Pilonidal sinus: Limberg flap, a better option for pilonidal sinus

Dr. Mohammad Nadeem Aslam, Dr. Sidra Shoaib, Dr. Majeed Chaudhary
Department of Surgery, Mayo Hospital, Lahore, Pakistan

Abstract
Pilonidal sinus disease has been treated for a long time with conventional open excision technique. The rhomboid flap of Limberg is a transposition flap that has been pleaded for treatment of this condition. We present our experience with the Limberg technique for both primary and recurrent pilonidal sinuses. 110 patients, with pilonidal sinus disease were treated with rhombic excision and Limberg transposition flaps. Under general anesthesia, all sinus tracts were resected en bloc, and the Fasciocutaneous Limberg flap was prepared from the gluteal region and closed it with a suction drain. Full primary healing was obtained in 110 patients, 1 patient had minimal necrosis of flap and 2 had gaping of flap. Minor infection occurred in 3 patients. But all these complications healed uneventfully. The average hospital stay was 3 days. Follow up period was 1 year and 1 recurrence occurred. So it was concluded that limberg flap may be a useful technique to treat pilonidal sinus
Keywords: Pilonidal sinus, Limberg, rhomboid transposition flap

INTRODUCTION

Intergluteal pilonidal disease is a commonly encountered condition in adult primary care, and it causes significant morbidity. A calculated incidence of the disease of 26 per 100000 inhabitants was found [1]. Pilonidal disease generally presents as a cyst, abscess, or one or more sinus tracts with or without discharge in the upper part of the natal cleft.
Men are affected three to four times more commonly than women [1,2] and the condition is most frequent in the third decade of life. It is infrequently encountered in patients older than 45 years [4].
The etiology of pilonidal cysts has been a matter of debate. The condition was probably first described by Mayo in1833, and it was felt to result from the congenital disposition but with time the view shifted towards acquired theory [3]. A widely acceptable view is that they are caused by local trauma, poor hygiene, excessive hairiness, and presence of deep natal cleft. [5, 6]
The management of pilonidal sinus disease is frequently unsatisfactory. Many surgical and non- surgical treatment modalities have been suggested, but the ideal and widely accepted treatment has still not yet been established [7]. In this regard, low recurrence rate, shorter hospital stay, less cost, minimal inconvenience and time off work are important considerations. Surgical techniques include laying the track open, wide excision with open wound, wide excision with marsupialization, excision with primary midline or asymmetric closure and techniques involving various flaps procedures. All the surgical procedures have their pros and cons.
The rhomboid flap of Limberg is a transposition flap that has been advocated for treatment of this condition [8]. In 1946, Limberg first described a technique for closing a 600 rhombus shaped defect with a transposition flap [9]. It is easiest to construct. It is a series of communicating equilateral triangles, with all angles meeting at 600. The advantage of this reconstruction is that it is very easy to perform and design. It flattens the natal cleft with a large, well-vascularized pedicle that can be sutured without tension. That eventually helps in maintaining local hygiene, avoids hair insertion by reducing the friction between buttocks, reducing humidity, maceration, erosions and scar formation at the natal cleft [10].
In this study we present our experience with this technique.


Materials and methods
Study was conducted in the Department of South surgical ward, Mayo hospital, Lahore and Sir Gangaram Hospital from 1st Jan 2007 to 31st December 2007. 110 patients with pilonidal sinus disease were included in the study. All the patients who presented with primary or recurrent pilonidal sinus disease were included, while the patients, who came with an acute pilonidal abscess, and patients having diabetes mellitus, uncontrolled hypertension, bleeding diathesis, steroid intake, recent myocardial infarction and smoking were excluded to control the confounding factors.

INCLUSION CRITERIA EXCLUSION CRITERIA
Primary pilonidal sinus Acute pilonidal abscess
Recurrent pilonidal sinus Co-morbid factors

All the patients were admitted to the hospital, one day prior to the operation. These patients were advised to return to normal activities after removal of stitches, after about 10 days, but to avoid excessive physical strain and strenuous sports for following 3 to 4 weeks. Follow up of all patients was performed on an outpatient basis, every month for 6 months. It included the detailed history and clinical examination by trained personnel. The outcome measures recorded were wound infection, healing time, time off work, gaping, necrosis and recurrence rate.
OUTCOME MEASURES % age
Wound infection 2.7 %
Time Off Work 10 days
Gaping 1.81%
Necrosis 0.9 %
Recurrence 0.9%

Wound infection was defined as the systemic signs associated with purulent discharge from the wound, necessitating open drainage or debridement. Recurrence was defined as, the reappearance of symptoms and sinus after complete healing of the wound. Data was analyzed by using SPSS software (version 11).

Surgical Technique
All the patients were admitted to the hospital, one day prior to operation. The hair around the natal cleft was shaved before operation. Under general anesthesia, the patients were positioned prone (Jack Knife) and the buttocks were strapped apart by using the adhesive tapes. Area to be excised and flap lines are marked prior to operation and a rhomboid incision including the sinus and its extensions is made down to the presacral fascia.



The flap is constructed by extending the incision laterally and down to the fascia of the gluteus maximus muscle. Flap should be exactly of the same angles and length of the defect made by the excision. The subcutaneous fat was undermined and lifted as a flap from the gluteal fascia extending down to the level of post sacral fascia to close the wound in a tension free manner.



