"Pit Picking" and Laser - Surgery of a Pilonidal Cyst (Pilonidal Sinus)

Getting to the (hair) root of the problem ...

Ceralas-Laser Fa. biolitec

This procedure was suggested and named "pit picking" by the British surgeon Peter Lord in 1965. It is the merit of John Bascom from Eugene, Oregon that "follicle removal" gained increasing popularity in the USA. He published favourable results with this minimal invasive surgery on an outpatient basis under local anaesthesia. The principles formulated by these pioneers of pilonidal surgey are still valid today:

  • "pick all pits" :  We must remove the midline pits and with them the offending hair follicle, remove all the hairs that have already been shed into the lesion.
  • "stay out of the ditch":  Large incisions in the midline have to be avoided, because wound healing is poor in this area. 
  • All sinuses and fistulas heal unless there is something keeping them open (and the something is hair).
  • Every attempt of wound closure by sutures is doomed to failure (unless asymmetric flap formation transfers the suture line to one side of the natal cleft). 
  • These rules have been confirmed by a large metanalysis of trials  (Cochrane - Analysis, German Guidelines for therapy of Pilonidal Sinus)

Pit Picking as originally described by Lord and Bascom

Bascom excised the pits "as small as a corn of rice" and removed hair, debris and granulation tissue out of the fistula tract through a lateral incision. I prefer the use of a dermatologic biopsy punch - a tool cutting out a circular piece of skin of 2 up to 5 mm of diameter - for the pit picking and do no longer use the lateral incision which is of no additional benefit in my personal experience.

 

The capsule of the fistula, in fact a kind of scar tissue separating the inflammatory process from the rest of the organism, is left in place.  All incisions are left open for healing by secondary intention.

 

Without doubt pit picking is the least invasive way to get rid of a pilonidal sinus. Postoperative treatment is easy, taking a regular shower once to twice a day and wearing a pad in the underwear as long as the wounds remain secrete fluid. Patients usually are off work only for a few days, can return to sportive activity within a week and experience little or even no pain in the days following the operation.

 

The overall success rate of this method averages 70 %. For the remaining 30 % early failure - eg. the fistula does not close within 4 to 8 weeks or hurts or opens again soon after closure - is much more frequent than true recurrence meaning a new pilonidal fistula develops out of a newly ingrown hair follicle. 

 

A main technical pitfall of pit picking is the fact that the critical step of the operation, the "cleaning" of the fistula tract, is done without direct view. The surgeon can never know if he has really removed every single hair within the Pilonidal cyst. This is especially relevant in situations when hair and connective tissue have merged to a inseparable unity or in a special form of pilonidal fistula when you find subcutaneous hair growth in an orderly fashion.

Pit Picking and Laser ablation of Fistula Tract (FiLaC), Endoscopy-assisted Pit Picking

In 2012 several surgeons had the idea of using the FiLaC (Fistula Laser Closure) technique of laser fistula sealing known from the use in anal fistula on a pilonidal fistula. Laser energy applied to the fistula wall by a fiber optic cable vaporizes inflammatory tissue and active hair follicles.

 

It has been shown that the success rate of Pit Picking is improved up to 80 % by additional FiLaC treatment. The Laser seems to be especially useful in operating large fistula cavities and long fistula tracts traversing the buttocks deep to the surface.

 

High resolution endoscopy can visualize the fistula tract from the inside. The surgeon is enabled to eliminate inflammatory material under direct vision and the completion of hair removal can be assessed. I first used this approach in 2014, results up to now have been encouraging.

Dr. Hofer Facharzt für Chirurgie, Viszeralchirurgie, Proktologie und Spezialist für Steißbeinfisteln in München Dr. Bernhard Hofer* und Klaus Bärtl, Fachärzte für Viszeralchirurgie und Proktologie*

2044 Patienten

mit Steißbeinfistel haben die Behandlung in unserer Praxis gewählt (Stand 11.04.17).

European Pilonidal Center

Zentrum zur Behandlung der Steißbeinfistel

in der Proktologischen Praxis München

Dr. B. Hofer und K. Bärtl

Brienner Str. 13

80333 München

089-292679

doc@darmsprechstunde.de

Allgemeine Chirurgen
in München auf jameda

Warum ein "Zentrum" zur Behandlung der Steißbeinfistel?

In Deutschland werden im Jahr etwa 20.000 Patienten an einer Steißbeinfistel operiert.

Die herkömmliche Therapie der Steißbeinfistel ("Metzger-Methode") führt nicht selten zu einem Monate bis Jahre langen Krankenstand.

Die meisten Patienten sind im jungen Erwachsenenalter, so daß Schule, Ausbildung, Studium und Start ins Berufsleben leiden können. Auch (Leistungs-) Sportler können und wollen sich eine Trainingspause nicht leisten.

Seit 2001 haben wir uns als einer der wenigen Ärzte in Europa auf die Behandlung des Sinus pilonidalis spezialisiert und in über 1200 Operationen seit Gründung der Praxis in München 2013 die Technik des Pit Picking weiterentwickelt. Nach Pit Picking, Laser-OP (FiLaC) und minimal tubulärer Exzision (Fistulektomie) wird Arbeits- und Sportfähigkeit wenige Tage nach einer Operation erreicht. Die Rate primärer Heilung liegt über 90 %.

Die OP des Pilonidalsinus ist schmerzfrei in örtlicher Betäubung möglich.

Die Nachbehandlung nach Pit Picking - OP ist einfach, Duschen, Baden und Schwimmen sind ohne Einschränkung möglich ab dem zweiten Tag nach der OP.

Dr. Hofer Spezialist für Steißbeinfisteln in München Dr. Hofer, Facharzt für Viszeralchirurgie und Proktologie
Klaus Bärtl Facharzt für Viszeralchirurgie und Spezialist für Steißbeinfisteln in München Klaus Bärtl, Facharzt für Viszeralchirurgie
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