideo- Assisted
Endoscopy
• Fistuloscope 8°, outer diameter 3.3×4.7mm,
working length handle 18cm, angled eyepiece
(Fig.17.4)
• Obturator
• Handle
• Endoscopic seal for working channel
• Wire tray for cleaning, storage, and
sterilization
• Coagulation electrode
• Brush
• Grasping forceps 2 mm diameter, length
30cm with double action jaws
• Plastic handle
• Outer sheath
• Camera
17.15.3 Device forPit Excision
• Dermatology biopsy forceps (Fig. 17.5).
Different sizes are available.
Fig. 17.4 VAAFT scope equipment
Fig. 17.5 Pit biopsy forceps
17.15.4 Energy! Dosage! Fiber!
• Energy: Total energy delivered depends on
the length of the tract.
• Dosage: 10W per second per mm in continuous mode using 1470nm wavelength.
• Fiber: 360° radial ber.
17.15.5 Technique
Preoperatively, a circular area of 6–10in. around
the opening of the sinus is shaved. The patient is
placed in a prone position under spinal anesthesia. After cleaning and draping, the pits are
excised using punch biopsy forceps (Fig.17.6a).
In the absence of a secondary opening, the sinus
tract is converted into a tunnel using a metal
probe inserted through the sinus opening and
brought out through an iatrogenic opening created 3–4 mm wide and 1–1.5 cm lateral to the
midline (Fig. 17.6b). Converting a sinus into a
tunnel helps visualize the tract and remove the
necrotic material. In the presence of a secondary
opening, the VAAFT scope is inserted through
this to visualize the entire tract (Fig.17.6c, d).
The hair and necrotic material are identied and
removed with sharp curetting followed by irrigation of the sinus tract (Fig. 17.6e–g). Alternatively,
the necrotic material can be removed with a brush
and forceps provided with the VAAFT equipment. The necrotic material is sent for
histopathology.
Corona 360° radial laser 600μm with distal
and outer diameters of 1800 μm is introduced
into the sinus through the working channel of the
video endoscope. The entire tract is then ablated
using laser equipment of 1470 nm wavelength.
The energy is released in a dosage of 10W per
second per mm, continuous mode (Fig. 17.6h).
While releasing the energy, make sure there is a
distance of at least 1cm between the laser ber
tip and the video endoscope lens. Otherwise, the
scope’s tip can be damaged with thermal energy.
The tract is again curetted and irrigated to
remove the burnt-out necrotic material. The nal
17.15 Video-Assisted Laser Ablation ofthePilonidal Sinus (VALAPS)
289
Fig. 17.6
(a–i) Steps of video-assisted laser ablation of
pilonidal sinus technique. (a) Excision of pits using pit
excision forceps. (b) Creation of an iatrogenic opening
1–1.5cm away from the midline (optional). (c) Insertion
of the VAAFT scope through the secondary opening of
pilonidal sinus. (d) Presence of necrotic material and hair
as seen under video endoscope. (e) Curetting of the sinus
tract. (f) Tuft of hair as seen after curetting the sinus tract.
(g) Irrigation of the tract. (h) Laser ablation of the sinus
tract using radial ber. (i) Closing of pits after excision
(optional)
290
Fig. 17.6 (continued)
step of the procedure is the closure of pits, which
is optional (Fig. 17.6i). The wound is nally
dressed using nanosilver gel ointment. At the
time of discharge, saline irrigation of the wound
is carried out to remove any leftover debris.
Patients are taught to dress the wound using sterile bandages and ointment. Follow-up of patients
is done after 1week.
17.15.6 Postoperative Care
• Diclofenac sodium as an analgesic and
Amoxycillin with Clavulanic acid 625 mg
twice daily as an antibiotic are prescribed for
5–7days.
• Of late, the wound is dressed with hemoglobin
spray containing 10% carbonylated hemoglobin, 0.9% sodium chloride, 0.7% phenoxyethanol, and 0.05% N-acetylcysteine. The
spray is inserted into the sinus tract using a
nozzle. It improves oxygen availability by
binding oxygen from the environment and dif-
17 Role ofLasers inPilonidal Sinus
fusing it into the wound bed. This accelerates
the recovery process [33]. A study on Hb
spray in wounds has shown a reduction in
wound size by 63% after 4 weeks [33].
