EP170 - A Novel Combined Approach of Sinus Laser Therapy(SiLaT) and Suture-Dragging for Treating Pilonidal Sinus Disease: A Case Report

Purpose/Background: Pilonidal sinus disease (PSD) is a chronic inflammatory condition of the sacrococcygeal region, characterized by the formation of sinus tracts or cavities, recurrent infections, and abscess formation. The absence of a consensus on the optimal surgical management for pilonidal sinus disease has spurred the exploration of minimally invasive and tissue-sparing techniques. Sinus laser therapy (SiLaT) is a promising advance, yet its success depends on complete debridement. Residual debris undermines laser efficacy, and extensive inflammation can limit its effectiveness. To overcome these limitations, we combined SiLaT with the suture-dragging technique from Traditional Chinese surgery. In this approach, a medicated silk suture is employed, which functions as a draining seton and stimulates granulation tissue growth, ensuring continuous drainage and the elimination of necrotic material.

Methods/Interventions: A 21-year-old male university student presented with a one-year history of a recurrent, symptomatic mass in the sacrococcygeal region. Physical examination revealed a 4 cm x 2 cm indurated and tender mass within the natal cleft. Inspection revealed two midline pits and a single, superficially ulcerated sinus opening located approximately 8 cm cephalad to the anus, with expressible purulent material.

The patient was treated with a combined SiLaT and suture-dragging protocol. The procedure began with probing the sinus tract, followed by electrocautery excision of the midline pits and trimming of the ulcerated openings to ensure drainage. All hair and necrotic debris were meticulously removed.

Following this mechanical preparation, circumferential 360-degree endoluminal laser ablation of the sinus wall was performed using a 1470 nm diode laser. The laser was set at a power of 3 W and meticulously applied, delivering a cumulative energy of 374.2 J over a total treatment time of 37.8 seconds to ensure complete epithelial destruction. Given the extensive nature of the lesion, the laser alone was insufficient to achieve complete cavity closure. Therefore, the suture-dragging technique was employed as an adjunctive measure to minimize tissue damage and preserve normal sacrococcygeal structures. This approach not only facilitated effective lesion management but also maintained postoperative drainage, which is critical in preventing re-accumulation and promoting healing from the wound base upward.

Results/Outcomes: A segment of the silk suture residing within the fistula tract was externalized and cleansed with a furanacillin solution. Subsequently, traditional Chinese medicinal powders were applied topically to the suture, with the specific agent selected according to the postoperative healing phase: Jiuyi Dan was employed in the initial debridement stage to promote the dissolution and detachment of necrotic tissue, while Shengji San was introduced later to encourage robust granulation tissue growth. The medicated silk suture was then reintroduced into the tract cavity, enabling direct and sustained therapeutic action on the wound bed. Follow-up clinical examination and MRI at more than three months post-procedure demonstrated complete resolution of the sinus tract, with no evidence of fluid collection or inflammatory changes, confirming treatment success without recurrence.

Conclusion/Discussion: In conclusion, this case validates the combined SiLaT and suture-dragging technique as an effective tissue-preserving strategy for PSD , achieving complete resolution without short-term recurrence.

Clinical Presentation and Procedural Workflow
A Physical examination revealed a 4×2 cm indurated and tender mass in the sacrococcygeal region, featuring two midline pits and a superficially ulcerated opening at its superior aspect.

B Sagittal T2-weighted MRI with fat suppression demonstrated a hyperintense sinus tract (yellow arrow) located left of the midline at the coccygeal level, confirming the diagnosis.

C Intraoperative probing confirmed tract continuity, with the probe passing from the midline pit through to the ulcerated opening.

D The initial surgical preparation involved the electrocautery excision of the midline pits and the trimming of the ulcerated opening to ensure adequate drainage patency.

E Circumferential endoluminal laser ablation was performed using a 1470 nm diode laser to achieve complete epithelial destruction of the sinus tract.

F The suture-dragging technique was employed to minimize tissue injury, maintaining postoperative drainage and enabling topical medication delivery directly to the fistula tract, thereby preserving surrounding healthy tissue.
Postoperative Wound Healing and 3-Month Efficacy Assessment
A Wound management followed a staged protocol: Jiuyi Dan was first applied for debridement, followed by Shengji San to promote granulation. The wound condition at 1 week postoperatively, following this protocol, is depicted.

B Postoperative wound appearance at 1 week, following the removal of the medicated suture.

C At 2 weeks postoperatively, the wound exhibited progressive epithelialization.

D By 3 weeks, the wound had achieved complete closure.

E The sacrococcygeal region at the 12-week follow-up, showing a well-healed scar and no clinical evidence of recurrence.

F Follow-up sagittal T2-weighted MRI with fat suppression, obtained at 3 months post-procedure, confirmed complete resolution of the pilonidal sinus tract, with no evidence of residual inflammatory activity or recurrence.