Pilonidal sinus disease is a complex condition that causes both discomfort and embarassment to suffers. Direct cost through absence from work is high. Controversy still exists regarding the best surgical technique for its treatment in terms of minimizing disease recurrence and patient discomfort. Thus, we conducted this study to evaluate the results of rhomboid excision and Limberg flap reconstruction in the surgical treatment of pilonidal sinus disease. This prospective study included 81 patients who had pilonidal sinus and were treated by the rhomboid excision and Limberg flap. The mean follow-up was 18 months and all patients were satisfied with the procedure. There were lower complication rates, minimal discomfort, patients disharged in 2-3 days and only two recurrences. The Authors recommend the Limberg flap procedure for pilonidal sinus disease. It is effective, with short hospitalization, low recurrence rate and shorter time off work

Assi, TB

I,Mortada

Jurjus,A

Oueidat, D

Tomasello,G

Archivio istituzionale della ricerca - Università di Palermo

Original article © EUROMEDITERRANEAN BIOMEDICAL JOURNAL  2016, 11 (03):15-21. DOI: 10.3269/1970-5492.2016.11.03 Available on-line at: http://www.embj.org Address of the authors: 1 Department of Surgery, Al-Zahraa Hospital, Beirut, Lebanon  2 Department of Laboratory Medicine, Psychiatric Hospital of the Cross, Jal El Dib, Lebanon 3 Dipartimento Universitario "BIONEC", Sezione di Anatomia Umana, University of Pa-lermo 4 Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon   Send correspondence to:  Abdo Jurjus, aj00@aub.edu.lb   Received: 29h January, 2016 — Revised: 10th February, 2016 — Accepted: 26th Fe-bruary, 2016 ISSN 2279-7165 - Euromediterranean Biomedical Journal [online] EUROMEDITERRANEAN BIOMEDICAL JOURNAL  for young doctors  SURGICAL TREATMENT OF SACROCOCCYGEAL PILONIDAL SINUS WITH THE LIMBERG FLAP: REVIEW OF 81 CASES.  Doreid Oueidat 1, Tarek Bou Assi 2, Giovanni Tomasello 3,  Ibrahim Mortada 4, Abdo Jurjus 4 Summary Pilonidal sinus disease is a complex condition that causes both discomfort and embar-rassment to sufferers. Direct cost through absence from work is high. Controversy still exists regarding the best surgical technique for its treatment in terms of minimizing disease recurrence and patient discomfort. Thus, we conducted this study to evaluate the results of rhomboid excision and Limberg flap reconstruction in the surgical treat-ment of pilonidal sinus disease. This prospective study included 81 patients who had pilonidal sinus and were treated by the rhomboid excision and Limberg flap. The mean follow–up was 18 months and all patients were satisfied with the procedure. There were lower complication rates, minimal discomfort, patients discharged in 2-3 days and only two recurrences. The authors recommend the Limberg Flap procedure for pilonidal sinus disease. It is effective, with short hospitalization, low recurrence rate and shorter time off work. Introduction Pilonidal sinus disease is a common medical condition that accounts for almost 15% of anal suppuration and is responsible for significant morbidity [1]. It is usually seen in young adults [2]. Males are affected more frequently than females by a ratio of 3:1, probably due to their more hirsute nature [3]. The origin of pilonidal sinus disease is not fully understood. There are many theories associated with its pathogenesis: The most important are the acquired and the congenital theories. However, the majority of opinion favors the acquired theory, which postulates that the sacro-coccygeal pilonidal infection originates in the natal cleft hair follicle that has become distended with kera-tin [4-5]. Thus, for treatment and pre-vention, the causative factors must be eliminated [6]. Several treatment mo-dalities have been advocated for pilonidal sinus disease, including shaving, incision and drainage, excision with primary clo-sure, excision with open packing and re-cently rhomboid excision with flaps sur-gery [7]. This study was carried out to evaluate the results of Rhomboid excision and Limberg flap reconstruction in terms of hospital stay, time to heal, recurrence rate, missed days off- work and finally patient satisfaction.  