Abstract
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Purpose
- Pilonidal sinus disease (PSD) is a chronic condition that primarily affects young adults. Sinus laser-assisted closure (SiLaC) has recently emerged as a minimally invasive alternative to conventional surgery, offering potential benefits in postoperative recovery and recurrence rates. This study evaluates the clinical outcomes, safety, and patient satisfaction associated with SiLaC.
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Methods
- We conducted a retrospective analysis of prospectively collected data from 218 consecutive patients who underwent SiLaC for PSD between February 2023 and December 2024. Demographic characteristics, intraoperative parameters, postoperative complications, healing rates, and recurrence rates were examined. Pain and patient satisfaction were assessed using a standardized questionnaire.
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Results
- The study cohort included 142 male patients (65.1%), with a mean age of 25.3±8.1 years. The mean operative time was 13.4±4.4 minutes, and all patients were discharged the same day. The overall complication rate was 15.1%, with most complications being minor abscesses (84.8% managed conservatively). Healing rates at 15, 30, and 45 days were 13.8%, 80.2%, and 98.1%, respectively, with a mean healing time of 26.1±9.8 days. Recurrence was observed in 8.7% of patients after a median follow-up of 11 months (range, 3–25 months), decreasing to 6.5% following a second SiLaC procedure. The mean pain score on postoperative day 1 was 2.8±2.4, and patient satisfaction at 30 days was 9.2 out of 10.
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Conclusion
- SiLaC is a safe, effective, and well-tolerated minimally invasive treatment for PSD, associated with favorable short-term outcomes, rapid recovery, and low recurrence rates. Further research is needed to optimize treatment protocols and assess long-term outcomes.
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Keywords: Pilonidal sinus; Laser therapy; Minimally invasive surgical procedures
INTRODUCTION
Pilonidal sinus disease (PSD) is a common condition of the sacrococcygeal region, occurring predominantly in young adults. Its incidence ranges from 26 to 100 cases per 100,000 individuals, with a strong male predominance and a reported male to female ratio of approximately 3.1:1 [1, 2]. The pathogenesis of PSD is multifactorial, with risk factors such as hirsutism, obesity, prolonged sitting, and chronic irritation or trauma to the natal cleft. These factors facilitate hair penetration into the subcutaneous tissue, resulting in chronic sinus tract formation, recurrent infections, and abscess development [2, 3].
Although PSD is relatively benign, it significantly impairs quality of life due to pain, recurrent infections, and limitations in daily activities. Surgical intervention is often required, leading to prolonged recovery, absenteeism from work or school, and varying degrees of postoperative morbidity.
Surgery remains the only definitive treatment for PSD. Excision with secondary healing is the most frequently performed procedure, favored for its radical nature [4, 5]. However, this technique has several drawbacks, including a wide recurrence rate (2%–42%) and an extended healing period of 1 to 3 months [2]. Additionally, the long wound-care requirements and functional restrictions during recovery contribute to considerable patient dissatisfaction.
To overcome these limitations, primary closure techniques have been proposed and are recommended by European guidelines as alternatives to secondary healing [6]. Primary closure enables faster return to normal activities, with reported recovery times of 5 to 25 days. Nevertheless, this approach is associated with higher risks of postoperative complications, particularly wound dehiscence and infection. Complication rates may reach 74% in midline closures and 35.1% with the Karydakis technique [2]. These complications can result in prolonged morbidity, the need for further surgical interventions, and, in some cases, higher recurrence rates compared with secondary healing [7, 8].
In recent years, several minimally invasive strategies have been developed to improve outcomes while reducing surgical morbidity. Among these, endoscopic approaches have been investigated, but their effectiveness remains uncertain due to variable recurrence rates and long operative times, sometimes exceeding one hour [9, 10]. More recently, sinus laser-assisted closure (SiLaC) has been introduced as a promising alternative, offering potential advantages such as shorter healing times, reduced postoperative pain, and earlier return to normal activities [11].
