The commonly adopted surgical techniques in contemporary science for management of PNS include incision and drainage, excision and healing by secondary intention, excision and primary closure, and excision with reconstructive flap techniques. In the present case, as the external openings were far away from the natal cleft and many ramifications were present, excision and healing by secondary intention was adopted. Kshara (alkali) and its different modalities like ksharavarti, Ksharasutra, etc. are unique contributions of ancient science. As Ksharasutra exerts both cutting and healing actions, it was used for threading between the main sinus and the external opening which was approximately 9 cm.
It is an accepted fact that average unit cutting time with Ksharasutra is 1 cm/week in fistula-in-ano and the ksharasutra is therefore changed once a week. In our case we have changed the ksharasutra every fourth day. The unit cutting time depends on various factors like the concentration of the drug, tissue of the tract and pressure applied by the ksharasutra on the tract. In this case, since we changed the ksharasutra every fourth day, good pressure was exerted on the sinus. It was considered appropriate to reduce the time to 4 days as it was not an anal fistula, and there was less chance of contamination of the tract since it was not connected to the anal canal.
Pilonidal disease is a complex condition that causes both discomfort and embarrassment to sufferers, and imposes direct costs to the healthcare system and indirect costs to society through absence from work. Regardless of the surgical technique concerned, standard principles of wound care are essential with repeated depilation of the natal cleft, removal of hair and any debris from the wound bed and keeping the wound edges separated using an appropriate dressing.