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Received date: 26/06/2025 Published date: 25/07/2025 Clinical case

Injury to the Rectum During Excision of the Epithelial Tract of a Sacrococcygeal Pilonidal Cyst

Gullu Khanlar Abdiyeva PhD*

Associate Professor, Department of Surgical Diseases III, Azerbaijan Medical University

*Corresponding author

Gullu Khanlar Abdiyeva PhD, Associate Professor, Department of Surgical Diseases III, Azerbaijan Medical University
E-mail: gulluabdiyeva@mail.ru

DOI: 10.55920/JCRMHS.2025.12.001512

Abstract

Introduction: Pilonidal cysts are located between the coccyx and the rectum, and therefore surgical excision carries the risk of rectal injury.

Materials and Methods: Under epidural anesthesia, we excised the sinus tract down to the rectal wall. The resulting wound was then closed, beginning from the coccygeal projection. The rectal wall defect was closed with a primary suture. Posterior rectal sphincteroplasty was performed. Complete wound healing was achieved 48 days postoperatively. Normal bowel evacuation during defecation was fully restored.

Discussion: This article presents a clinical case of a 29-year-old male diagnosed with “rectal wall injury during excision of the epithelial tract of a sacrococcygeal pilonidal cyst.” During surgery, the posterior rectal wall was damaged while cleaning the sinus tract. The complication occurred due to the lack of preoperative investigation, including tract probing, ultrasonography, fistulography, or MRI. Methylene blue dye was also not used intraoperatively to define the number and direction of sinus tracts. This serious complication could likely have been avoided with complete diagnostic workup.

Conclusion: It is crucial to understand that in cases of pilonidal cysts, the risks associated with leaving the condition untreated may be greater than the risks of surgery. Prevention of rectal injury requires both surgical experience and thorough preoperative planning.

Keywords: Sacrococcygeal Pilonidal Cyst, Postoperative Complication, Prevention

Introduction

A sacrococcygeal pilonidal cyst is a narrow tubular cavity located in the sacrococcygeal region, lined by epithelial tissue and often containing one or more sinus openings [1]. More than 5% of individuals are affected by this condition and its associated complications [2]. The disease predominantly affects young, working-age males between the ages of 15 and 40 [3,4]. Due to its anatomical position between the coccyx and the rectum, there is a risk of rectal injury during surgical excision [5]. Although rectal injury is a rare complication, its likelihood increases with surgical inexperience or the use of inappropriate operative techniques [6].

Aim: The aim of this study is to prevent serious postoperative complications associated with pilonidal cyst excision.

Clinical Case

On November 5, 2024, a 29-year-old male patient was admitted to the Department of Surgical Diseases III with the diagnosis: “Injury to the rectal wall during excision of the epithelial tract of a sacrococcygeal pilonidal cyst” (Figures 1 and 2). The patient presented with complaints of pain and the passage of fecal matter through the site of rectal wall injury during defecation.

Figure 1 & 2: Rectal Wall Injury Following Excision of the Epithelial Tract

Under epidural anesthesia, excision of the fistulous tract tissue was performed down to the rectal wall. The newly formed wound was then sutured with Vicryl No. 48, starting from the projection of the coccyx. The injured portion of the rectal wall was closed with a primary suture. A portion of the skin and subcutaneous tissue was intentionally left unsutured for postoperative observation. Posterior sphincteroplasty of the rectum was carried out (Figures 3 and 4). Hemostasis was achieved. A rectal gas drainage tube was placed to reduce pressure in the ampullary region of the rectum.

The patient was discharged on the 11th postoperative day for outpatient follow-up and care. Post-discharge recommendations included daily warm sitz baths at 37°C and regular dressing changes until complete wound healing (Figure 5). Full epithelialization of the wound was achieved 48 days after surgery (Figure 6). Normal bowel function during defecation was completely restored.

Figure 3: Fifth postoperative day following rectal sphincteroplasty.

Figure 4: Tenth postoperative day following rectal sphincteroplasty.

Figure 5: Thirtieth postoperative day following rectal sphincteroplasty.

Figure 6: Forty-eighth postoperative day following rectal sphincteroplasty.

Discussion

According to the discharge summary and the patient’s history, a diagnosis of “pilonidal cyst of the coccyx” was established based on clinical and laboratory investigations. After preoperative preparation, the cyst was excised under general anesthesia using two elliptical marginal incisions. During the operation, while cleaning the epithelial tract under the coccyx, the posterior wall of the rectum was inadvertently injured.

Upon reviewing the cause of this complication, it was found that prior to surgery, no tract probing, ultrasound imaging, fistulography, or MRI of the epithelial tract had been performed. Intraoperatively, methylene blue was not used to determine the number and direction of the sinus tracts. A complete preoperative diagnostic workup could have prevented this serious complication.

It is important to understand that with a diagnosis of pilonidal cyst, the risk of complications is higher when the condition is left untreated than after surgical intervention.

Conclusions

Prevention of rectal injury depends on the surgeon’s experience and careful operative planning. Our recommendation to junior surgeons is that in cases of patients with a pilonidal cyst of the coccyx, it is essential to perform the abovementioned diagnostic methods and thoroughly evaluate the results prior to surgery.

References

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Huurman EA, Galema HA, de Raaff CAL, Wijnhoven BPL, Toorenvliet BR, Smeenk RM. Non-excisional techniques for the treatment of intergluteal pilonidal sinus disease: a systematic review. Tech Coloproctol. 2023 Dec;27(12):1191–1200.
Kalaiselvan R, Bathla S, Allen W, Liyanage A, Rajaganesshan R. Minimally invasive techniques in the management of pilonidal disease. Int J Colorectal Dis. 2019 Apr;34(4):561–568.
Sit M, Aktas G, Yılmaz EE. Comparison of three surgical flap techniques in pilonidal sinus surgery. Am Surg. 2013 Dec;79(12):1263–8.
Sevinç B, Damburacı N, Karahan Ö. Long-term results of minimally invasive treatment of pilonidal disease using platelet-rich plasma. J Visc Surg. 2020 Feb;157(1):33–35.
Keshvari A, Keramati MR, Fazeli MS, et al. Karydakis flap versus excision-only technique in pilonidal disease. J Surg Res. 2015 Sep;198(1):260–6.

Journal of Clinical Case Reports, Medical Images and Health Sciences (ISSN 2832-1286) is a peer-reviewed journal dedicated to publishing clinical images from all sectors of medicine. The goal of this magazine is to disseminate information about new discoveries and treatments in science and medicine.

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