Shalyaja Nadi Vrana is a type of Nadi Vrana, the etiopathology of which is described by Acharaya Sushruta in Nidana sthaana and its treatment aspect in Chikitsa sthana. It can be correlated to Pilonidal sinus disease, which is common benign anorectal problem affecting young person. It is of infective origin and occurs typically in the sacral region. In spite of advances in surgical management, failure rates and recurrence rates are high leading to considerable morbidity in these otherwise healthy patients. PSD is an umbrella term for a spectrum of abnormalities ranging from relatively asymptomatic simple midline pits or sinuses to complex chronically inflamed cavities with multiple fistulous tracks to treatment failure. Most patients present with chronic symptoms but a significant proportion present with an acute abscess. Different stages of the disease may be amenable to different treatment strategies. Pilonidal sinus disease (PSD) is a common condition affecting 26/100,000 of the general population, predominantly young, and employed males. PSD is rarely self-limiting and, therefore, surgery is the mainstay of treatment. Many surgical methods are described including sinus/pit-based procedures, excision with open management, excision and midline closure, and excision with completely off midline flap repair or flap closure which crosses the midline. Adjuvant laser treatment and shaving are also described. Despite all these options, the recurrence may be as high as 60.4% at 24 months post-surgery. This article discusses the etiopathogenesis and effective management approach of Shalyaja Nadi Vrana (Pilonidal sinus) by Surgical and parasurgical approaches.The ancient Ksharasutra technique is a minimally invasive procedure which has less recurrence and complications if performed methodically.