Introduction
A coccyx fistula (in technical terms, the pilonidal sinus or pilonidalsinus) is an inflammation in the gluteal fold (Rima ani) that runs between the coccyx and the anus. Probably the most common cause is the ingrowth of hair in this part of the body, which can lead to inflammation of the skin and hair follicles (boils). It is not uncommon for additional bacteria to migrate into the inflamed hair root and increase the inflammation.
If this inflammation progresses further and further, without the pus that has developed being able to drain off, a cavity (cyst) filled with secretion forms under the skin. As soon as there is an outflow to the outside, one speaks of a fistula. Several such drains can also form from a cyst, and a regular duct system under the skin is formed.
Because of the increased hair, very hairy men are particularly affected by a coccyx fistula. Depending on the severity of the inflammation, any intermediate stage between complete freedom from symptoms and inability to sit or walk can develop. Since the inflammation is usually difficult to treat and often recurs repeatedly, surgery is often the only way to treat the coccyx fistula permanently. However, even after an operation, a recurrence must often be expected.
Duration of the operation
There are different methods for the treatment of a pilonidal sinus (coccyx fistula). The choice of the method depends on the extent and type of the coccyx fistula. Therefore, the duration of the procedure can also vary.
There are both open operations and semi-surgical, so-called minimally invasive procedures for the treatment of a coccyx fistula. However, all surgical options pursue the same goal, namely to relieve the fistula, to drain a possibly existing abscess, and to comprehensively remove the fistula ducts. Usually, the duration of such an operation is between half an hour and one hour.
Outpatient procedures are usually shorter, as the treatment can be performed under local anesthesia, thus eliminating the need for anesthesia induction and drainage. Compared to general anesthesia, the patient’s stay in the operating room is shortened. Regional anesthesia is also a possibility, in which the duration of the procedure is on average shorter than with general anesthesia.
However, it must be kept in mind that not every procedure and type of anesthesia is equally suitable for every case and every patient, so that ultimately the surgeon, together with the patient, must determine the appropriate procedure. The exact duration of an operation depends on the anatomical conditions and the type of coccyx fistula, so that in the case of complicated fistula ducts or extensive abscesses, a slightly longer surgical course may be possible. Overall, however, it can be said that the duration of a coccyx fistula operation can be estimated at approximately half an hour to one hour.
- Operation after Karydakis
- Pit Picking
- Laser treatment
In the conventional surgery or the modified form according to Karydakis, the patient lies on his stomach under general anesthesia and all parts of the fistula are removed. This type of complete removal by cutting out the affected tissue is also called excision (ex=out, caesare=cut). Only in the case of smaller fistulas can the operation be performed under local anesthesia.
In order not to leave any parts of the duct system and the cyst behind, the dye methylene blue is often used after incision of the cyst to stain all parts and to show them in the surgical field. It is not uncommon for the entire tissue to be removed deep down to the coccyx, and a “hole” is even created in the gluteal fold. The removal of the tissue often makes simple suturing impossible, and also carries a high risk of wound healing disorders and the recurrence of another coccyx fistula.
Therefore, in these cases the wound is left open and not sutured. In this open procedure, the wound is covered with special dressing materials or wound sponges, and heals from the depths over several months. In Karydakis’ surgery, the tissue is cut out from the side of the buttock cheeks, because the Greek doctor Karydakis had found out that directly in the buttock fold, due to the high temperatures, bacteria and other factors, there are very unfavorable conditions for wound healing.
This procedure was modified by several other doctors. In its basic principles, the operation according to Karydakis is still performed today.The wound is then covered airtightly with wound sponges or other materials, often as part of so-called negative pressure wound therapy (NPWT), and a small suction pump is connected to the drainage system (drains are the tubes that drain the wound fluid to the outside), and negative pressure is created in the wound when the pump is switched on. Vacuum therapy (NPWT) improves wound healing because the wound remains clean by sucking in the secretion, and the negative pressure promotes blood circulation in the tissue.
Pit picking” is the smallest intervention in the treatment of coccyx fistulas that currently exists and can always be performed on an outpatient basis under local anesthesia. In pit picking, the fistula ducts are also cut out with small incisions in the prone position, and an approximately two-centimeter-long incision is made at the side, from which the wound secretion should drain away. The procedure, which was developed by John Bascom in 1980, is always performed on an outpatient basis under local anesthesia.
The post-operative period is described as almost painless and free of complications, so that most patients can resume their everyday life (including sports and work) immediately after the procedure. It is based on the knowledge that the fistula ducts (pits) of the gluteal fold are lined with skin over a few millimeters in depth. This provides a kind of splint for the migration of pathogens, dead skin cells and hair under the skin.
These can deposit there and cause inflammation. Based on this theory, “pit picking” involves “picking” and scarring the open fistula ducts (pits). In this way, the pits close up, thus closing the inflamed cavity.
The “pits” of the gluteal fold are “picked out” with very small incisions (1-3 mm in size). If necessary (advanced inflammation), a small relief incision of 10 to 15 mm is made on the side of the gluteal fold to allow the drainage of inflammatory secretions. The entire procedure of pit-picking takes only a few minutes.
A bandage is applied after the procedure. Some patients experience a small circulatory weakness postoperatively, but this is not a cause for concern. Small post-operative bleedings are also possible, but are then directly breastfed.
It should be noted that the recurrence rate for this procedure is about 20%. This means that statistically, one in five can suffer a relapse. In contrast, the risk for women is only 4%.
Smoking and overweight increase the risk by a further 10 to 15% each. After the operation, all everyday activities are possible without restrictions. After about 2 to 3 weeks the wound should be dry.
However, there may also be delays. After 6 weeks at the latest, the wound should have healed. In principle, it is possible to treat a coccyx fistula with laser treatment.
It should be noted, however, that laser procedures at the current state of medical recommendations do not really have any significance in the primary treatment of coccyx fistulas. Compared to conventional procedures, such as surgical excision or minimally invasive surgery, laser treatments are negligible. It is not certain to what extent laser treatment can prevent a relapse of the disease and therefore no recommendation can be made for such treatment.
However, there are clinics that offer laser surgical procedures. These are microsurgical procedures, where usually only a small incision of 5 mm maximum size is sufficient. The tissue of the fistula tract is then destroyed with the laser in a quasi-targeted manner, the surrounding tissue is to be spared as much as possible.
The after-treatment of such procedures is very simple, since only small wounds are created that heal quickly. Laser treatment is currently still of particular importance in the after-treatment of coccyx fistulas. By means of laser epilation, hair can be removed from the affected area. At the moment there is no recommendation for this either, as it is not sufficiently clear whether laser hair removal actually prevents the formation of a new coccyx fistula or whether the use of laser epilation is obsolete after all.