Limberg flap procedure for pilonidal sinus disease: results of 353 patients

Purpose Pilonidal sinus disease is common especially in young adult males. Many surgical and nonsurgical methods have been described. Some surgical techniques for the treatment still have high recurrence rate. The aim of this study was to evaluate advantages and long term results of Limberg flap surgical technique. Methods From November 2001 to December 2004, 353 patients [335 male, 18 female; average age = 24.65 ± 4.2 (range, 15–53) years] with primary or recurrent pilonidal sinus disease were operated on under spinal anesthesia by rhomboid excision and Limberg flap. Follow-up examinations were made at the end of the 4 weeks and 3, 6, 12, 18, and 24 months after surgery. Results The mean duration of symptoms was 23.28 ± 16.09 (range, 2–140) months. The mean duration of hospital stay was 4.51 ± 2.85 (range, 2–19) days. Thirty nine patients (11%) had recurrent disease. Total wound dehiscence and flap necrosis did not occur in any patient. Recurrences were observed in 11 patients (3.1%) at the end of the follow up period. Conclusion Quick healing time, short hospital stay, early return to daily life, low complication and recurrence rate are the important advantages of the Limberg flap procedure. We think using closed suction drain in Limberg flap operation is not necessary. In the light of this study results, Limberg flap surgical technique may be an ideal operation for pilonidal sinus disease.     

Sinus laser closure (SiLaC) versus Limberg flap in management of pilonidal disease: A short-term non-randomized comparative prospective study

IntroductionFistula Laser Closure (FiLAC) is a method that was originally applied in the treatment of perianal fistulas. Because of promising results, diode lasers were later on used to treat pilonidal sinus disease in a method called sinus Laser Closure (SiLaC).The aim of this study is to compare between SiLaC and Limberg flap in management of pilonidal disease.MethodsA prospective, nonrandomized comparative study. A short-term follow-up of 71 patients with pilonidal disease was analyzed (24 operated on using the SiLaC technique and 47 using the Limberg technique). With a primary outcome is healing rate and recurrence and a secondary outcome is other measures i.e. complications, hospital stay and postoperative pain.ResultsThe median operative time in the SiLaC group was 26.45 ± 5.41 min (20–35 min) and in the Limberg group 58.63 ± 7.42 min (50–75 min). In the SiLaC group, the primary healing was achieved in 23 out of 24 patients (95.8%) with a total complication rate of 20.83%. There were two cases of recurrence after initial healing in each group.ConclusionSinus laser Closure (SiLaC) is comparable to Limberg flap technique in the terms of healing rate and recurrence with better outcome regarding operative time, hospital stay and post-operative pain.     

Early experience with the use of rhomboid excision and Limberg flap in 16 adolescents with pilonidal disease

Background

Rhomboid excision with Limberg flap (RELF) repair has been shown to be effective in the management of pilonidal disease (PD) in adults. Wide excision allows complete removal of diseased tissue, and the rotational flap allows tensionless coverage as well as helps flatten the natal crease, which is believed to contribute to the recurrence of PD.

Methods

This study is a retrospective review of all adolescents who underwent excision of pilonidal disease using RELF at a single institution for a period of 18 months.

Results

Sixteen adolescents with PD were treated with RELF during this period. All procedures were completed with no intraoperative complications. Mean operative time and hospital stay were 92 ± 30 minutes and 1.8 ± 0.29 days, respectively. Mean follow-up was 11 ± 6.0 months. One patient had recurrence of his disease, and one needed prolonged wound care after wound breakdown. Six others had minor complications including 4 patients (25%) who had superficial wound separation that resolved promptly with dressing change. One patient had a superficial wound infection. One patient had residual pain.

Conclusion

Rhomboid excision with Limberg flap is effective in the management of PD in adolescents. The 6% recurrence rate is similar to that reported in the adult literature. Despite the limitations of this study, the low morbidity, hospital stay, and recurrence rate noted with our initial experience are very encouraging.     

