Pilonidal Cystectomy - Procedure, Benefits and Recovery

Pilonidal Cystectomy is a surgical treatment that removes a pilonidal cyst or abscess (boil) and the infection surrounding it. Pilonidal cysts are exceptionally harsh growths that develop in the buttock's cleft and generally get infectious.

Pilonidal cystectomy is by far the most successful form of therapy for pilonidal cysts. Although it has a substantial rate of recurrence, thus it may be necessary to repeat the process. 

Anatomy and Physiology of the Skin

The skin is the largest external and primary protective organ of the body. It is made up of three layers of tissues. The upper layer is the epidermis, the layer below the epidermis is the dermis, and the third layer is the subcutaneous tissue.

1. The epidermis provides a waterproof barrier and contributes to the tone of the skin.
2. The dermis contains connective tissue, hair follicles, blood vessels, lymphatic vessels, and sweat glands.
3. The subcutaneous tissue (hypodermis) is made of fat and connective tissue.

The skin covers the entire external surface and serves as a first-order physical barrier against the environment. Its function includes:

1. Protection against microorganisms, dehydration, ultraviolet light, and mechanical damage.
2. Sensation of pain, temperature, touch, and deep pressure starts with the skin.
3. Mobility: The skin allows smooth movement of the body.
4. Endocrine activity: The skin initiates the biochemical processes involved in Vitamin D production, which is essential for calcium absorption and normal bone metabolism.
5. Exocrine activity: The skin secretes products that can harm the body such as urea and ammonia. 
6. Immunity development against pathogens.
7. Regulation of Temperature: Skin participates in thermal regulation by conserving or releasing heat and helps maintain the body’s water and homeostatic balance.

Generally, pilonidal cystectomy is done to treat acute and chronic pilonidal cysts or abscesses. 

Pilonidal cyst surgery is generally indicated for patients with:

1. Pain and discomfort from the presence of the pilonidal cysts
2. Severe infection
3. Multiple cysts with sinus tract
4. recurrent cyst despite undergoing incision and drainage procedure

Pilonidal cystectomy is generally performed under general anaesthesia to keep the patient comfortable throughout the surgery. The procedure usually takes about 45 to 60 minutes to complete depending on several factors such as the patient's age, other medical conditions of the patient and the complexity of the case. A trained General Surgeon (Proctologist) or a Dermatologist and other professional staff perform the pilonidal cystectomy through the following general steps:

1. The surgeon will advise the patient to be in a jack-knife position. In this position, the patient lies on the abdomen, and the head and feet of the patient are at a lower level with the middle portion above the level. This position allows the surgeon to clearly visualise the pilonidal sinus cyst and assist in proper surgery.
2. The anesthesiologist will administer general anaesthesia to prevent any discomfort during the surgery. 
3. The cyst and sinus, along with the skin pores, surrounding tissues, and follicles near the infectious region, will be cut and eliminated with a scalpel by the surgeon. 
4. The pus will be suctioned out, and the skin will be cleansed with saline. Any inflamed tissue that persists will be eliminated, and later the region will be cleaned once more until there is no trace of microbes. 
5. The wound may be kept open to prevent infection, based on how much tissue was removed. The wound may be covered with gauze if a considerable amount of tissue has been eliminated.  
6. A drainage tube may also be kept in place to help fluid drain and avoid relapses. 
7. The healthcare professional may need to use stitches to seal the incision if it is large. It may be necessary to produce skin flaps to seal the incision in some circumstances. 
8. If the wound is sealed following cystectomy, there is a higher risk of the infection returning.

The patient may expect the following before or on the day of the surgery.

Before Pilonidal Cystectomy

A patient may expect the following before the surgery:

1. To diagnose properly, the doctor will ask the patient about the symptoms that he/she experiences. 
2. Doctor will: 
   1. Ask the patient about his/her occupation, lifestyle, family history as well as medical history. 
   2. Recommend some blood tests to look for any infections or allergies.
   3. Advise the patient to undergo a pre-anaesthesia check-up. Based on the check-up report, the hospital will confirm the surgery date.
   4. Ask the patient to avoid certain medications or food.
   5. Instruct the patient on how to prepare for the procedure.
   6. Explain the detailed surgery procedures, duration of the surgery and hospital stay, and how to prepare for the surgery.

