A novel minimally invasive technique for epidermoid cyst removal using needle-hole extraction and radio frequency unit

Pandey’s cyst removal device

• Size of instrument: 5 inches in length [Figures 1a and b]

• Material: Autoclavable stainless steel, medical grade

• Description:

1. One end has a spherical sanding part, which is 3 mm in diameter and has sanding spikes for the removal of the capsule/wall of the cyst through the same needle hole incision.

2. The other end has a 3 mm-diameter scoop to remove the remnants of the cyst wall/capsule after it has been destroyed and freed from adhesions using the sanding sphere.

3. The entire equipment is 5 inches long and fully autoclavable and reusable, hence environment-friendly.

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Figure 1: (a) Dr. Pandey’s no-scar Cyst remover instrument. (b) A diagrammatic representation of Dr. Pandey’s no-scar cyst-removing instrument with a sanding sphere (3 mm diameter) with spiked structures at the one end and a scoop of diameter 3 mm on the other end.

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Technique and step

1. The skin is cleaned, prepared, painted, and draped, and the entire procedure is performed in the minor Operation theatres(OT)/procedure rooms with all standard protocols and standard operating procedures(SOP).

2. A small needle incision is made using a 26-gauge needle, and it is extended depending on the size with a needle tip of the radio cautery, depending on the size of the cyst.

3. We then express out all the contents, placing firm pressure over the periphery using comedonal extractors.

4. Once the majority of the material is out, we probe for the capsule and cyst wall and here is where we use our special instrument, Pandey’s cyst removal device (patent approved) or in its absence the smallest comedonal extractor at our disposal to help in expressing out the capsule and the wall.

5. We then hold the wall component with toothed forceps and gently pull and remove it whole.

6. We use the blunt tip of the radio cautery in the coagulation mode to destroy the cyst wall further from within.

7. We use a solution of povidone-iodine, hydrogen peroxide, and normal saline to irrigate the resultant space and also remove the debris

8. If needed, we used N-butyl-2-cyanoacrylate for wound closure; rarely, an absorbable suture was used to approximate the skin. In most cases, the needle hole requires no such treatment.

9. The patient is given topical antibiotic creams, sunscreens, oral antibiotics, and pain killers depending on the size of the cyst, medical condition, and history of the patient.

10. The removed contents are handed over to the patient for histopathological examination, as the same is strictly recommended [Video 1].

Comparison with traditional methods

In our analysis of traditional methods, which we prefer not to elaborate further or mention by name, the main difference is in the size of the incision and the tissue damage involved. In the standard procedure, a sizable incision using a blade, cautery, or similar instruments is made and the capsule is extracted, sometimes resulting in rupture of the wall and spillage of the content.¹⁴ When the whole cyst is tried to remove en masse, it results in wider suture lines, significant scarring, and more collateral tissue damage in some cases.¹⁵ Conventional methods also result in more postoperative complications, especially infections, and thus, the need for prolonged antibiotic support. A study by Gandaglia et al. demonstrated that minimally invasive procedures significantly lower the risk of infection and scarring compared to traditional methods.¹⁶

Our approach has multiple advantages over conventional methods. First, the technique is minimally invasive and offers improved cosmetic results which are especially important for cysts in cosmetically sensitive regions. Second, the needle-hole method makes it possible to excise the entire cyst wall without a large incision, decreasing the chance of an ugly scar. A study by Ayme et al. found that patients who underwent minimally invasive procedures reported higher satisfaction levels due to reduced scarring and quicker recovery.¹⁷ Finally, an RF cautery unit greatly increases the precision and reduces the duration of the operation as well as the time of recovery. Sempowski supports the efficacy of such devices in enhancing surgical precision and reducing recovery times.¹⁸ Our technique is different, as it also includes an additional step to completely evacuate the cyst wall and surrounding structures using Pandey’s cyst removal device. This extra step reduces the risk of both recurrences, one of the most common shortcomings of classical methods. Thus, cosmetic benefits and rapid recovery are clear advantages of our approach with smaller incisions, less tissue insult, and the majority of cases being sutured less.

Comparison with other available innovative techniques

• In the study by Jun et al.,¹⁹ they compared the one-stage excision method with the conventional methods for sebaceous cysts excision. They involved 351 patients, among whom 166 had undergone one-stage excision and 185 received conventional treatment. In our study, 92 cases had undergone successful intact cyst wall removal out of 100 patients with the innovative technique. In our study, no significant complications were observed, while in their study, they reported a 6.0% postoperative wound infection rate in the non-conventional treatment group and a 1.6% rate in the conventional group. This suggests that our noble technique provides better results and may have a lower complication rate compared to the methods discussed in their study. We in our procedure achieved wound closure wherever needed using N-butyl-2-cyanoacrylate without the need for sutures. Whereas the one-stage excision method involved closing the wound with non-absorbable sutures, which may contribute to a longer healing process and increased patient discomfort.

• In the study by Funayama et al.,²⁰ they used a modified one-staged technique for Rrmoving epidermal cysts using a trepan with minimal scarring, smaller postoperative scar, and no recurrences. Their result aligns closely with ours. However, the trepan method reports a flawless success rate across 55 cases, whereas our method achieved a comparable 92% success in a larger cohort of 100 patients. The larger sample size lends greater credibility to our findings. They have followed up patients for up to an average of 13.6 months which is lacking in our study.

• Wu et al.²¹ removed the cyst content with a laser punch, followed by the removal of the cyst wall about a month later by excision. This method was successfully applied to 12 patients, with no complications reported and no recurrence observed during follow-up periods of 3–24 months. In contrast, our study provides a larger sample size of 100 patients, with a success rate of 92%. Both studies report no significant complications, indicating that both procedures are safe. However, the smaller sample size and the two-step laser procedure may limit the generalizability and practicality, respectively. Compared to our study with a larger cohort and single visit procedure, it would cater to broader clinical applications and patient convenience.

• Wei Liang Chen,²² in his study enucleated facial sebaceous cyst by creating a minimal elliptical incision through a keratin-filled orifice. He enrolled 11 patients in his study. All 11 cysts were successfully enucleated, indicating a 100% success rate. In contrast, our study reports that the cyst wall and capsule were successfully removed intact in 92 out of 100 patients, resulting in a success rate of 92%. While both studies report successful outcomes with minimal complications, they present a smaller sample size with a higher success rate and detailed follow-up on patient satisfaction. However, our study has larger sample size and highlights the use of advanced techniques like RF cautery, which may offer benefits in terms of incision management.

• In the study by Park et al.,²³ they performed minimal incision suction-assisted excision of a large epidermal cyst. This method also focused on minimal incisions and complete cyst removal, paralleling the goals of our technique. Suction-assisted excision relies on negative-pressure removal contrasts with our method’s innovative use of RF cautery to manage adherent cyst walls. Both approaches demonstrate ingenuity in technique. Both methods report high safety profiles with minimal complications. However, our study’s larger patient population (100) as compared to theirs offers stronger evidence of its efficacy and generalizability.¹⁹ They have reported one case of hematoma as a complication, whereas with our method, there were none reported.