Despite its increasing adoption, laser therapy for PSD is still relatively new, and the evidence base remains limited. Although preliminary studies suggest favorable outcomes, most available data derive from retrospective case series with small patient cohorts and short follow-up periods. Moreover, no randomized controlled trials have directly compared laser therapy with conventional surgical methods, leaving questions about its long-term efficacy and recurrence rates unresolved [12].
The purpose of this study was to present our clinical experience with laser treatment for PSD, focusing on its outcomes, benefits, and limitations.
METHODS
Ethics statement
This study was approved by the Institutional Review Board of Grand Hôpital de l'Est Francilien (No. 2025-001). The requirement for informed consent was waived due to the use of deidentified data and the retrospective nature of the study. All procedures were conducted in accordance with the principles of the Declaration of Helsinki.
Study design and study population
This study retrospectively analyzed data extracted from a prospectively maintained registry that included consecutive cases of elective SiLaC procedures performed at Grand Hôpital de l’Est Francilien, Coulommiers, between February 2023 and December 2024. The registry was specifically designed to capture comprehensive information on preoperative, intraoperative, and postoperative aspects of patient care.
Inclusion criteria were adult and pediatric patients aged 13 years or older who were diagnosed with pilonidal disease requiring surgical treatment. Routine medical imaging was not systematically performed. After drainage of a pilonidal abscess, the SiLaC procedure was offered in cases of persistent symptoms or the presence of sinus pits. A total of 218 patients were included in this study.
Surgical technique
Procedures were performed under either general or locoregional (spinal) anesthesia, according to patient preference, with the patient positioned prone. A single dose of 1 g metronidazole was administered for antibiotic prophylaxis.
Radial diode laser probes with dual wavelengths of 1470 nm and 980 nm were used (Leonardo Dual 45, Biolitec). The energy setting was 10 W, delivered as 6.5 and 3.5 W for the respective wavelengths in continuous mode.
All sinus pits were excised with a 4-mm biopsy punch, while larger lateral openings were resected with a scalpel (Fig. 1A, B). The subcutaneous cavity was explored with a curette, and all hairs and residual debris were carefully removed (Fig. 1C). The cavity was irrigated with a povidone-iodine solution, after which the laser probe was introduced into the openings to achieve uniform thermal coagulation of the cavity walls (Fig. 1D).
A second exploration was then carried out with a curette, followed by a second laser application to optimize tissue coagulation and ablation. Openings were left unsutured to facilitate drainage and promote optimal healing (Fig. 1E), whereas lateral orifices were sutured. A compressive dressing was applied and maintained for 24 hours.
All patients were discharged the same day. A 7-day course of prophylactic antibiotics was systematically prescribed: amoxicillin-clavulanic acid (1 g twice daily) or, in cases of allergy, pristinamycin. Standard analgesics (paracetamol and tramadol) were prescribed as needed for postoperative pain. Upon discharge, patients were instructed to shower once or twice daily and massage the operated area during washing to facilitate the evacuation of residual fluids through the surgical openings. A routine 2-day work stoppage was prescribed.
A questionnaire assessing satisfaction and pain (visual analog scale) was provided at discharge and collected during postoperative follow-up. The full version of the questionnaire is available in Supplementary Material 1.
Postoperative follow-up visits were scheduled at 15 days and 1 month after surgery (Fig. 1F). Healing was defined as complete closure of all orifices. An additional systematic telephone follow-up was conducted in February 2025.
RESULTS
Characteristics of patients and surgical procedures
Between February 1, 2023, and December 31, 2024, a total of 218 patients underwent the SiLaC procedure. Of these, 142 (65.1%) were male, with a mean age of 25.3±8.1 years (range, 13–55 years) and a mean body mass index (BMI) of 25.3±4.2 kg/m2 (range, 18–43 kg/m2). Seventy-two patients (33.0%) were smokers. Pilonidal disease was chronic in 173 patients (79.4%), and SiLaC was performed after prior incision and drainage of an abscess in 45 patients (20.6%). Additionally, 30 patients (13.8%) had recurrences after previous excision with secondary healing. Patients presented with an average of 2 sinus pits (range, 1–6 sinus pits). Among the study population, 53 patients (24.3%) had secondary fistulous orifices, which were classified as complex cases.
