Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Pilonidal Cystectomy
Your symptoms and physical exam suggest that you have a pilonidal cyst. A pilonidal cyst is an abnormality
of the tissue over the tailbone, that frequently causes problems by getting infected. A pilonidal cyst may
initially be treated with incision and drainage. It then needs to be excised, or will have a high chance of
recurrent infection.
Description of the Procedure
Surgical excision of a pilonidal cyst can usually be performed without admission to the hospital. The timing
of the surgery is typically after an acute infection is resolved. The pilonidal cyst is excised along with all of
its tracts. The wound may not be sutured shut if there is extensive ongoing infection noted at the time of
surgery. If the wound is left partially or completely open, it will be packed with dressings which will need to
be changed on a daily basis.
Alternatives for Treatment
There are no other currently recommended treatments for pilonidal cysts. Without surgical removal of the
pilonidal cyst, symptoms will usually improve on antibiotics, but the condition will still persist.
Benefits of Treatment
Surgical excision offers a safe, convenient and low risk treatment of a pilonidal cyst. The chance of a
recurrence of an infection is very high without treatment.
Risks/Complications of Treatment
1. Recurrence of pilonidal cyst– a recurrent infection or cyst may develop.
2. Pain – a sense of discomfort over the tailbone will be experienced for several days following the
operation. Pain medicine helps but will not completely eliminate the pain. This usually resolves
spontaneously.
3. Bleeding – bleeding may occasionally occur after surgery.
4. Reactions to anesthesia or surgery – this could show up as a heart attack, blood clots, pneumonia,
sore throat, or potential death, in rare cases.
5. Infection – the surgery site may occasionally become infected. Occasionally, this may be severe
enough to require major surgery to correct. An infection might require prolonged treatment of a
slowly healing wound.
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. Most people experience pain, and are not able to
resume normal work activities for a week or two after surgery. If the wound is packed open, dressing
changes may be required for as long as several months until the wound is healed.
(see other side)
Consent for Treatment
I understand my condition to be a pilonidal cyst. I have read and understand the above
explanation of the procedure required to treat the pilonidal cyst. My surgeon has answered
my questions, and I choose to proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon
permission to act on his best judgment in deciding to remove or biopsy tissues that appear to
be diseased, understanding that complications may arise from that action.
I understand that while most people with a pilonidal cyst benefit from surgical excison, I may
not. My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom
you invite to attend the surgery will be informed of the surgical finding, your surgical status,
and anticipated recovery issues for effectiveness of communications. Because of the anesthetic,
you may or may not remember these important details.
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
I waive the right to read this form, and do not want to be educated and informed of treatment
risks; nonetheless, I understand the need for this surgery and grant permission to the surgeon
to proceed on my behalf.
SIGNATURE _____________________________________________________ DATE _________________
11/04revpjd