What’s the deal with LASER surgery for pilonidal sinus (SiLaC)?

It sounds so simple!

Lasers are used for many things in the medical profession, and especially in surgery. Lasers are currently being used to eradicate pilonidal sinuses, and a beam of light sounds like such a simple and pain free solution to a difficult problem. I think when patients envision a laser being used for surgery, they think of a beam of light shining on the tissues and magically curing problems!

In some situations that is exactly what happens, but in others, the laser is used very differently. In the case of eradicating a pilonidal sinus, the laser is attached to a fiber-optic conduit, which brings the light energy to a specialized tip, that turns the light into heat. So, no part of a light beam is in contact with the tissues, but a red-hot fiber-optic tip is used to burn tissues.

There is a category of “minimally invasive” treatments for pilonidal disease that remove the pits and sinus tracts, but do not address the shape or depth of the gluteal cleft. These rely on some method to remove the sinus “tunnel” and hope it will heal. The tunnel can be eradicated with chemicals, surgery, or heat. In the case of laser surgery, heat is used to burn the tissues in hopes that they will subsequently heal and that the sinus will not recur.

So, this is a destructive process, involves burning tissue, may not be pain free, and may or may not be a permanent solution to a patient’s pilonidal disease. In general, it is no more effective than EPSiT, pit picking or Gips procedures, which accomplish the same thing without the expensive laser equipment. The five year results of  “pit picking” or the “Bascom 1” procedure has recently been published, and this series demonstrated a 62% failure rate.

Also, it should be noted that this is very different from using a laser to permanently destroy hair follicles, in order to prevent hair regrowth. In that case, a light beam is indeed used. But, it is not a treatment modality that we feel is necessary in taking care of pilonidal disease.

So, although laser pilonidal cystectomy sounds very “space age” and pain free, it is just a minor variation of already described procedures to treat pilonidal disease. In our clinic, we do not perform the “minimally invasive” procedures, but rather prefer the cleft-lift because of its superior success rate.


How to evaluate the quality of a cleft-lift

For a surgeon some operations are easier to learn than others. The cleft-lift procedure can be challenging to learn, and one of the problems for a surgeon trying to learn this without a mentor, is knowing when a cleft-lift looks good, as opposed to when it needs more tweaking. An operation like an appendectomy is easy for a surgeon to evaluate: if the appendix has been removed, he or she have achieved their goal! The goal of a cleft-lift is more subjective, and how it should look is not always intuitive to surgeons trying this for the first few times. Because of this, some surgeons are not convinced that the cleft-lift is a successful operation, because when they tried it, it failed.

I have created a web page that shows the differences between a successful and an unsuccessful cleft-lift. It shows an image of a successful cleft-lift, and is annotated as to why it succeeded, and another image of a failed cleft-lift, with the same annotations. This page may be more helpful to surgeons than patients – but even as a patient, it may help to know this information.

I did not include the photos in this post, because they are somewhat graphic, and you may not want to see them. But, if you are interested, this link will take you to the page.

Summary of the 2019 International Pilonidal Society Conference

This year’s conference presented a rare opportunity to hear pilonidal surgeons from all over the world share their experiences and techniques in dealing with this problem. One of the main points of agreement in this conference was that IN 2019 THERE IS NO PLACE FOR WIDE EXCISION AS A TREATMENT FOR PILONIDAL DISEASE. The presenters felt that this was an outmoded method of surgical therapy, and should be relegated to history as an operation that has been surpassed by other more successful procedures, with less difficult recovery.

The presentations regarding specific procedures varied considerably, but were in two categories: flap procedures and minimally invasive procedures. The minimally invasive procedures included:

  • Pit Picking
  • Gips procedure
  • EPSiT
  • Laser ablation
  • Phenol ablation
  • Fibrin glue
  • Lord-Millar procedure

These procedures are all similar, in that they attempt to destroy the sinus tract and midline pits using various methods. They are not appropriate for all situations, and the results are variable from surgeon to surgeon, and between the various procedures. The consensus was that there is an indication for these operations in the treatment of pilonidal disease, but that exact indication has not been defined.

Most of the discussion of flap procedures centered around the Cleft-Lift and Karydakis Flaps. The presenters had uniformly good results with these procedures when used with all types and degrees of pilonidal disease. It was felt that the technique had the best cosmetic result and had the highest success rate. It was interesting to hear surgeons from the UK, Turkey, Germany and the U.S. all describe similar positive experiences with this operation.

I presented a series of 500 patients with follow-up from months to decades, with very low complication and failure rates, even in cases of the most difficult disease. There was much interest in my technique and results, and I believe that our clinic is one of the most successful in the world in treating these difficult cases.