A modification of primary closure for the treatment of pilonidal disease in day-care setting

Aim  The best surgical technique for treating sacrococcygeal pilonidal disease (PD) is still controversial. We evaluated the outcome of a modified primary closure for the treatment of pilonidal sinus.
Method  One hundred and fifty-two consecutive patients with PD, who underwent excision and primary closure under local anaesthesia according to our method, participated in this prospective study. The duration of operation and of hospitalization, postoperative pain, time to first mobilization, postoperative complications, time to resumption of work were assessed.
Results  The median operative time was 30 min (range: 15–40); the median postoperative pain visual analogue scale score was 1 (range 0–3). All patients were mobilized between 2 and 4 h after surgery and discharged within 10 h. Postoperative complications included eight small debridements of an infected wound (5.3%) and one case of wound dehiscence (0.6%). No recurrence was detected during a median follow-up of 22 months (range: 10–34 months).
Conclusion  The low complication rate, near total absence of wound dehiscence, the compliance of the patients, the type of anaesthesia and the patient satisfaction makes this method effective. A randomized trial with long-term follow-up is warranted.     

Cleft closure for the treatment of pilonidal sinus disease

Aim Treatments for pilonidal sinus disease are numerous and prone to failure. In complex disease, the morbidity is high. In contrast with complex operations, the cleft closure procedure can be done simply and successfully with better cosmetic results. We present the results of a single‐centre experience of this procedure. Method One hundred and fifty patients had the operation; most were treated as a day case and many were operated under local anaesthetic. Results Primary healing occurred in 83 (60%) of 139 patients. Recurrences requiring surgery have been seen in 5.3%. The long‐term cosmetic appearance has been noted to approach normality. Conclusion Cleft closure is a simple and highly effective operation to treat recurrent or extensive pilonidal sinus disease.     

Limberg Flap Versus Primary Closure in the Treatment of Primary Sacrococcygeal Pilonidal Disease; A Randomized Clinical Trial

Pilonidal sinus is a chronic intermittent disease, usually involving the sacrococcygeal area. This study was undertaken to compare the results of rhomboid excision followed by Limberg flap with that of excision and primary closure in patients with primary pilonidal sinus. A total of 120 patients with pilonidal disease were randomly divided into group A who underwent excision and primary closure (n = 60) and group B who underwent the rhomboid transposition flap procedure (n = 60). Length of hospital stay and postoperative complications in two groups were compared. Duration of hospital stay (P < 0.001) and time to resumption of work (P < 0.001) was less for group B, and postoperative complications were fewer in group B (P < 0.05). During follow-up of 2 years, no recurrence was detected in patients in group B, whereas five patients developed recurrence in group A (P = 0.02). Limberg flap procedure is better than the simple excision and primary closure for the management of sacrococcygeal pilonidal disease.     

Modified Limberg flap reconstruction compares favourably with primary repair for pilonidal sinus surgery

Background: The present study analyses the results of wide excision with primary closure (PC), wide excision with classical Limberg flap reconstruction (LF) and wide excision with modified Limberg flap reconstruction (MLF) in the surgical treatment of sacrococcygeal pilonidal disease. Methods: One hundred and sixty‐two well‐documented patients who were operated on for pilonidal disease and followed for more than 1 year were analysed retrospectively. Group 1 was composed of patients with excision plus PC (n = 78) while group 2 included those with excision plus a LF reconstruction (n = 40), and group 3 included those with excision plus a MLF reconstruction (n = 44). Results: There were no significant differences among the three groups with respect to age, sex distribution, frequency of recurrent disease, or follow‐up periods (P > 0.05 for all comparisons). Significant disadvantages regarding postoperative infection rate, mobilization time, discharge from hospital, and time off work were noted for primary closure, compared with both LF and MLF reconstructions. Following a median follow‐up period of 4.2 years, 14 recurrences (17.9%) developed in the PC group, three (7.5%) in the LF group, and none (0%) in the MLF group. The zero recurrence rate in the MLF group was significantly lower than that in the PC group (P = 0.003). On the other hand, the recurrence rate in the LF was not found to differ significantly from that in the PC group (P = 0.126). Comparing the LF and MLF groups, none of the surgical end points reached a statistically significant difference (P > 0.05 for all comparisons). Conclusions: For the surgical treatment of sacrococcygeal pilonidal disease, excision plus a classical or modified Limberg flap reconstruction proved to be superior to excision plus primary closure in terms of infection, mobilization time, discharge from hospital and time off work. Additionally, MLF reconstruction resulted in a statistically lower recurrence rate when compared with PC.     

