Pilonidal Cystectomy Surgery: Everything You Need to Know

Pilonidal cysts are extremely painful growths that form in the cleft of the buttocks and often become infected. A surgical procedure called a pilonidal cystectomy is used to remove a pilonidal cyst or abscess (boil) and surrounding infection. Cystectomy is the most effective treatment for these cysts, however, there is a high rate of recurrence and the procedure may need to be repeated.

Mature Male Patient In Consultation With Doctor In Office
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What Is Pilonidal Cystectomy Surgery? 

Pilonidal cysts develop near the crease between the buttocks, known as the intergluteal cleft. An impacted or ingrown hair follicle, along with debris like dead skin cells and dirt, become enclosed in a pocket that forms a cyst.

The ingrown hair often continues to grow under the skin, irritating the cyst leading to infection. A pilonidal abscess or boil forms and fills with foul-smelling pus. For most patients, the abscess erupts through the skin, draining pus.

A pilonidal cystectomy is often required to clear out the infection.

Pilonidal cystectomy is a minor surgical procedure that is typically scheduled and performed by a colorectal surgeon on an outpatient basis. General or regional anesthesia may be used to manage pain during the removal of an infected pilonidal cyst or abscess.

Possible Risks

Pilonidal cystectomy is a generally safe procedure. Your doctor will discuss the benefits and risks with you before surgery. Possible risks include:

  • Bleeding
  • Infection
  • Lengthy healing time
  • Recurring pilonidal cysts

Purpose of Pilonidal Cystectomy

The pain of an infected pilonidal cyst is often excruciating. It feels as if you were to press your tailbone up against the sharp corner of a table and hold it there.

The condition is most common in men between puberty and age 40, however, women can get pilonidal cysts as well.

Risk factors for developing pilonidal cysts include having thick, wiry hair on the lower back, sitting for long periods of time, and friction, such as a belt rubbing against the skin. During World War II, these cysts were so common among GIs driving Jeeps that pilonidal disease was referred to as "Jeep seat."

Pilonidal cysts often become infected, leading to pilonidal sinus disease. The sinus is a cavity below the skin that connects to the surface through your pores. The infection spreads from the cyst into the sinus tract and, over time, can lead to recurring infections that become increasingly severe and painful.

Signs of pilonidal sinus disease include:

  • Severe pain near the tailbone
  • Tenderness in the lower back
  • Swelling in the area
  • Foul-smelling drainage
  • Fever

An infected pilonidal cyst is diagnosed by a visual examination by a primary care physician, dermatologist, ER doctor, or colorectal surgeon. Ultrasound also may be used to determine the scope of the infection.

First-Line Treatments

Other treatments will likely have been tried (and failed) before your doctor recommends pilonidal cystectomy.

The typical first-line treatment is to lance the boil. This can be done in your doctor's office or emergency room using local anesthesia.

Once the area is numb, the doctor will make an incision into the abscess to drain the pus. Antibiotics are not usually prescribed for pilonidal infections unless an accompanying skin infection (i.e., cellulitis) is present.

Lancing may work to remove the initial infection, but pilonidal cysts can be complex, and they frequently return and worsen over time.

The next level of treatment is lansing and incising/draining. This is also done using local anesthesia and may be performed in the doctor's office, an outpatient surgical center, or an emergency room setting.

This procedure involves unroofing (splitting open) the cyst, curetting (scraping out) the base, and marsupializing (suturing the edges). The wound is left open to drain. This, too, is usually a temporary fix, and the pilonidal sinus cavity experiences recurrent infections.

If the cyst does not heal after draining or you continue to have problems, a pilonidal cystectomy may be needed to surgically remove the cyst and surrounding tissue.

How to Prepare

Pilonidal cystectomy is sometimes performed as an emergency procedure during an acute flare-up of pain, but it is most often a scheduled surgery that takes place at either a hospital or outpatient surgical center.

What to Bring

Pilonidal cystectomy does not require an overnight stay and you will be discharged following the procedure. Since the surgery is performed under anesthesia, you will be not allowed to drive afterward, so arrange transportation in advance.

Don't forget to bring your insurance documents, identification, and any additional paperwork your surgeon requires the day of the procedure.

What to Wear

It is recommended to wear something comfortable that is easy to change out of. You will be in a hospital gown for the procedure. Do not wear any jewelry and leave anything of value at home.

Food and Drink

Your doctor will instruct you on whether you will need to stop eating and drinking before the procedure. If you are going under general anesthesia, it is typically recommended to not consume anything in the eight hours before the procedure.