Methods This work was conducted in a surgical unit of two Lebanese general hospitals from Mars 2008 to February 2014. It in-cluded 90 patients. Age, sex, clinical presentation, complications, inpatient stay and outcome were recorded. Nine patients had no follow up, disappeared and were excluded from this study result-ing in 81 patients who were treated by rhomboid excision and flap reconstruction (Limberg flaps). The patients who had pilonidal abscess were first managed by incision and drain-age, followed later on by a definitive sur-gery. The operations were performed un-der either general or spinal anesthesia. All patients were placed in prone position with buttocks strapped for wide expo-sure. After scrubbing and draping, the SACROCOCCYGEAL PILONIDAL SINUS, p.16 EMBJ, 11 (03), 2016— www.embj.org Figure 1a. Rhomboid-shaped excision  Figure 1b. Rhomboid-shaped excision that includes the sinus till the presacral fascia  area to be excised was marked and the flap lines delineated (Figure 1a). Methylene blue dye was injected through the sinus opening and antibiotics were administered intravenously at the induc-tion time of anesthesia, then twice daily for two days followed by oral antibiotics for eight days. Thereafter, patients were reviewed at 2 - 4 weeks interval. Outpa-tient follow-up continued for 18 months to exclude or identify recurrence. A rhomboid-shaped excision was carried out, with equal size on both sides and included the sinus till the presacral fascia (Figure 1b). A right or left sided Limberg transposition flap, reaching the gluteus maximus fascia, was fully mobilized on its inferior edge and transported medially to fill the rhomboid defect (Figure 2). He-mostasis was achieved by the use of electrocautary. A suction drain was inserted in the wound cavity through a separate stab incision. The subcutaneous tissue was approximated with interrupted 20 vicryl, and the skin was closed with interrupted 30 nylon (Figure 3). Drain was removed after 48-72 hours. Finally, alternate su-tures were removed on the 12th postop-erative day, and the rest of the sutures were removed on the 14th day.  OUEIDAT ET AL., p.17 EMBJ, 11 (03), 2016— www.embj.org Figure 2. Limberg transposition flap mobilized to fill the rhomboid defect  Figure 3. Skin closure using nylon sutures  Results This study included 90 patients (62 male and 28 female) that were operated by rhomboid excision and Limberg recon-struction but nine patients were excluded due to loss of follow-up. Among the re-sulting 81 patients, 57 were males and 24 females with a ratio of 2.3 to 1. The mean age at presentation was 25.5 years (range 17-69). Eight patients presented with recurrent sinus (9.9%), 52 patients presented with discharge (64.2%), 14 with pain (17.3%) and 7 with pilonidal abscess (8.6%) (Table 1). The operative time ranged from 55 to 85 minutes. Seroma developed in 5 patients (6.17%) that were managed by conser-vative measures, three patients devel-oped infection (3.7%) and were treated with antibiotics, two patients had necro-sis at the tip of the flap (2.47%) and also two patients had recurrences (2.47%) at 5 and 7 months postoperatively (Table 2). In addition, the time off-work ranged from 10-15 days while the time to walk without pain ranged from one week to two weeks (Table 3).  Discussion Sacrococcygeal pilonidal sinus can be a chronic and recurring condition which is sometimes difficult to cure [1]. Although many surgical treatment methods have been described, the ideal treatment method has not yet been established for pilonidal disease. In fact, few surgical treatments provided long-term good re-sults. Excision and packing, excision and primary closure or flap technique (Limberg) are surgical procedures that have been postulated for treatment of pilonidal sinus. These procedures re-flected the need for a safe and efficient surgical method for this disease. The tra-ditional method of wide excision and lay open the sinuses resulted in a hospital stay of 5-14 days, healing time of 6-10 weeks, and recurrence rate of 8%-21% EMBJ, 11 (03), 2016— www.embj.org Table 1. Clinical presentation of the patients  SACROCOCCYGEAL PILONIDAL SINUS, p.18 Complaint Number of  patients Percentage Recurrent sinus 8 9.9% Pain 14 17.3% Discharge 52 64.2% Abscess 7 8.6% Table 2. Postoperative complications  Complications Number of  patients Percentage Seroma 5 6.17% Infection 3 3.7% Necrosis 2 2.47% Recurrence 2 2.47% Clinical outcomes Days Time off-work 10-15 Pain 7-14 Hospital stay 2-3 Healing time 12-14 Drain removal 2-3 Table 3. Clinical outcome s [1-8]. They were followed by prolonged morbidity with an open granulation wound [9, 10]. The resultant scar was broad, adherent to the sacrum and fre-quently broken down. Previous attempts to improve these results by various methods of primary closure reduced the healing time to less than 2 weeks, but hospitalization remained almost the same, between 7-10 days, and recur-rence rate varied between 8%-30% [11-13]. Such data appeared favorable for the primary closure approach. However, a high complication rate had been re-ported because of tissue tension [6]. Moreover, recurrence remains the main problem associated with this surgical procedure and range from 21.4% to 40% in some other studies [14, 15]. On the other hand, the flap technique (Limberg) had been associated with lower compli-cation and recurrence