Update Course Rewind: Surgical Management of Pilonidal Disease 2024

Wide excision and packing is probably the most common operation that happens worldwide for pilonidal disease, with most pilonidal work not done by people doing advanced pilonidal work.

Antibiotics are not used unless patients are coming in with an active infection.

Some patients with minimal external manifestation don't drain very effectively and experience severe pain with large, bulging abscesses, while others present with multiple draining abscesses but typically don't report pain or require antibiotics.

Wide excision with off midline closure goes back to the 1960s when Caris first described it, and the Limberg flap has been used since the 1940s.

Lord and Millard described a minimally invasive approach in 1965 that is almost the same operation Dr. Gibbs described in 2008.

Current success rates are closer to 70-75% where one minimally invasive operation gets you to full healing and lasting recurrence-free healing.

Some institutions use laser tract ablation, phenol to sclerose the tracts, or fibrin glue, but none have been proven superior.

For a first abscess, the approach is to drain it and see what you're dealing with.

Minimally invasive approaches are offered quickly because it is a 20-minute intervention under sedation with no activity restriction and no narcotic requirement.

In the Gibbs procedure, all pits are excised using circular punches, then the internal cavity is scraped out to remove inflammation, hair, and necrotic fat, leaving the wounds open to heal.

The Ebzi procedure was described in 2013, doing everything through a small incision with a large scope that is not available in the United States.

In the hybrid Gibbs approach, an eight French cystoscope is put into the openings after cleaning to make sure all hair is removed, and this has been done for the past five years with satisfaction.

If not starting with minimally invasive as the first surgical intervention for most people, you're doing it wrong.

All patients should get laser hair removal once they're healed.

Patients need to be attentive to hair removal (waxing or laser) throughout adolescence and into adulthood, with the longer they can sustain it, the better.

Laser is not permanent but knocks hair down to a lower level.

For patients where one or two minimally invasive approaches did not work and they have significant ongoing symptoms, the treatment moves to off-midline closure with the Bascom cleft lift as the preferred choice.