Consent Form For Pilonidal Cystectomy

Paul E. Savoca, MD, FACS, FASCRS

The doctor has explained that I have the following condition:

The following procedure will be performed:
Removal of a sinus (track) between the buttocks

There are some general risks and complications of the procedure, which include:
(a) Small areas of the lungs may collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
(b) Clots in the legs (deep vein thrombosis or DVT) with pain and swelling. Rarely part of this clot may break off and go to the lungs which can be fatal.
(c) A heart attack because of strain on the heart or a stroke.
(d) Death is possible due to the procedure.
There are specific risks and complications of the procedure which include:
The wound may need to be left open and packed regularly until it heals and this could be several weeks or even months.
The wound, if sutured, may break open and discharge blood or infected material. This may need further surgery.
The scar may thicken and redden and be painful.
The sinus problem may recur. This may need further surgery.
Increased risk in obese people of wound infection, chest infection, heart and lung complications and thrombosis.
Increased risk in smokers of wound and chest infections, heart and lung complications and thrombosis.

The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur. The doctor has also explained relevant treatment options as well as the risks of not having the procedure.

I acknowledge that:
The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes.
The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure.
I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital.
The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly.
I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements,

Name of Patient:_______________________________________

I have explained the patient’s condition, the need for treatment, the procedure and the risks as well as all relevant treatment options and their risks, the likely consequences of those risks as well as the significant risks and problems specific to this patient.

I have given the patient/ substitute decision-maker an opportunity to ask questions about any of the above matters and raise any other concerns which I have answered as fully as possible. I am of the opinion that the patient/ substitute decision-maker understood the above information.

Name of Doctor: Paul E. Savoca, MD, FACS, FASCRS

Discharge Instructions for Pilonidal Cystectomy


  • You will be given a prescription for pain medication. Follow the directions given by your doctor for taking this medication. To avoid upset stomach, take your pain medication as prescribed with food in your stomach.
  • Take these drugs exactly as directed. Never take more than the recommended dose, and do not take the drugs more often than directed. If the drugs do not seem to be working, consult your physician.
  • Do not share these or any other prescription drugs with others because the drug may have a completely different effect on the person for whom it was not prescribed. Some people experience drowsiness, dizziness, lightheadedness, or a false sense of well-being after taking prescription pain medications. Anyone who takes these drugs should not drive, use machines, or do anything else that might be dangerous until they know how the drug affects them. Nausea and vomiting are common side effects, especially when first beginning to take the medicine. If these symptoms do not go away after the first few doses, check with the physician who prescribed the medicine. Side effects may include: dizziness, lightheadedness, nausea, sedation, vomiting, if these side effects occur, it may help if you lie down after taking the medication.
    • Don’t drive while you are taking narcotic pain medication.
    • Don’t lift anything heavier than 15 pounds until your doctor says it’s okay.
    • Don’t mow the lawn, use a vacuum cleaner, or do other strenuous activities until your doctor says it’s okay.
    • You may walk indoors, outdoors, up and down stairs.
    • Expect to be off from work/school for at least one to two weeks following this surgery. Your surgeon will give you more guidance on return to normal activities.
    • Avoid constipation:
      • Eat fruits, vegetables, and whole grains.
      • Drink 6–8 glasses of water a day, unless otherwise instructed.
      • Use a fiber supplement and a stool softener twice a day. This is particularly true while taking narcotic pain medications.

Wound Care:
For comfort take pain medication prior to dressing change. The basic principle is to shower the wound twice a day and reinsert a fresh gauze in the wound after each shower.

  • Leave the dressing from surgery in place until the day after surgery.
  • The morning after surgery, remove the tape and outer dressing from the wound, getting in the shower and allow the rest of the dressing that is packed in the wound to be soaked with water and then pull it out. Unfortunately, this does hurt a bit.
  • When the dressing is removed, you may see a small amount of bleeding. This is normal.
  • Vigorously irrigate your wound in the shower for 5-10 minutes, using a hand-held shower head, it you have one. Aim showerhead directly at the wound. Bending forward helps open the wound. Let the water clean the area thoroughly.
  • Wrap a thin, clean wash cloth or 4×4 plain cotton gauze around your finger and clean gently, but thoroughly, the inner surface of the wound, removing any surface covering to expose clean, healthy pink tissue. Don’t scrub.
  • After shower, pat the skin around the wound edges dry.
  • The repacking of the wound is what usually requires help from another person. Wash hands. You may use gloves, but this is not necessary.
  • Moisten a fresh 4×4 inch plain cotton gauze with tap water. Squeeze out excess water.
    (The dressing should be damp, not wet).
  • Pack the wound gently but not tightly with the moist gauze. Use a Q-tip or your finger to ensure that the gauze reaches the bottom of the wound and place it so that all inner wound surfaces are in contact with the moist gauze.
  • Cover with a dry outer dressing and secure with tape or elastic bandage.
  • Dispose of the old dressing in plastic trash bag with twist tie.
  • As your wound heals, it will close from the bottom and sides, and you will need less and less gauze to pack it.
  • Shave the skin at least 2 inches around the wound at least once weekly. Use adhesive tape to pick up loose hair.

Follow up appointments are essential to ensure the wound is healing normally. The doctor will tell you how soon they need to see you back for the first follow up appointment.

When to Call Your Doctor:
Call the office if you have any of the following:

  • Excessive Bleeding
  • Increasing pain
  • Increased redness or drainage of the incision
  • Fever 100.5°F, or higher