rates.In this study, 81 patients with sacrococcygeal pilonidal pathology were managed with rhomboid excision and Limberg flap reconstruction. The average hospital stay was 2.2 days; shorter than any other procedure (5-14 days). The healing time was 2 weeks in-stead of 6-10 weeks and recurrence were noted in only 2 patients (2.47%). Akein et al reported a recurrence rate of 2.91% and Ertan of 2%. Necrosis was detected in 2 patients (2.47%), which may be due to faulty technique and lack of experi-ence at the beginning of this study or to the formation of thrombi at the level of the surgical anastomosis as reported by Montesano et al [16]. Time-off from work was 10 to 15 days, significantly shorter compared to those treated with primary closure (14-25.5) [17-19]. This shorter duration was similar to that reported by other authors [20, 21]. Concerning the time to walk without pain, it ranged from 7-12 days in the Limberg flap. However, excision with primary closure caused re-striction of activity because of tissue ten-sion [22]. Most complains by the patients after pilonidal sinus surgery were caused by wound tenderness. Holm and Hulten reported that patients treated with the flaps method were found to walk without pain earlier than patients treated with primary closure [23]. Some authors be-lieved that the primary closure was more comfortable in small defects. Healing time was shorter after excision and clo-sure, but more recurrence occurred com-pared with Limberg flap [24, 25]. Levent-golu et al showed that the Limberg flap procedure was effective, with low compli-cation rates, shorter time of returning to normal activity and shorter hospitaliza-tion [26]. Mahdy observed also in his study that wound infection and dehis-cence were 11.6% and 6.7% respectively in primary closure group and 1.68% in Limberg flap group with no recurrence in his series [8]. Moreover, Ertan deter-mined a recurrence rate of 2% in the Limberg flap method and 12% in the pri-mary closure procedure and stated that Limberg flap resulted in a better outcome with respect to recurrence, complica-tions, time required for wound healing, off work time and general health condi-tions [18]. However, he suggested that the Limberg flap treatment must be re-served for patients with problematic pilo-nidal disease in term of chronicity or fail-ure to heal following excision [18]. Muzi et al showed that there is approximately 16% failure of healing with the procedure of excision and primary closure. This fail-ure results from the fact that a primary closure is rarely completely free of ten-sion and the recurrence rate was as high as 38% [27]. However, for insulin de-pendent diabetes mellitus, Rashidian et al. noticed that they had higher complica-tion rates with the flap method and sug-gested to excise the pilonidal sinus and lay it open [28]. Moreover, it is recom-mended, for patients who had suspected carcinoma in the sacrococcygeal sinus, to do a frozen section in order to confirm that the margins were free of the dis-ease, before any local flap was used to cover the area [29]. In brief, an ideal op-eration should minimize financial cost, allow patients to return quickly to work, inflict minimal pain with low recurrence rate. Hence, the current study highlights and reinforces previously published series that demonstrated the safety and the ef-ficiency of Limberg flap reconstruction for pilonidal sinus disease compared to other surgical techniques.    EMBJ, 11 (03), 2016— www.embj.org OUEIDAT ET AL., p.19 Conclusion Pilonidal sinus disease is a complex con-dition that causes both discomfort and embarrassment to sufferers and physi-cians. However, with the Limberg flap method, both the patient and physician are more satisfied. The Limberg flap method has many advantages as it is easy to perform; it flattens the natal cleft with large vascularized pedicle and is su-tured without tension. It is useful in both primary and recurrent diseases, with very low complication and recurrence rates; shorter hospitalization, earlier healing and shorter time off-work. In ad-dition, the technique has a satisfying es-thetic outcome. So, the authors highly recommend the use of Limberg flap re-construction for pilonidal sinus disease because its results were superior to other techniques mentioned in the literature.  References 1. Oueidat D, Riskallah A, Dirani M, Bou Assi T, Jurjus A. 25 years’ experience in the management of pilonidal sinus dis-ease. 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SURGICAL TREATMENT OF SACROCOCCYGEAL PILONIDAL SINUS WITH THE LIMBERG FLAP: REVIEW OF 81 CASES

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SURGICAL TREATMENT OF SACROCOCCYGEAL PILONIDAL SINUS WITH THE LIMBERG FLAP: REVIEW OF 81 CASES

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