Rhomboid excision and Limberg flap for managing pilonidal sinus: long‐term results in 411 patients

Objective To investigate the results of rhomboid excision and the Limberg flap procedure to treat pilonidal sinus disease. Method The records of 411 patients with pilonidal sinus disease, who underwent rhomboid excision and Limberg flap procedure, were analysed. All sinus tracks were resected en bloc, and a Limberg flap was prepared from left or right gluteal region. A suction drain was routinely used. Results The mean follow‐up period was 109.2 ± 4.5 months (range: 12–183 months). Recurrence occurred in 12 (2.91%) patients who were all male. In 42 (10.21%) patients, anaesthesia or hypoaesthesia of the upper portion of the flap occurred; this was temporary in 25 patients. Twelve (2.91%) patients developed a seroma and 15 (3.64%) a wound infection. The average hospital stay was 3.2 days (range: 1–10 days), and the average time of return to work was 12.4 days (range: 7–18 days). The average time to walk without pain was 13.4 days (range: 10–28 days) and the average time to sitting on the toilet without pain was 16.1 days (range: 12–28 days). Conclusion The Limberg flap procedure is effective and has a low complication rate, short time for returning to normal activity and short hospitalization.     

Comparison of Karydakis flap reconstruction versus primary midline closure in sacrococcygeal pilonidal disease: Results of 200 military service members

Purpose  There is a high incidence of sacrococcygeal pilonidal disease (SPD) among young males. Despite increasing data on the treatment of SPD, no standard treatment has yet been established. The goal of this study was to compare the Karydakis flap reconstruction with a primary midline closure (PMC) in the treatment of patients with SPD. Methods  The study included 200 patients treated over a period of 30 months. After a power analysis, the study was run on a two-directional basis (both retrospective reviews of patient charts and a telephone interview for prospective evaluation). The surgical findings, complications, recurrence rates, and degree of satisfaction based on a questionnaire were assessed. Results  The duration of the surgery was longer in the Karydakis group. Complications were more frequently seen in the PMC group. The recurrence rate was 4.6% for the Karydakis group and 18.4% for the PMC group. Of patients who underwent the Karydakis operation, 70.8% were completely satisfied with the procedure, while only 32.6% of patients who underwent the PMC reported excellent satisfaction. A significantly higher number of patients in the Karydakis group recommended the same procedure to other patients with SPD. Conclusion  The Karydakis method may be a preferable option in the treatment of SPD, due to the low rate of recurrence and the promising satisfaction rates.     

Oblique excision with primary closure for the treatment of pilonidal sinus

Although pilonidal disease of the sacrococcygeal region is common, controversy still exists regarding its treatment. The goal of treatment should be to prevent recurrence while minimizing the patient's postoperative pain and disability. During a two-year period, 32 consecutive patients (Group A) were treated for chronic pilonidal disease by oblique excision and primary closure. The results were compared with 45 patients (Group B) who had been treated by vertical excision and primary closure. Patients with acute pilonidal abscess or recurrent pilonidal disease were excluded from the study. The mean follow-up was 15.9 months for Group A and 19.6 months for Group B. The average length of hospital stay and time for return to daily activities were 3.18±1.31 vs. 5.53±4.11 days and 10.4±14.37 vs. 12.91±39.17 days in Groups A and B, respectively (p<0.001 and p<0.01). The overall recurrence rate was 35.5% in Group B whereas there were no recurrences in Group A. On the basis of our current experience, oblique excision with primary closure achieves the most promising treatment of this condition.     

