Vardhman Mahavir Medical College & Safdarjang Hospital, New Delhi, India
*Corresponding author Email: Umeshjethwani89@gmail.com
Pilonidal sinus disease is a common condition usually seen in young adults. Although several methods have been described all have been associated with high recurrence rates. This study was carried out to evaluate the advantages, results of rhomboid excision and Limberg flap reconstruction in the management of pilonidal sinus disease.
Materials and methods
This prospective study was conducted in a surgical unit of a tertiary care centre from July 2011 to May 2013. It includes 67 patients who were treated for pilonidal sinus disease by Limberg flap.
All patients tolerated the procedure well with minimal postoperative discomfort and were discharged in 2–3 days. There was only one recurrence seen in the series.
Limberg flap is very effective for pilonidal disease with low complication rates, short hospitalisation, low recurrence rates, earlier healing and shorter time off-work. The surgery can be mastered easily.
Pilonidal sinus disease is a common condition usually seen in young adults. The estimated incidence is 26 per 100 000 people affecting men twice as often as women[1,2]. Aetiology is uncertain but relates to the implantation of loose hair into the depth of natal crease. Other factors associated are increased sweating with sitting and friction, poor personal hygiene, obesity, local trauma, narrowness of natal cleft, etc[3,4]. Implantation of hair leads to infection and abscess formation later leading to discharging sinus. There has been a debate regarding the best treatment for pilonidal diseases for many years. An ideal operation should be simple, should not need prolonged hospital stay, should have low recurrence rate, and should be associated with minimal pain, wound care and decrease the patient’s time off-work. In 1946, Limberg first described a technique for closing a 60° rhombus-shaped defect with a transposition flap. It meets the entire requirement for being the ideal procedure for sacrococcygeal pilonidal sinus if performed according to appropriate surgical principles.
This study was carried out to evaluate the advantages, results of rhomboid excision and Limberg flap reconstruction in the management of pilonidal sinus disease.
This work conforms to the values laid down in the Declaration of Helsinki (1964). The protocol of this study has been approved by the relevant ethical committee related to our institution in which it was performed. All subjects gave full informed consent to participate in this study.
This prospective study was conducted in a surgical unit of a tertiary care centre from July 2011 to May 2013. It includes 67 patients who were treated for pilonidal sinus disease by Limberg flap. Patients who had pilonidal abscess were first managed by incision and drainage they later underwent definitive surgery. Surgery was performed under general or regional anaesthesia. Patients were placed in prone jack-knife position with buttocks strapped for wide exposure. After painting and draping, the area to be excised is marked and flap lines are marked (Figure 1). The rhomboid incision (with each side equal in length), includes the sinus, is made down to the presacral fascia (Figure 2). The flap is constructed by extending the incision laterally down to the fascia of the gluteus maximus muscle (Figure 3). Haemostasis is achieved by the use of electrocautery. The flap is transposed to the rhomboid defect created by excision of the sinus. A suction drain is placed in the wound cavity through a separate stab incision. Subcutaneous tissue is approximated with interrupted polyglactin 2-0 suture. The skin is closed with interrupted nylon 3-0 suture (Figure 4). Drain is removed after 48–72 hours. Alternate sutures are removed on 10th postoperative day (POD). Rest of the sutures are removed on the 12th–14th POD.
Marking of rhomboid incision and Limberg flap
Defect after rhomboid excision
Making Limberg Flap
Immediate postoperative photograph
Postoperatively patients’ are advised to avoid prolonged sitting or exercise for two weeks. Hair removal either by shaving or by hair removal cream is advised for at least 1 month. Patients are followed up in OPD monthly for 6 months.
Length of hospital stay, duration of inability to work, postoperative complications and recurrence were recorded. Duration of inability to work is defined as the time from the date of surgery to the date on which patient returned to normal activities, including employment and leisure activities.
Sixty-seven patients were operated by rhomboid excision and Limberg flap reconstruction. Among them there were 50 males (74.6%) and 17 females (25.37%). The mean age of presentation was 26 years old (range 16–50 years old). Ten patients presented with recurrent sinus (14.9%). Forty-three patients (64%) presented with discharge, 16 presented with pain, four with infection and four with pilonidal abscess (Table 1).
The operative time ranged from 60 to 100 minutes. Hospital stay ranged from 48 to 72 hours. The stitches were removed after 12–14 days (Table 2).
Early postoperative data
Seroma developed in three patients, which was managed by conservative measures. Two patients developed mild infection which was treated with antibiotics. One patient developed necrosis at the tip of the flap. One patient developed recurrent lesion 6 months postoperatively, which may be due to improper excision of the sinus (Table 3).
The time off-work ranged from 12 to 22 days. The time to walk without pain ranged from 10 to 16 days (Table 4). The mean follow-up period was 4 months.
Pilonidal sinus disease is an acquired condition affecting young adults. A long list of surgeries have been described which itself reflects the need for a safe and efficient surgical method for this entity. Recurrence is the main problem associated with all surgeries described which ranged from 21.4% to 100% for incision and drainage, 5.5%–33% for excision and open packing, 8% for marsupilisation, 3.3%–11% for Z plasty[6,7]. Flap techniques have been associated with lower complication and recurrence rates. With the Limberg flap technique, internal flap cleft can be flattened and tissue can be approximated without tension.
In this study, 67 patients with sacrococcygeal pilonidal disease were managed with rhomboid excision and Limberg flap reconstruction. Recurrence was noted in one patient (1.49%). Akin et al. operated on 411 patients and reported recurrence rates of 2.91%, so our results were comparable to them. Superficial necrosis was seen in one patient (1.49%), which may be due to the design of the long flap or fault technique. El-khadrawy operated on 40 patients and had superficial necrosis at the tip of the flap in four patients (10%). Time off-work in our study patients was 12–18 days. This was similar to that reported by Abu Galala et al..
Several studies have been reported till date and our results are also comparable with them in terms of hospital stay, complication and recurrence rate (Table 5).
Comparison of results with other studies
The advantages of Limberg flap reconstruction are:
• Flattens the natal cleft with a large well-vascularised pedicle that can be sutured without tension. • Midline dead space and scar is avoided. • Useful in complex sinuses with multiple pits where radical excision leaves large defect. • Easy to perform, learn and design. • Useful in recurrent pilonidal disease. • Reduces hospital stay and time to resume normal activities.
• Flattens the natal cleft with a large well-vascularised pedicle that can be sutured without tension.
• Midline dead space and scar is avoided.
• Useful in complex sinuses with multiple pits where radical excision leaves large defect.
• Easy to perform, learn and design.
• Useful in recurrent pilonidal disease.
• Reduces hospital stay and time to resume normal activities.
Limberg flap is very effective for pilonidal disease with low complication rates, short hospitalisation, low recurrence rates, earlier healing and shorter time off-work. The surgery can be mastered easily. The results of this study favour rhomboid excision and Limberg flap reconstruction for pilonidal disease.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Early postoperative data
|Operative time||60–100 minutes|
|Hospital stay||48–72 hours|
|Healing (removal of stitches)||12–14 days|
|Drain removal||48–72 hours|
|Necrosis at tip of the flap||1||1.49|
|Clinical outcomes||Range (days)|
|Time to walk without pain||10–16|
Comparison of results with other studies
|Author/s||Patients (no.)||Hospital stay (days)||Complication (%)||Recurrence (%)|
|Katsoulis et al.
|Akin et al.
|Urhan et al.
|Mentes et al.
|Aslam et al.