Surgery was carried out under either general or spinal anesthesia, depending on patient preference. A mean of 1.87±1.15 pits (range, 1–6 pits) were treated, and 53 patients (24.3%) required excision of secondary orifices. The mean energy delivered was 955±204.6 J, and the mean operative time was 13.4±4.4 minutes (range, 7–37 minutes). No intraoperative complications were reported. All patients underwent ambulatory surgery and were discharged the same day, except for 1 patient (0.5%) who required an overnight hospital stay for headaches. The characteristics of the patients are summarized in Table 1.
Postoperative course and patient satisfaction
By postoperative day 30, the overall surgical complication rate was 15.1%. A total of 33 patients developed an abscess. Of these, 28 (84.8%) were managed with a 2-week antibiotic course, 3 (9.1%) required wound packing, 1 (3.0%) required surgical drainage and packing, and 1 (3.0%) developed a perianal abscess (Fig. 2). Rehospitalization was required in 3 of 218 patients (1.4%): 2 related to anesthesia and 1 due to an abscess necessitating surgical drainage. Healing rates at 15, 30, and 45 days were 13.8%, 80.2%, and 98.1%, respectively, with a mean healing time of 26.1±9.8 days (range, 10–60 days).
A total of 76 patients (34.9%) completed the questionnaire assessing postoperative pain and satisfaction. The mean postoperative pain scores were 2.8±2.4, 2.2±2.2, and 0.9±1.6 at 1, 5, and 15 postoperative days, respectively. At 30 days after surgery, the mean patient satisfaction score was 9.2±1 (range, 5–10). Regarding sick leave, 22 patients (10.1%) required an extension beyond the standard 2-day prescription due to persistent pain or work-related constraints. The intraoperative and postoperative details are summarized in Table 1.
Follow-up and recurrence
The median follow-up period was 11 months (range, 3–25 months). During this time, 19 patients (8.7%) experienced recurrence, with a mean time to recurrence of 6±4 months (range, 2–19 months). Of these patients, 8 (42.1%) were treated with excision and secondary healing, 5 (26.3%) underwent a second SiLaC procedure, and 6 (31.6%) either declined or were awaiting further treatment. Among patients who underwent a second SiLaC, no further recurrences were observed after a median follow-up of 5 months (range, 2–13 months). After 2 SiLaC procedures, the overall success rate was 93.6% (Fig. 3).
DISCUSSION
To the best of our knowledge, this study represents one of the largest cohorts in the literature evaluating the efficacy of SiLaC in the treatment of PSD [12]. Our findings confirm that laser treatment is a simple and reproducible technique, with a success rate exceeding 90% and consistently high levels of patient satisfaction.
PSD is a benign but increasingly prevalent disease, with approximately 30,000 surgical procedures performed annually in France alone [5]. Despite the introduction of minimally invasive methods, wide excision with secondary healing remains the most common approach, although European guidelines recommend alternative strategies [4, 6]. Of particular note, the 2024 European guidelines explicitly endorse laser treatment as a therapeutic option, highlighting its growing recognition in PSD management [6]. Since its initial description during World War II, surgical treatment of PSD has changed little, underscoring the gap between evolving technology and clinical practice [13].
