Surgical Management of Pilonidal Sinus Disease

Pilonidal sinus disease is a chronic condition of the natal cleft characterised by the formation of sinus tracts, cysts and abscesses driven by hair penetration and local sepsis. Surgical management aims to eradicate diseased tissue, minimise recurrence and hasten return to normal activities. Traditional excisional techniques range from wide local excision with healing by secondary intention to primary midline closure; the latter is associated with high long-term recurrence. Off-midline closure methods, notably Limberg and Karydakis procedures, employ flap reconstruction to flatten the cleft and divert tension away from the midline, yielding low recurrence rates and faster healing. More recently, minimally invasive and endoscopic approaches such as video-assisted ablation and endoscopic pilonidal sinus treatment have been introduced to reduce tissue trauma, postoperative pain and hospital stay. Choice of technique is influenced by disease complexity, patient preference and surgeon expertise, giving rise to considerable global variation in practice. Preoperative imaging, tailored flap selection and standardised protocols for postoperative care are increasingly recognised as key factors in optimising outcomes.

Research from Nature Portfolio

Large-scale analyses confirm that recurrence rates in pilonidal sinus disease are highly procedure-dependent and influenced by follow-up duration. A merged data meta-analysis demonstrates that off-midline flap techniques such as Limberg and Dufourmentel achieve recurrence rates below 2 per cent at two years, whereas primary midline closure can exceed 60 per cent over longer follow-up. Flap procedures not only lower recurrence but also accelerate wound healing and reduce overall morbidity. A subsequent global assessment reveals that these techniques retain superior outcomes across diverse geographic regions, although the frequency of their use varies markedly between countries. Incisional drainage alone shows the highest recurrence, while Karydakis and Bascom modifications maintain consistently low rates irrespective of regional practice patterns, underscoring the universal benefit of tension-free, off-midline reconstruction.

Surgical Management of Pilonidal Sinus Disease publication trend

The graph below shows the total number of articles in surgical management of pilonidal sinus disease across all publications each year (not limited to Nature Index journals).

Technical terms

Off-midline closure: Surgical technique that transposes a flap of skin and subcutaneous tissue away from the midline to reduce tension and scar contact with the natal cleft.

Flap procedure: Reconstruction method in which adjacent skin and subcutaneous tissue are mobilised to cover an excision defect, commonly used in Limberg, Karydakis and Bascom operations.

Endoscopic Pilonidal Sinus Treatment (EPiST/PEPSiT): Minimally invasive technique using an endoscope to visualise and ablate sinus tracts under direct vision, preserving skin integrity and reducing tissue trauma.

Recurrence rate: Proportion of patients in whom pilonidal disease reappears following initial surgical intervention, typically assessed at fixed follow-up intervals.

References

1. Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence. Scientific Reports (2018).
2. Pilonidal sinus disease: Review of current practice and prospects for endoscopic treatment. Annals of Medicine and Surgery (2020).
3. Impact of geography and surgical approach on recurrence in global pilonidal sinus disease. Scientific Reports (2019).
4. Pediatric Endoscopic Pilonidal Sinus Treatment (PEPSiT) in Children With Pilonidal Sinus Disease: Tips and Tricks and New Structurated Protocol. Frontiers in Pediatrics (2020).
5. Minimally invasive pilonidal sinus treatment: A narrative review. Open Medicine (2019).