Introduction

Pilonidal cyst is a chronic inflammatory process that occurs with frequency in the sacrococcygeal region, usually associated with the presence of hair in this region.^{1 , 2 , 3 , 4 , 5 and 6} Its presentation is more common in males, with a ratio of 3:1, usually in the third decade of life.^{7 and 8}

The methods used for pilonidal cyst treatment are eminently surgical. Several forms are described, such as incision and curettage and excision and flap rotation, as well as excision with second intention healing.^{9 , 10 and 11} These approaches are quite aggressive, resulting in a large wound that must be cared for. With the advent of new technologies and the pursuit for minimally invasive procedures, Meneiro described in 2013 an approach for endoscopic treatment of pilonidal cysts (E.P.Si.T.).¹² This procedure was developed after the use of a fistuloscope for anal fistulas,^{13 and 14} being applied to this pathology.

The aim of this study is to describe the first report of this technique in Brazil, held by our team, in June 2014.

Surgical technique

To perform the procedure, a spinal anesthesia is required; the patient is placed in a ventral recumbent position, with identification of the orifice of cyst drainage. The surgeon stands between the patient's legs and the video set is positioned to the left of the surgeon (Fig. 1). To perform the technique, a kit, which includes the fistuloscope (Karl Storz GmbH, Tuttlingen, Germany; Fig. 2), an obturator, an endobrush, a unipolar electrode and a grasping forceps, is used. The 18-cm length fistuloscope has an 8° angled eyepiece; the device has a diameter of 3.2 mm × 4.8 mm, being connected to an optical fiber and to a continuous irrigation system. After the passage of the fistuloscope through the cyst hole with infusion of 1% glycine or mannitol, the surgeon searches the cyst, looking for accessory tracts as well as for abscesses. Once the obturator of the equipment is removed, the surgeon starts removing hair and devitalized tissues. After studying the cyst and finishing the tissue removal, the whole-tract cauterization stage begins. To that end, the surgeon uses the electrocautery connected to a power source to remove all granulation tissue present in the cyst cavity. Necrotic tissue is removed with brushing the cavity; with that, the whole tract is cleaned. At the end of the procedure, the surgeon creates an external opening to facilitate drainage of the cavity, and also to enlarge the initial hole (Fig. 3).

Fig. 1 -  Introduction of the fistuloscope. 

Fig. 2 -  Fistuloscope, Karl Storz GmbH (Tuttlingen, Germany). 

Fig. 3 -  Final aspect. 

Discussion

Pilonidal cyst is a very common disorder, with an estimated incidence of 26 cases per 100,000 people, affecting men three times more than women.¹⁵ Men are more affected thanks to their natural hirsutism. The occurrence of a pilonidal cyst is also associated with obesity, sedentary lifestyle and local irritation or trauma.^{16 and 17} The treatment of pilonidal cyst is mainly surgical; there are various techniques described in the literature, e.g., incision and curettage, excision, techniques combined with plastic surgery with rotation flaps, marsupialization or fistulotomy.¹⁸ The ideal method should combine a smaller loss of tissue, minimal postoperative morbidity, cosmetic results, rapid return to work activities, low cost and low recurrence rate.¹⁹ However, although numerous surgical methods have been described, none of them encompasses all of these characteristics.²⁰

The main techniques used - incision and curettage and excision - result in large wounds, requiring local care and a delayed healing, as well as the possibility of local recurrence.

In an effort to minimize this drawback, various techniques have been described, e.g., flap rotation and the use of flaps; however, these techniques are not without complications, and wound infection (0.8-7.6%), seroma (1.5-5.2%), dehiscence (4.1%), flap necrosis (3%) and recurrence (1.2-4.9%) have been reported.^{21 , 22 , 23 and 24}

In 2013, Meinero et al. described a new technique for pilonidal cyst approach with the use of a fistuloscope. With this instrument and under direct vision, it is possible to destroy all granulation tissue and to remove the entire infected area of the cyst, leaving a small open wound for drainage. In their initial series of 11 patients, all subjects had their wounds healed within one month after surgery, with an average return to work in 3.5 days.

There was no recurrence in a 6-month follow-up period (ranging from 1 to 9 months).¹²

In 2014, Milone et al. published their series with this procedure in 27 patients, with a 12-month follow-up. All wounds healed within 15 days, with recurrence in only one patient, two months after surgery. These studies show that this is a very effective technique for the treatment of this disease.²⁵

In this paper, we describe our experience with an initial case, using this technique in a 32-year-old male patient. The patient was placed in the prone position under spinal anesthesia and intravenous sedation. The fistula orifice was catheterized; then the fistuloscope was introduced, using a solution of glycine 1.5%. The tract of the cyst was identified and studied, with removal of hair inside the lesion. In sequence, the tract was cauterized, with removal of devitalized tissue; finally the drain orifice was enlarged. The patient has been followed up (to date, during 10 months), with good healing and no signs of recurrence.

Conclusion

This is a minimally invasive procedure with little aggression to the tissues involved. Its great advantages are an early return to activity and a small surgical scar, with less pain/inconvenience to the patient. On the other hand, the technique has the disadvantage of the availability of a fistuloscope kit for performing the procedure.