Primary closure techniques, whether midline or off-midline, have demonstrated lower recurrence rates but remain underutilized due to high postoperative complication rates, technical challenges, and variability in surgeon expertise [2]. The use of laser therapy for anal fistulas was first described by Wilhelm [14] in 2011, which prompted increasing interest in applying the technique to PSD. SiLaC offers several advantages over conventional surgery. Technically, it is straightforward, with a mean operative time of 13 minutes, significantly shorter than endoscopic procedures [9]. The learning curve has been estimated at approximately 20 cases [15]. Moreover, SiLaC has no absolute contraindications, and patients with multiple midline pits or secondary fistulous tracts can benefit from treatment. While no strict requirements regarding surgeon experience exist, our data indicate that the technique is highly standardized and reproducible, making it feasible even for surgeons without extensive prior experience in laser-based procedures.
Reported postoperative complication rates after SiLaC range from 0% to 23%, with seromas and abscesses being most frequent [12]. In our cohort, the complication rate was 15.1%, consistent with published results [15]. Most complications were abscesses, 84.8% of which were successfully managed with antibiotics, while the remainder required wound packing. We believe the proportion of patients managed with packing was disproportionately high, likely due to the involvement of healthcare providers unfamiliar with SiLaC-specific postoperative management. Notably, all patients requiring packing had been managed by practitioners other than the operating surgeon. This finding highlights the importance of standardized postoperative care protocols and education for nonspecialized providers. One severe case of perianal abscess occurred, likely attributable to excessive intraoperative energy delivery. While risk factors for complications remain undefined, laser energy parameters are likely to be critical. Further research should aim to establish optimal settings that maximize efficacy while minimizing adverse events. Importantly, 24.3% of our patients presented with secondary tracts, which we classified as complex cases. These patients achieved outcomes comparable to the overall cohort, suggesting that SiLaC can be applied effectively not only to simple pits but also to complex presentations. Nevertheless, subgroup analyses with longer follow-up will be necessary to better define recurrence and complication risks in these patients.
The postoperative course after SiLaC is generally well tolerated, with pain typically mild and resolving within 2 to 3 days. This rapid recovery allows early return to daily activities, with some patients resuming work the following day. The combination of minimal downtime and favorable results likely explains why patients who experience recurrence often choose repeat laser treatment over traditional excision. In our study, postoperative pain and satisfaction were assessed using a standardized questionnaire. The results demonstrated very low pain scores and a mean satisfaction score of 9 out of 10 at 30 days, confirming high patient acceptability.
Another important, but underexplored, consideration in PSD treatment is cost. At our institution, patients undergoing wide excision with secondary healing typically require 2 months of postoperative wound care, including approximately 100 calcium alginate dressings per patient, at a cost of around €500. This figure excludes additional costs such as nurse visits and lost workdays, which almost certainly exceed the price of a single laser fiber. Although SiLaC appears cost-effective on this basis, comprehensive economic evaluations are needed. Future research should integrate quality-of-life outcomes, indirect costs, and healthcare system burden to fully evaluate the economic implications of different treatment strategies.
In our series, recurrence occurred in 8.7% of patients after a single SiLaC procedure and 6.5% after 2 procedures. These results are lower than those reported in some series [16, 17] but consistent with a systematic review of the literature [12]. Nevertheless, specific risk factors for recurrence remain poorly understood [18]. Retained foreign bodies, particularly hair and debris, appear to play a central role [15]. A combined endoscopic-laser approach may theoretically improve the removal of foreign material and further reduce recurrence rates. Gulcu and Ozturk [19] conducted a retrospective case-matched study comparing endoscopic treatment alone versus endoscopic treatment combined with laser therapy. They reported similar success rates for both approaches, but wound healing and patient comfort were improved with adjunctive laser treatment.
Minneci et al. [20], in a randomized clinical trial involving 302 patients, demonstrated that 1-year recurrence rates were significantly lower in patients who underwent laser hair removal compared with those managed with standard recommendations (hygiene measures and mechanical or chemical hair removal). Based on this evidence, we systematically recommend laser hair removal for our patients, advising initiation before surgery and continuation after wound healing. However, because of its high cost and lack of reimbursement within the healthcare system, only 3% of our patients were able to undergo this procedure.