• Micronized amniotic membrane provides an
excellent environment for cell proliferation
[34]. Micronized granules of dehydrated
human amnion chorion membrane coated
with 0.5% (w/w) broad-spectrum antimicrobial biocide, PHMB (polyhexamethylene
biguanide), can also be inserted into the
sinus tract. The dressing is required twice a
week.
• Instructions are also given to keep the surrounding area clean and maintain personal
hygiene. The patients are advised to shave the
surrounding area every 2weeks.
17.15.7 Results ofVALAPS
At our center, an efcacy study was undertaken
of 38 participants with PSD, 35 (92.10%) of
whom were males, and 3 (7.90%) were females.
The participants were between 18 and 34 years
(only 1 patient was 45-year-old). There were 16
(42.10%) students, 13 (34.21%) I.T. professionals, and 9 (23.68%) drivers by profession. None
of the patients had diabetes, hypertension, and
dyslipidemia.
The mean operational time was
25.2± 6.23min. The mean VAS pain score at
1h from surgery was 3.5± 0.5, at 6h, it was
2.2±0.3, and at 24h of surgery was 1.1±0.2
(Fig.17.7).
0.
1.
2.
3.
Pain score
Pain score
17.15 Video-Assisted Laser Ablation ofthePilonidal Sinus (VALAPS)
4
291
5
3
5
2
5
1
5
0
Fig. 17.7 Pain score on rst, third, and seventh day
3.5
2.2
Hour 1Hour 6Hour 24
It took an average of 3±1.2days to return to
work. The mean duration for recovery was
21 days. Out of 38, 12 patients complained of
discharge from the wound site for about 7–8days.
Two patients were lost in follow-up. Seven
patients had a recurrence in whom the procedure
was repeated. The overall success rate was
95.3%. The success rate of video-assisted procedures is shown in Table17.3.
A summary of the various procedures showing technical steps, complications, and recurrence rates is shown in Table17.4.
1.1
Table 17.3 Success rate of video-assisted laser ablation
of pilonidal sinus
Journal
Epub
Clinical trial
2014 [35]
Epub
Comparative study
2019 [36]
International Journal of Current
Advanced Research
Research article [37]
Success rate
(%)
96.3
92.5
95.3
292
17 Role ofLasers inPilonidal Sinus
Table 17.4
Type of procedure Technical steps Complications
V-Y advancement
ap [1]
Z plasty [41]
Bascom procedure
[26]
Bascom cleft lift
closure [43]
Karydakis [15]
Limberg ap [38]
Table 17.5
Journal Author Success rate
Journal of the Society
of Laparoscopic and
Robotic surgeons
2017 [45]
Int J Colorectal
Disease
2019 [46]
Journal of
Coloproctology
2020 [47]
Recurrence rate of various surgical procedures in pilonidal sinus
• Creation of full-thickness V-shaped
incision down to the gluteal fascia
• It is closed to form a postrepair suture line
in the shape of a Y [1]
• Excision of the affected part with the
placement of lateral aps incised down to
the level of the fascia [41]
• Midline follicle excision and lateral
drainage [26]
• Excision of the sinus tracts with the
placement of a full-thickness skin ap
across the cleft and closed off-midline
[43]
• Elliptical excision of the affected part with
xation of the ap base to the sacral fascia
• The ap is closed by suturing the edge
off-midline [15]
• A midline rhomboid incision to the
presacral fascia [38]
Results of EPSiT
• The pits—which are the primary source
• Wound site infection
0–10.2%
• Wound dehiscence 10.2%
• Seroma 0–4.6%
[38–40]
• Wound infection 60%
• Seroma 56%
• Wound dehiscence 48%
• Hematoma 52%
[42]
– 15% [26]
Minor complications 34.5%
[43]
Infection 1.8% 0.9–4.4%
Minor complications 16.7%
[44]
• The sinus cavity—the tract
Gabriella
Giarrantano
Piercarlo
Meinero
97%
95%
• The lateral midline tract or abscess, and
• The hair
Any procedure that takes care of these disease
characteristics and has low recurrence should be
considered an ideal treatment.
Elias Saikaly Complete
wound
healing in all
the patients
Complete excision can be midline or offmidline. Midline excisional methods are associated with higher recurrences and, therefore, not
recommended. Off-midline excisional techniques
are the most commonly employed, e.g., the
17.15.8 Results ofMinimally
Invasive Procedures
Limberg ap or Karydaki’s procedure.
