07. Complete ambulatory removal of a sacro-coccygeal cyst and immediate skin suture
KEYWORDS: Pilonidal sinus surgery, pilonidal cyst, sacro-coccygeal cyst, coccygeal cyst
No laser therapy, curettage, phenol treatment, endoscopic procedures, or procedures that leave an open wound.
Echography yields erroneous indication. A small amount of methylene blue and hydrogen peroxide is injected. This is the solution.
In the event of recurrent infection, pilonidal or sacro-coccygeal cysts must be completely removed, and the skin must be sutured. No curettage, laser therapy, phenol treatment, endoscopic procedures or operations that cause an open wound should be carried out. Indeed, a sacro-coccygeal cyst can be completely removed, and the skin sutured during an ambulatory session, enabling the patient to go home immediately.
The procedure begins with the skin excision; this also encompasses the ostia of the fistulous passages, from which hairs often emerge.
With regard to echography, it should be borne in mind that this examination does not reveal the true dimensions of the chronic inflammatory tissue of the pilonidal cyst. Echography can only provide information on the peripheral fistulous passages that reach the skin. The skin ostia are visible on examination of the region.
In this procedure, the formation is completely removed and the skin is sutured. The results are very good; there are no recurrences and no open skin lesions. To achieve perfect healing, without recurrences, a small quantity of a solution of methylene blue and hydrogen peroxide must be injected into the skin ostium of a fistulous passage. The solution is prepared as follows. First, methylene blue in powder is placed in a container and dissolved in a small amount of physiological solution, and 3% hydrogen peroxide is placed in another container. Then, a 1 mL syringe is used to aspirate 0.3 mL of the hydrogen peroxide, followed by the solution of methylene blue up to a final amount of 0.8 ml.
This solution is injected, without using a needle, into an ostium of the cyst. The hydrogen peroxide in the solution drives the methylene blue into all the branches, staining the pathological tissue blue and enabling it to be distinguished. In this way, the pilonidal cyst can be completely removed. The three ostia of the fistulous passages are encompassed within the skin excision.
Once local barrier anesthesia has been carried out, the skin is incised. The narrow skin flap includes the external apertures, both open and closed, of the sacro-coccygeal cyst. In this patient, there are three.
The operator first uses a scalpel, and then scissors, to isolate the pathological tissue that has been stained by the methylene blue. No blue-stained tissue remains on the walls. The pilonidal cyst, together with its branches, is larger than indicated by the echography. Indeed, the distance between the outlets of the fistulous passages is more than twice the distance evidenced echographically. This means that the echographic image may prompt the operator to perform an excision that is not radical, which would inevitably result in recurrence and make healing slow and difficult. Once the formation has been removed, the operator checks the bottom of the area, which remains pigmented. If any areas of anomalous thickening are noted, they are removed. The operator uses a finger to check the fasciae that cover the bone, which must remain intact. Once the margins of the excision have been checked, subcutaneous suturing is carried out to eliminate the empty spaces. The skin is then sutured by means of simple interrupted stitches. No drainage is required. The patient can immediately return home after being instructed to ensure that the area is kept clean. Healing is perfect.
Capurro S. (2022) Complete ambulatory removal of a sacro-coccygeal cyst and immediate skin suture. CRPUB Medical Video Journal. Other techniques section. http://www.crpub.org
This video provides all the elements needed in order to remove a pilonidal cyst correctly and with very good results. What else needs to be said?
Let me repeat that I would never perform this procedure without injecting a small amount (no more than 1 mL) of methylene blue in hydrogen peroxide into the cyst. As can be seen, echography is not reliable; the tissue to be removed must always be highlighted. I may add that it is advisable to shift the skin excision by a few millimeters from the gluteal fold. If an infection is present, I carry out local antibiotic therapy before removing the pilonidal cyst; I do this by inserting clindamycin or teicoplanin or gentamicin, again with 3% hydrogen peroxide, into an ostium of a fistulous passage. When the infection has resolved, the cyst can be removed.
I can also add that this is an extremely easy procedure to perform successfully. Indeed, it always amazes me to see dozens and dozens of publications, complete with tables and statistics, that describe irrational methods that inevitably lead to recurrences, complications and unsightly scars. Nevertheless, the "Nobel Prize" for irrationality must surely go to those phlebologists who treat a three-dimensional pathology by means of two-dimensional techniques (sclerotherapy, phlebectomy, saphenectomy, laser therapy, functional ligature, loctite, etc.)
No comments yet