Pilonidal sinus is a benign disease that usually affects young male patients. It is an acquired entity, usually asymptomatic, with primary pits and subcutaneous tracts in the natal cleft. If it gets infected, it becomes painful with an acute abscess, promoting recurrent soiling from primary and secondary openings, many off the midline. After a period of infection, pilonidal sinus can become a complex disease with several tracts and secondary openings, making surgery difficult and hard to recover from. Excessive natal cleft hair/body hair is the main factor for developing a pilonidal sinus.
Classical surgery includes the removal of skin and subcutaneous tissue, with the pilonidal sinus/cyst within. Even when primary skin closure is possible, suture dehiscence is a common complication. Midline closure has high rates of infection and wound dehiscence, with a recurrence rate of up to 38%. Off-midline closure techniques (e.g., Limberg, Karidakis, V-Y flaps) need longer hospitalizations, drains, and a wound dehiscence rate of up to 15%. In sum, classical surgery is associated with postoperative pain and several weeks to months to recover, with consequent absence from school or work. Nowadays, there is no gold standard to treat a pilonidal sinus.
I am using the LASER procedure to treat pilonidal sinus. I believe this technique can be offered as a first-line treatment, even in complex cases. Basically, the pits are removed, intense curettage is performed, and a laser diode is inserted through the pits which delivers energy (10W/3s) causing the destruction of the tracts and shrinkage effect. Treatment must be done through the primary pits, and then through all secondary openings if there are any. If the patient is eligible, this procedure can be done on an outpatient basis.
What is the healing rate? What is the complication rate? What is the recurrence rate? Dr. M. Dessily from Belgium, published in 2019 the results of 200 consecutive patients treated by the SiLaC (Sinus Laser-assisted Closure) procedure in the Department of Coloproctology and Digestive Surgery in La Louvière. They included 144 men and 56 women. SiLaC procedure was delayed 6-8 weeks in case of an acute abscess. The authors infiltrated the subcutaneous tissue around the sinus with saline solution to decrease skin-burning risk. The range of primary pits per patient was 1-5 (mean 1.57). Additionally, 30% of patients had a secondary opening out of the midline from a previous abscess. The mean operative time was 9.4 min (6-16 min). Impressive and far faster than classical procedure.
The authors delivered per pit a mean of 352.6 Joules. This is a high dose of energy. Is it necessary? According to the authors, Joules delivered per pit did not influence healing. I am using only 30-100 Joules with the Dermworks Laser diode. Painkillers were used for less than 7 days by 85.5% of patients, and 23.5% did not use them at all. Complication rate was 15% (9.5% infection; 4% fibrin membrane obstructing the drainage pit; 1.5% hematoma). All postoperative infections were treated with antibiotics and by gently reopening the pits.
The mean time for healing was 19.5 days, and 94% of patients (188) were healed within 2 months (like other reports: 90.3% and 92%). Dr. Dessily et al report a recurrence rate of 15.2% (mean time for recurrence: 6.54 months). According to the authors, there were two risk factors for recurrence: the presence of secondary openings, and postoperative complications (particularly infection). It is essential to highlight that the Joules delivered per pit had no influence on the healing or recurrence rates. Patients with a recurrence or a non-healing pilonidal sinus were offered a second SiLaC treatment. From those, some did not want any further procedure since they were far better after the first SiLaC, and those who were submitted to a second procedure had a 75% success rate.
A drawback of this study is the inclusion of only primary disease not submitted to a previous procedure (surgery or SiLaC). Patients submitted to a suture procedure or a lay open surgery may be unsuitable for SiLaC, some authors say. However, other authors compared the SiLaC procedure between patients with and without previous surgery. The results were similar in both groups.
The SiLaC procedure is very fast and easy to perform. But the major advantage it brings to pilonidal sinus treatment is that it can be used for every stage of the disease. Patients with only one primary pit or several primary pits, patients with multiple secondary openings, and patients with multiple tracts, are all suitable for laser treatment. Is this the true one technique fits them all? The authors state that “the best indications of SiLaC are for an advanced disease with multiple primary pits and secondary openings since it prevents these patients from having large excisions and long-lasting postoperative home care”. This statement is very important because a new technique is usually validated with simple cases. In contrast, since the very beginning, the SiLaC procedure has been indicated for the treatment of complex cases of pilonidal sinus. Classical surgery of these complex cases with multiple tracts is associated with significant postoperative pain, several months to full recovery, frequent wound dehiscence, and secondary healing of a large surgical wound. In my opinion, those are the cases in need of a better solution than wide excision. With SiLaC those hard times may become a rare picture. As the authors state “although a secondary opening increases the risk of recurrence after SiLaC, the benefits of the procedure outweigh the risks because, in patients with advanced disease, it prevents the need for morbid wide excisions”.
Should the SiLaC procedure be offered as a first-line treatment? I believe so. When indicated, a minor invasion should always come before a major invasion.
Link to PubMed (tricks and tips about the procedure and postoperative care):
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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