The New Minimally Invasive Techniques for Pilonidal Sinus Disease Surgery: Choosing the Right Technique for the Right Patient—A Narrative Review

<i>Background and Objectives</i>: Pilonidal sinus disease (PSD) is a common condition affecting predominantly young adults and it is associated with a substantial impact on quality of life. Despite the wide range of available surgical options, optimal management remains controversial due to heterogeneous recurrence rates, wound complications and prolonged recovery. Over the last decade, a paradigm shift has occurred from midline excision toward off-midline closure techniques and minimally invasive procedures. This narrative review aims to critically appraise contemporary surgical strategies for PSD, comparing outcomes, indications and limitations, with particular emphasis on patient selection. <i>Materials and Methods</i>: A narrative review of the literature was conducted using PubMed, Scopus, and major guideline repositories. Relevant randomized controlled trials, systematic reviews, meta-analyses, observational studies and national and international guidelines were reviewed and synthesized, with a focus on healing time, recurrence, postoperative complications and patient-reported outcomes. <i>Results</i>: Midline primary closure is consistently associated with higher recurrence and complication rates and is no longer recommended. Off-midline flap techniques provide the most durable results in recurrent or complex disease. Minimally invasive approaches, including endoscopic and laser-assisted techniques, offer faster recovery and high short-term patient satisfaction in selected primary cases, but should not be considered equivalent to flap surgery in complex or recurrent PSD due to limited long-term evidence. Current guidelines uniformly advocate individualized, patient-tailored treatment strategies and discourage midline closure. <i>Conclusions</i>: Surgical management of PSD should be individualized according to disease complexity, prior interventions and patient expectations. While minimally invasive techniques represent an attractive option for selected primary disease, off-midline flap procedures remain the standard of care for extensive or recurrent cases. High-quality comparative studies with standardized outcome definitions and long-term follow-up are required to refine treatment algorithms.