More About “Minimally Invasive” Pilonidal Surgery

Fibrin Glue. Kshar Sutra, Phenol, RFA, and Seton Treatment of Pilonidal Disease

In a previous post I discussed several “minimally invasive” pilonidal treatments, and you can read about them here. However, there are a few other kinds of minimally invasive therapies that are worth discussion. They are:

  • Fibrin Glue
  • Kshar Sutra
  • Phenol Injection
  • RFA (Radio Frequency Ablation)
  • Seton treatment
  • Cryosurgery

These are all addressing the pilonidal sinus tract, which is one of the more common presentations of pilonidal disease. These treatments would have no place in the treatment of a large, non-healing wound. I’ll describe each of these separately:

Fibrin Glue Treatment of Pilonidal Sinus

The sinus tract is cleaned out of hair and debris. Fibrin glue is then injected into the sinus tract to obliterate any space in the sinus tract. (Fibrin glue is a biological adhesive which consists of concentrated human fibrinogen which is activated by the addition of bovine thrombin and calcium chloride.)

Kshar Sutra Treatment of Pilonidal Sinus

The sinus tract is cleaned out, the midline pits are removed, and a medicated thread is put in the sinus tract origin, and out the sinus tract exit, and tied in a circle. It is left in place until it causes the tract to scar down and heal.

Phenol Injection for Pilonidal Sinus

This is a technique that is more popular in Europe than the United States. The sinus tract is cleaned out and some form of phenol is instilled into the tract. There are several forms of phenol such as cream-gel, liquid and crystals. Phenol is a caustic, antiseptic, germicide, and has a local anesthetic effect. (It has been used as an embalming fluid!)

RFA (Radio Frequency Ablation) of Pilonidal Sinus

In this technique the sinus is surgically removed, and an electrocautery unit is used to destroy the residual sinus tissue. As surgeons, we use electrocautery in almost every operation. It is a machine that turns electrical energy into heat energy. (often termed a “Bovie” after the inventor). In this instance, certain kinds of tips are used on the machine to facilitate the procedure.

Seton Treatment of Pilonidal Sinus

This is similar to kshar sutra, in that a thread is placed through the two ends of the sinus and tied. Patients come in weekly for the thread to be tightened, until it cuts through the tissues. The inflammation from the thread obliterates the sinus.

Cryosurgery for Pilonidal Sinus

This is very similar to using RFA or Laser – where energy is used to destroy the sinus, but in this case liquid nitrogen is used to destroy the tissues by freezing.

You may be noticing a theme here:

  • They all of these put something in the sinus tract to obliterate it (chemicals, heat energy, freezing, foreign body, glue).
  • They are not very different than EPSiT, SiLaC (laser surgery), pit picking, or Gips Procedure.
  • They may or may not be able to be done in an office setting.
  • They all require multiple post op visits.
  • They do not re-shape the gluteal crease.

The literature regarding the success rates of these procedures is not the most robust. However, when the literature is evaluated the recurrence rate is reported as 15% – 40%. Many studies contain small numbers of patients and short follow up times. Of course, only surgeons with good results report their outcomes, and many surgeons don’t write papers about this at all!

My take on all of these minimally invasive procedures is:

  • They are are a reasonable first step in a specific group of patients with a SHALLOW CLEFT who present with ONLY a sinus or two.
  • They are NOT an option when dealing with open wounds and non-healing surgery.
  • The patient has to accept that there is a significant failure rate. At best one out of five patients will fail, and more likely two out of three (Update: an article from June 2022 has demonstrated a 62% failure rate of pit picking at five years. You can download and read the article by following this link).
  • None of these procedures has been shown to be significantly better than the others.
  • Although they may cause some minor scarring and distortion, they do maintain the original shape of the gluteal cleft, if that is of cosmetic importance to the patient.
  • They are not widely accepted by surgeons, and it may be difficult to find one to perform the procedure.
  • In almost all situations, if they fail, a cleft-lift is still a future option.

I do not perform any of these operations, because I do not feel that the success rate is worth the time, expense and discomfort for a procedure with a low success rate. Especially, if it requires travel across the country to see me. If you are interested in these minimally invasive procedure, I suggest you try to find someone local to evaluate and treat you. If the minimally invasive therapy fails, then come see me for a cleft-lift.

Is the Cleft-Lift a New Procedure?

My surgeon said he never heard of it because it was a new, specialized procedure.

It depends on your definition of “new”. The cleft-lift is a procedure that has had several modifications, within the category of operations for pilonidal disease collectively called “off midline closures”:

  • In 1973 Dr. George Karydakis, a Greek surgeon, published his experience with a successful operation to treat pilonidal disease with an off midline closure. We call his procedure the Karydakis Procedure, and it is very similar to the cleft-lift.
  • Dr. John Bascom began writing about this in 1987 and has published numerous articles on the subject. He modified the Karydakis Procedure, and called his modification a “cleft-closure”, and later changed the name to “cleft-lift”. It is often referred to as the Bascom Cleft-Lift.
  • Dr Immerman has been performing the Bascom Cleft-Lift since 1993, and now has an approximate overall 98% success rate with a single procedure. He has some slight modifications as well.
  • This operation is not a “secret” and there are many, many scientific papers on the subject.
  • A retrospective meta-analysis of 89,000 worldwide patients, followed for up to 20 years, was published in February 2018 which showed that the Bascom Cleft-Lift and Karydakis Procedures had the lowest recurrence rate. You can download and read that article here.

So these procedures have been in the surgical literature for well over 40 years, and are widely known by pilonidal surgeons throughout the world. When studying a board certification study course ten years ago (created by the American College of Surgeons) I came across a question on pilonidal disease where the correct answer to “which procedure has the lowest recurrence rate” : is the cleft-lift. (Indicating that it is the accepted answer to the question as recognized by the ACS.)

So, this is not a new procedure. It is not fringe science. It is not a gimmick. It is not “fake news”. This is one of the best ways to treat pilonidal disease in 2020. (Minimally invasive surgery is also an option, and I discuss that here.) Of course, it is “specialized” – as is every other operation we surgeons perform. If your surgeon has not heard of the cleft-lift procedure, I cannot explain why. You will have to draw your own conclusions.

So, this is not a new operation, but if you are struggling with pilonidal disease, it may give you a new life.