5 QUESTIONS ABOUT PILONIDAL CYSTS: EXCISION OR LASER

1. WHAT IS A PILONIDAL CYST?

During embryonic formation, at the bottom of the spine, in the intergluteal groove, the skin closed in on itself, creating a pocket or pilonidal sinus or pilonidal cyst or sacrococcygeal cyst.

The cyst under the skin contains hairs and their pilosebaceous appendages, which secrete sebum. This sebum can emerge through the skin via a small hole 1 to 2 millimetres in diameter, which indicates the presence of the underlying cyst and allows secretions to escape. The cyst can also rupture and fistulate at a distance, causing inflammation and infection.

2. IS IT SERIOUS?

Let's face it, it's a pathology :

• Common (20,000 patients undergo surgery in France every year)
• Benign (there is never any cancer on the parts of operated pilonidal cysts).

The relative seriousness is linked to possible infection when the secretions from the cyst are not evacuated through a cutaneous orifice.

This can result in an abscess or even spontaneous discharge of pus a few centimetres from the cyst orifice, indicating a distant fistula.

3. HOW CAN IT BE RECOGNISED?

From adolescence onwards, most often in boys (3 times out of 4).

In no case is it due to a lack of hygiene (a question often asked).

Before any complications arise, the symptoms are discomfort, pain, intermittent swelling in the gluteal cleft and even the discharge of secretions or hairs through the opening.

Examination of the gluteal cleft reveals the cyst's orifice or pertus on the midline, which is the diagnostic sign.

At the time of infection, it will be an abscess, i.e. a red, hot, painful swelling, sometimes with fever, which develops over 2 or 3 days and requires emergency surgical treatment.

If the infection progresses more slowly, it may spread to the skin through a distant orifice, resulting in a fistula.

These three stages in the development of the cyst are indications for surgery. Ideally, at the stage of a simple orifice with no infectious manifestations.

4. WHAT IS THE SURGICAL TREATMENT: EXCISION OR LASER (SILAT)?

This is a short surgical procedure (about twenty minutes), performed under general anaesthetic and covered with anti-staphylococcal antibiotics.

EXCISION :

The cyst is removed in its entirety by passing at a distance from the cyst in healthy tissue.

To achieve this, an indigo carmine marker injected through the cyst orifice will tattoo the cyst entirely in blue and allow surgical removal without leaving any of the cyst wall which could be the cause of recurrence. The deep passage always goes as far as the fascia covering the sacrum. If there is a fistula, it is marked by the blue that has diffused into the cyst and is removed at the same time. The operation ends with a mesh using pure calcium alginate fibres.

In the case of a large abscess, it may be preferable to first simply incise the abscess to avoid making too large an excision, and to remove the cyst 10 days later.

LASER OR SILAT :

Unlike excision, this technique does not remove the cyst but destroys its wall. Through one or more skin orifices 5 mm in diameter, the surgeon successively introduces a curette to remove the cyst material and hairs, followed by a laser fibre which destroys the cyst shell and causes the cavity to be blocked by the walls coming together. Here again, a dressing of calcium alginate wicks is applied to the small orifice(s) and a compression dressing is applied.

THE CHOICE BETWEEN EXCISION AND LASER :

• In the case of excision, the rate of recurrence is less than 5% if the exeresis was total, which is noted on the anatomopathological examination of the specimen that was examined and if the packing was always done to the bottom of the wound.
• In the case of laser technique, the real lightness of the follow-up care is somewhat offset by a recurrence rate of 15 to 25% depending on the studies and some haematomas or infections more frequent in the aftermath.
• The indication should be discussed with the surgeon during the pre-operative consultation. There are certain contraindications to laser treatment, such as obesity, the absence of a dimple in the gluteal cleft or several secondary orifices, etc.

5. WHAT ARE THE DISCOMFORTS, CONSTRAINTS AND POST-OPERATIVE TREATMENTS?

• The operation will be performed on an outpatient basis
• Antibiotic treatment for 2 days after excision or 8 days if the cyst has been operated on at the abscess stage or using the laser technique.
• Painkillers on request, depending on the level of discomfort.
• 7 days off work after laser treatment, or 2 weeks or even 3 or 4 weeks after excision, depending on the width of the excision and the occupation.
• The wound must be cleaned daily with physiological saline by a nurse near the patient's home or workplace. The laser technique takes a few weeks and excision 8 weeks.
• A shower can be taken if the nurse re-dresses the wound immediately afterwards or, better still, by using watertight adhesive films which are stuck over the dressing while the patient is washing.
• Complete healing with epidermalization takes an average of 2 months for excision, and discomfort is generally limited to 1 week for laser and the first 3 weeks for excision.
• There are no aesthetic after-effects whatever the technique, as the scar is often not very large despite the extent of the resection and is located in the gluteal cleft.

IN CONCLUSION:

The pilonidal cyst is a frequent, benign condition whose treatment should ideally be carried out at the early, unsymptomatic stage, with a simple small hole in the gluteal cleft indicating its presence.

A small excision or laser technique allows rapid healing, with little postoperative discomfort.

Doctor Patrick JULIENNE

TURIN Clinic, PARIS ^8th

Tel Secretariat: 01.40.08.88.07

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