On the day of the Pilonidal Cystectomy

The patient may expect the following on the day of surgery:

1. The patient must reach the hospital before the scheduled time to avoid the last-minute hustle. In addition, it will help the patient to relax before the surgery.
2. The patient will be asked to sign a consent form before the surgery.
3. The staff will instruct the patient to remove jewellery, dentures, and contact lenses before the surgery.
4. The healthcare staff will ask about the medical history and last meal.
5. The healthcare staff will also check all other vitals such as blood pressure, blood sugar, body temperature etc. 
6. Before beginning the procedure, the staff will shave and disinfect the lower back area.  
7. The anesthesiologist will administer the anaesthesia. It might be general or local based on the case and comfort.
8. The patient will then be shifted to the operating room.

A patient who has undergone pilonidal cyst surgery can expect the following after the surgery:

The recovery process in the hospital

1. Post-surgery, the patient will be moved to the hospital ward so that he/she can recover.
2. The patient will be kept in observation until the after-effect of anaesthesia wears off.
3. The doctor will cover the wound with a bandage and prescribe painkillers.
4. The recovery period depends upon if the wound was left open or not. A closed wound can recover in 4 weeks, while an open wound might take months to recover.
5. Once the patient's condition stabilises, the patient will be discharged after providing detailed information about the home care, scheduled medicines, and initiation of activities.
6. Most patients are discharged from the hospital on the day of the surgery. However, the patient may need to stay at the hospital for 2 to 3 days in some cases. The average time of stay at the hospital after surgery is around 12 hours.

Recovery process/expectation after hospital discharge

1. Instructions provided by the doctor must follow at home.
2. The doctor will suggest the patient to clean the wounded area and shave the hair of the wounded site regularly to prevent a recurrence. 
3. The patient must avoid strenuous exercises and activities for about two weeks after surgery.
4. The patient must:
   1. Get enough sleep and rest when he/she feels tired.
   2. Avoid sitting on hard surfaces for long periods until the incision has completely healed.
   3. Drink plenty of fluids and try bland, low-fat foods like plain rice, broiled chicken and yoghurt.
   4. Avoid constipation and straining with bowel movements
   5. Avoid fried and spicy foods, alcohol and smoking.
   6. Stop swimming or soaking baths for about 2 to 3 weeks after the surgery.
   7. Avoid sexual intercourse until the cyst is completely recovered.

First follow-up appointment

1. The first follow-up appointment post-surgery will be scheduled within 4 to 6 days after the surgery.
2. During the follow-up visit, the doctor will ask about:
   1. Any discomfort experienced after the surgery 
   2. Any reaction to anaesthesia 
   3. If you still have any bleeding 
   4. Any other complication

3. The doctor might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.

4. The patient will also be informed regarding future visits to examine if the implant is in place and functioning properly.

Pilonidal Cystectomy is typically the first surgical procedure considered to treat pilonidal cysts. There are several benefits associated with pilonidal cystectomy. These include:

1. Reduced inflammation
2. Reduced pain
3. Less occurrence of infection
4. Improved quality of life
5. Go home the same day

Pilonidal cystectomy is a simple and safe procedure. However, as with any surgical procedure, there are some risks associated with the surgery that a patient may experience while undergoing the procedure. Some of the risks and complications associated with pilonidal cystectomy are:

1. Increased pain, swelling or redness near the incision
2. Bleeding
3. Fever and other signs of infection, such as chills
4. Lengthy healing time
5. Recurring pilonidal cysts
6. Pus draining from your incision

When is consultation with the doctor needed?

The patient must consult the doctor when he/she experiences:

1. Pain which often gets worse when sitting
2. A small dimple or large swelling near the buttocks
3. Infection in the surgical area
4. An abscess with draining pus or blood
5. Pus discharge from the surgical site

If the pilonidal cyst is not treated in time, it can be uncomfortable and may affect daily activities. Following are the complications that might follow if the pilonidal cyst is left untreated.

1. The size of the cyst might increase 
2. The symptoms and the severity might enhance 
3. Accumulation of fluid and pus, rupturing of cyst multiple times, and a giant raw patch might appear, leading to immense pain. 
4. The cyst might further induce the progression of a type of skin cancer- squamous cell carcinoma. 

The cost of pilonidal cystectomy ranges from ₹35,000 to ₹80,000. The cost varies based on the following factors:

1. Patient’s age
2. Other medical conditions that the patient may have
3. The severity of the pilonidal cyst
4. Technique and equipment used
5. The type of hospital facility availed - individual room or shared