Spindler et al. [16] identified specific risk factors associated with higher SiLaC failure rates in PSD. Among these, elevated BMI appears to be an important predictor, as overweight and obese patients show increased risks of recurrence or treatment failure. One possible explanation is that excess adipose tissue in the sacrococcygeal region may impair wound healing and promote persistence or recurrence of sinus tracts. Additionally, the presence of extensive suppuration before treatment has also been recognized as a risk factor, suggesting that a high initial inflammatory and infectious burden may compromise the effectiveness of laser therapy. These findings emphasize the importance of careful patient selection for SiLaC and suggest the potential need for preoperative optimization, particularly through weight management and infection control, to improve outcomes.
Despite its strengths, including a relatively large sample size and prospective design, this study has several limitations. First, as a single-center study, the findings may not be fully generalizable to other institutions with different surgical practices. Additionally, while our follow-up period was sufficient to evaluate short-term outcomes, long-term recurrence rates remain to be determined. Future multicenter studies with longer follow-up periods are essential to confirm the durability of SiLaC outcomes. Another limitation is the absence of direct comparison with alternative approaches, such as endoscopic treatment or primary closure, which would allow for a more precise evaluation of the relative advantages of SiLaC.
Conclusions
SiLaC is a promising, minimally invasive option for the treatment of PSD, offering favorable short-term outcomes, rapid recovery, and potential cost advantages. Its inclusion in the 2024 European guidelines underscores its increasing acceptance in clinical practice. Our findings further highlight high patient satisfaction and low postoperative pain, reinforcing its role as a potential first-line treatment. Nevertheless, further research is needed to optimize treatment protocols, better define risk factors for recurrence and complications, and establish the long-term efficacy of laser therapy compared with conventional techniques.
ARTICLE INFORMATION
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Conflict of interest
No potential conflict of interest relevant to this article was reported.
-
Funding
None.
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Author contributions
Conceptualization: FE; Data curation: FE, DS; Investigation: all authors; Methodology: FE; Writing–original draft: FE; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Supplementary materials
Supplementary materials are available from https://doi.org/10.3393/ac.2025.00927.0132.
Fig. 1.Sinus laser-assisted closure procedure. (A) Sinus pit (arrow). (B) Sinus pit excised using a biopsy punch. (C) Subcutaneous cavity explored using a curette with debris removal. (D) Introduction of the laser probe into the openings and thermal coagulation of the cavity. (E) View at the end of the procedure. (F) Result at 1 month postoperatively. The arrow indicates the cicatrized orifice.
Fig. 2.Complication after sinus laser-assisted closure procedure: perianal abscess.
Fig. 3.Flowchart for management recurrence and overall success rate. SiLaC, sinus laser-assisted closure.
Table 1.Baseline characteristics of the study population (n=218)
|
Characteristic |
Value |
|
Age (yr) |
25.3±8.1 (13–55) |
|
Sex |
|
|
Male |
142 (65.1) |
|
Female |
76 (34.9) |
|
Body mass index (kg/m2) |
25.3±4.2 (18–43) |
|
Smoker |
72 (33.0) |
|
Hidradenitis suppurativa |
3 (1.4) |
|
Recurrent disease (after excision) |
30 (13.8) |
|
Chronic pilonidal disease |
173 (79.4) |
|
No. of sinus pits |
2 (1–6) |
|
Pilonidal disease with secondary fistulous orifices |
53 (24.3) |
|
Energy delivered per procedure (J) |
955.0±204.6 |
|
Operative time (min) |
13.4±4.4 (7–37) |
|
30-Day postoperative complication |
33 (15.1) |
|
Abscess treated with antibiotic |
28 (12.8) |
|
Abscess treated with packing |
3 (1.4) |
|
Abscess treated with surgical drainage |
1 (0.5) |
|
Perianal abscess |
1 (0.5) |
|
Healing time (day) |
26.1±9.8 (10–60) |
|
30-Day postoperative satisfaction score |
9.2 ± 1.0 (5–10) |
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