Suction drain was placed in the wound cavity, through a separate stab incision. Subcutaneous tissue was approximated with interrupted 2/0 vicryl. Skin was closed with mattress interrupted stitches with prolene 4/0. Drain removed on 2nd day. Sutures were removed on 10th post operative day.


Results
110 patients were included in the study which included 102 males and 8 female patients. All were between 17- 30 years of age. Of these sinuses 103 were primary and 7 were recurrent. Full primary healing was obtained in all 110 patients, 1 patient had minimal necrosis of flap and 2 had gaping of flap which healed secondarily. Minor infection occurred in 3 patients. But all these complications healed uneventfully. Average drain removal is 2 days. The average hospital stay was 3 days. There was 1 recurrence, at one of lower corner, after 6 months of follow up.






COMPLICATIONS NO. %age
Flap Necrosis 1 0.9
Gaping 2 1.81
Wound Infection 3 2.7
Recurrence 1 0.9








Discussion
Pilonidal sinus is characteristically a blind epithelial tract (the sinus) situated in the skin of the natal cleft, a short distance behind the anus and generally containing hair [17]. The incidence is highest in males. The etiology and pathogenesis of pilonidal sinus is still a matter of debate. According to present view it is basically caused by excessive hairiness, poor hygiene, and humidity [18]. Other factors affecting the incidence are increased sweating associated with sitting and buttock friction, poor personal hygiene, obesity, and local trauma, Increase depth, narrowness of the natal cleft and the friction movements of the buttocks paves the way for loose hair to collect and insert in deep cleft [19]. The cleft is further prone to the collection of loose hairs, by increased sweating associated with sitting and buttock friction, poor personal hygiene, obesity, and local trauma. The hair is perceived as a foreign body, initiates an inflammatory response and can then lead to a pocket of infection leading to abscess or sinus formation [20].
The surgical treatment should intend towards removing all the sinus tracts as well as the predisposing factors that contribute in the formation of pilonidal sinus. The goals of the ideal procedure for the treatment of this disease should be reliable wound healing with a low risk of recurrence, a short period of hospitalization, minimal inconvenience to the patient, and low morbidity with few wound-management problems [21]. Also, treatment should allow the patient to resume normal daily activities as quickly as possible. The advantage of this reconstruction is that it is very easy to perform and design. It flattens the natal cleft with a large, well-vascularized pedicle that can be sutured without tension. That eventually helps in maintaining local hygiene, avoids hair insertion by reducing the friction between buttocks, reducing humidity, maceration, erosions and scar formation at the natal cleft. Any midline dead space is eliminated and a midline scar is avoided. It is a particularly useful technique for complex sinuses with multiple pits and extended tracts where radical excision leaves a large defect [22]. The alternative of healing with secondary intention would require prolonged supervised wound care. This operation is also suitable for cases where simpler operations have failed. The use of local flap accelerates healing.
In our study overall complication rate was around 5%. 2.7% had minor wound infection that healed with antibiotics. 1.81% had gaping wound which healed with secondary intention and 0.9% had minor skin flap necrosis which also healed but with scarring. There was 0.9% recurrence in 6 month period.
Our results with the Limberg flap are therefore comparable with other series that have shown wound complication and recurrence rates of 0-16% and 0-5% respectively [10-16, 19, 21, 23-24]. Interestingly, 75% of the complications in our series occurred in patients with primary pilonidal sinuses. This may reflect the fact that in those cases the Limberg flap was applied in complex primary pilonidal sinuses necessitating extensive tissue dissection.
We also feel that preoperative antibiotic prophylaxis is important for prevention of wound infection, although there is no published convincing evidence for this practice.
The importance of the post-operative wound care should also be stressed. Exercise or sitting down on the wound should be avoided for two weeks and the patient has to return slowly to normal activities. Hair removal either by shaving the edges of the wound is mandatory (4, 5, 8). This has to be continued at least until complete healing of the wound, but preferably on a long-term basis.
The aim of all surgery should be to minimize both the financial burden to the community and the cost to the patient in terms of time off work, number of dressings and post-operative visits, complications and recurrences. We have experienced that the transposed rhomboid flap for closure of the wound after pilonidal sinus excision meets these criteria and its advantages outweigh the need for a few days hospital stay. However, it is important to discuss with patients when offering them the various surgical options, as the procedure is not without complications and can result in prolonged morbidity and/or a second procedure in a few cases.
Comparison of various studies
Name of author Year Study carried out at No. of patients
Hospital Stay complication Recurrence
Katsoulis IE et al [19] 2006 Colorectal Unit, Surgical Department,
Guy's and St Thomas' Hospitals,
London, UK 25 4
16%
Urhan MK et al [23] 2002 Department of Surgery, Ankara Training and Research Hospital, Ankara, Turkey 102 3.7 7% 4.9 percent
Mentes BB [24] 2004 Colorectal Surgery Division, Department of Surgery, Gazi University Medical School, Ankara, Turkey. 238 2.10 +/- 0.20 days (range 1-3 days) 2% 1.26%
Akin M et al [21] 2007 Department of General Surgery, Gazi University School of Medicine, Besevler, Ankara, Turkey 411 3.2 15.75% 2.91%
Dr.Mohammad
Nadeem Aslam 2007 Department of Surgery, Mayo Hospital, Lahore, Pakistan 110 3 5% 1%


Conclusion
Limberg rotation flap can be recommended as a preferred procedure in the management of chronic pilonidal sinuses. It has the advantages of short hospital stay, early wound healing, rapid return to work and very low recurrence rate with excision and the open wound.


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