A pilonidal sinus always requires surgical treatment. If there is a highy acute abscess, it can be relieved before surgery by stab incision and operated on electively after regression of the inflammatory signs.
During surgery, the fistula ducts and the surrounding tissue should be excised comprehensively. For better exposure of the fistula ducts, one can inject methylene blue into the opening of the fistula during surgery. Thus, smaller branches are not overlooked.
The opinions on the post-op approach after the excision are diverging. In principle, one can decide between primary wound closure by suture, or secondary wound healing. Studies show that the open procedure with secondary wound healing leads to less recurrences. However, secondary wound healing takes about 6-8 weeks during which a regular wound treatment is required.
In a primary wound closure, the post-operative treatment is less complicated, but recurrences are more frequent. The tendency to recurrence canprobably be prevented best by sufficient excision, maximally sterile procedure when closing the wound, and generous post-operative antibiosis - but the increased risk of recurrence remains.