Medications

Your doctor will advise you on whether you need to make any alterations to your current medications. Certain drugs can interfere with medical procedures and should not be taken prior to any surgery. In particular, blood thinners may cause problems with blood clotting during surgery.

Be candid about your use of any recreational drugs, marijuana, alcohol, and nicotine, as these may affect your response to sedation.

Don't assume that your entire surgical team knows what medications you are taking. Repeat it to them on the day of your procedure so they are aware of what you have been on and how much time has passed since you last took it. 

What to Expect on the Day of Surgery

A day or two before your scheduled pilonidal cystectomy, you will be notified when to arrive at the facility to check in. The procedure itself should take about 45 minutes.

Before the Procedure

After you check in on the day of your procedure, you'll be taken to a room to change and have a brief exam. You will review your medical history with a nurse, answer questions about the last time you ate or drank, and have your vitals checked.

From there, you will be brought into the procedure room set up with a surgical table, medical equipment, and computers. You will lie face down on the table and the surgical team will prepare the skin on your lower back for surgery by shaving and disinfecting it.

The anesthesiologist will connect you to an IV to give you medicine to relax. If you are having general anesthesia, you will be asleep for the procedure. Some patients instead opt for regional anesthesia, such as an epidural or spinal block, which numbs the area while keeping you awake and alert.

During the Procedure

Once the anesthesia has taken effect, the surgeon will use a scalpel to cut and excise the cyst and sinus, including the skin, pores, underlying tissue, and hair follicles surrounding the infection.

The area will be suctioned to remove pus and cleaned with saline. Any remaining inflamed tissue will be removed and the area will be cleaned again until no sign of infection remains.

Depending on how much tissue was excavated, the wound may be left open to keep watch for infection. If a lot of tissue has been removed, the wound may be packed with gauze. In addition, a drainage tube may be left in to help fluid continue to drain and prevent reinfection. 

If the wound is large, your doctor may need to close it up with stitches. In some cases, skin flaps may need to be created in order to close the wound. There is a greater risk of recurring infection if the wound is closed after cystectomy.

After the Procedure

Immediately following the cystectomy, you will be taken to the recovery room and monitored as the sedation wears off. Once you are steady on your feet, you will be discharged with instructions for caring for the incision, bathing, and making a follow-up appointment.

Recovery

The timeline for healing after pilonidal cystectomy varies based on how the surgery was performed. If your wound was stitched closed, complete healing usually takes four weeks, while wounds left open to drain can takes months to completely heal.

Most people can return to work in two to four weeks after surgery, however, it is advised to avoid strenuous exercise and activity until the area is completely healed. You will likely need several follow-up appointments.

Do not drive the first 24 hours after surgery and while you are taking narcotic medication. In general, you can drive once you feel comfortable sitting in the driver's seat and using the brake and gas pedal. The timeline for this varies depending on your individual circumstances. 

There is a high rate of pilonidal cyst recurrence. It is important to follow your doctor's instructions carefully to ensure complete healing.

Healing

The first few days after pilonidal cystectomy can be uncomfortable. Since the wound is by your tailbone, it may be difficult to sit or find a comfortable position. Sitting on a soft pillow or donut seat may bring relief.

Over-the-counter pain relievers like Tylenol (acetaminophen) should help ease the discomfort. If not, your doctor may prescribe pain medicine to take on a short-term basis.

It is very important to keep the wound clean and dry until the skin is fully healed. Your doctor will give you instructions on how to care for the wound, including changing the packing and dressing, and bathing. Pat the area dry after showers, but avoid taking baths until the wound is healed over.

Lifestyle Adjustments

Once the site is healed, it is important to keep the skin in the buttocks crease clean and free from hair. Young men may need to shave, wax, or use hair removal cream every two to three weeks until the hair shafts begin to soften and thin out around age 30.

If you prefer a more permanent solution, laser hair removal or electrolysis may be a better option. A small study of 60 patients found post-surgical laser hair removal significantly reduces the risk of recurring pilonidal disease.

People who have jobs that require sitting for long periods of time, such as truck drivers, are at increased risk of recurrence. If you have a desk job, consider switching to a standing desk or setting an alarm to stand up and stretch your legs several times throughout your shift.

Possible Future Surgeries

Pilonidal sinus disease can be a chronic, recurring condition. About 50% of people who have a cyst removed require a second cystectomy, and some may need repeated procedures to treat pilonidal sinus disease.

A Word From Verywell

Pilonidal cysts are painful and often difficult to treat. Their location on the tailbone can make them prone to irritation and reinfection. It is important to keep the area clean, dry, and hairless to facilitate healing after a cystectomy and prevent painful infections in the future.

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Article Sources
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