Soll etal. proposed sinusectomy as a minimally
invasive procedure for pilonidal sinus with low
The results of EPSiT are shown in Table17.5.
recurrence rate and faster return to work after surgery [48]. Meinero etal. revolutionized this eld by
employing a stuloscope that allowed better visu-
17.16 Discussion
alization of the sinus tract [32]. Gips et al. 2008
performed minimally invasive surgeries employing
While treating pilonidal sinus, one is dealing
with four parts of the disease:
trephines [49], video-assisted ablation of the pilo-
nidal sinus (VAAPS), and endoscopic pilonidal
Recurrence
rate (%)
• 0–11%
[38–40]
32% [42]
4.7% [43]
[15]
7.1% [44]
17.17 Your Queries, My Answers
293
sinus treatment (EPSiT). Prosthetic plugs were
employed by Milone etal. Their minimally invasive approach did not leave any surgical scar [30].
Pappas etal. in 2018 described a minimally invasive procedure for PSD using a diode laser [50].
The technique I use for my patients is a hybrid
procedure where the pits are removed by punch
biopsy forceps followed by video-assisted laser
ablation of the pilonidal sinus. The recurrence
will be high unless the primary source of infection is removed. The sinus cavity will not heal
unless all the hair is removed that can be better
managed under vision. The cavity can be curetted, and hemostasis achieved using a laser. It can
be ablated using a fan-shaped technique. Dressing
the wound after the surgery is an essential aspect
that increases the cure rate. Patients should be
taught to take proper care of the area.
Minimally invasive techniques in pilonidal
sinus provide many advantages. They have
shorter operative time, shorter hospital stay, less
postoperative pain, faster healing rates, and early
return to work.
Several studies have been cited by Peter C
Minneci etal., 2018 to establish the effectiveness
of laser hair epilation in minimizing PSD recurrence [51]. Wagih Mommtaz Ghanam etal. published a study in 2011 that found a very low
recurrence rate of 2.3% in individuals who had
laser epilation as an adjunct to pilonidal sinus surgery. Lavelle etal. recorded a decrease in recurrence rate following laser hair epilation [52].
International guidelines have included the role
of minimally invasive procedures in pilonidal sinus
management. In 2019, the “American Society of
Colon and Rectal Surgeons (ASCRS)’’ issued a
weak set of guidelines for minimally invasive treatments in chronic and acute pilonidal diseases
involving endoscopic or video-assisted procedures
for PSD.The grade of recommendation is 2B, as
shown in Table 17.6 [53]. Italian Society of
Colorectal Surgery has also included minimally
invasive procedures in its guidelines for managing
PSD in 2021. The grade of recommendation is 1B
[54]. According to guidelines, minimally invasive
treatments are validated techniques that should be
the treatment of choice in limited pilonidal disease
(single pit or multiple pits on the midline).
Table 17.6 Operative management of pilonidal sinus
disease. Grade of recommendation by ASCRS [53]
Presentation
of the disease
Presence of
an abscess
Chronic
pilonidal
disease
Complex
and
recurrent
chronic
pilonidal
disease
Acute and
chronic
pilonidal
disease
Operative
management
I&D regardless
of whether it is a
primary or
recurring
episode
Excision and
primary repair
(with
consideration for
off-midline
closure)
Flap-based
procedure
Minimally
invasive
techniques
Grade of
recommendation
Strong
recommendation
based on moderatequality evidence,
1B
Strong
recommendation
based on moderatequality evidence,
1B
Strong
recommendation
based on moderatequality evidence,
1B
Weak
recommendation
based on moderatequality evidence,
2B
17.17 Case Presentation
Mr. C, a 25-year-old male patient, complained
of pain at the base of the tailbone and difculty
in sitting since 5 months. He occasionally
noticed wetness in the tailbone area. He was
prescribed antibiotics by a general physician
but had no relief. When the patient consulted
me, on local examination, a small pit could be
seen in the midline. There was no secondary
opening. He was diagnosed to be a case of pilonidal sinus. The patient was taken for surgery,
and a hybrid procedure combining Video
Assisted Laser Ablation of Pilonidal Sinus
(VALAPS) and pit excision was performed.
The wound was dressed with octenidine for 2
days, followed by dressing with Amnion
Chorion granules and hemoglobin spray from
the third postoperative day onwards. The patient
was given instructions to keep the area clean
and shaved. Postoperative wound care was
explained. The wound fully healed after 2
weeks of surgery (Fig. 17.8a–d).