Limberg flap in management of pilonidal sinus disease: systematic review and a local experience

Objectives: To review published evidence of Limberg flap (LF) use in pilonidal sinus disease (PSD). We also included our local experience of LF.

Methods: Medline and Embase database were searched for the words ‘pilonidal, sinus, Limberg, flap’. Non-English articles and those not-related to our scope of search were omitted. We included a retrospective study of patients underwent LF in our district hospital. Data including length of hospital stay, post-operative complications and recurrence were collected.

Results: Literature review revealed 68 studies (22 case series, 35 comparative studies, nine RCTs and two meta-analyses). Recurrence rate was 0–7.4% in case series. Recurrence rate in comparative studies was 0–8.3%, compared to 4–37.7% for primary closure and 0–11% for Karydakis flap. RCTs showed that LF or its modification is superior to primary closure, with comparable results to Karydakis flap. About 26 patients included in the cohort study (16 male, average age 27 years). Six patients presented with recurrent disease. Post-operative length of hospital stay was four to seven days. Post-operative complication rate was 11.5% – [two partial wound dehiscence, one wound infection]. Recurrence rate was 7.7%. Average follow-up was 18 months.

Conclusions: Limberg flap presents a safe and effective method that can be offered for patients with primary or recurrent PSD.     

Short and long-term results of the Karydakis flap versus the Limberg flap for treating pilonidal sinus disease: a prospective randomized study

Background

Pilonidal sinus is a common disease that mostly affects young people. Although various surgical techniques have been described for treating sacrococcygeal pilonidal disease (SPD), controversy still exists as to the best surgical technique. The purpose of this study was to compare the efficiency and short-term and long-term results of the Karydakis flap with that of the Limberg flap for treating SPD.

Methods

In this prospective randomized study, 269 patients with SPD were recruited to undergo either the Karydakis flap (n = 135) or the Limberg flap (n = 134) procedure between September 2004 and September 2008.

Results

The mean operative time for the Karydakis group (42.32 ± 8.64 minutes) was shorter than that for the Limberg group (50.14 ± 6.96 minutes) (P = .01). The complication rate for the Karydakis group (n = 15 [11.1%]) was lower than that for the Limberg group (n = 28 [20.8%]) (P = .029). The visual analogue scale score for postoperative pain at the operation site on the 30th day was lower in the Karydakis group than in the Limberg group (2.22 ± 1.01 vs 3.23 ± 1.14, P = .01). The visual analogue scale score for satisfaction with the cosmetic appearance of the scars in the Karydakis group was 7.08 ± 1.75, whereas it was 3.16 ± 1.40 in the Limberg group at the 3rd month (P = .01). Length of hospital stay was significantly shorter in the Karydakis group than in the Limberg group (3.40 ± .94 vs 3.8 ± 1.19 days, P = .03). Only 4 patients in the Karydakis group developed recurrence (3%), whereas 9 patients (6.9%) did so in the Limberg group (P = .151).

Conclusions

The Karydakis flap procedure should be chosen instead of the Limberg flap for treating uncomplicated SPD because of its lower postoperative complication rate, lower pain scores, shorter operation time and length of hospital stay, and good cosmetic satisfaction. However, no differences existed between the 2 surgical procedures in terms of recurrence prevention.     

The application of the Limberg flap repair technique in the surgical treatment of pilonidal sinus disease

Pilonidal sinus disease (PNSD) challenged surgeons for decades. Limberg flap repair (LFR) is a common treatment for PNSD. The purpose of this study was to observe the effect and risk factors of LFR in PNSD. A retrospective study was conducted on the PNSD patients who visited two medical centers and four departments in the People's Liberation Army General Hospital and were taking LFR treatment between 2016 and 2022. The risk factors, the effect of the operation, and complications were observed. The effects of known risk factors on the surgical results were compared. There were 37 PNSD patients: male/female ratio of 35:2, average age: 25.1 ± 7.9 years. Average BMI: 25.2 ± 4.0 kg/m², average wound healing time: 15.4 ± 3.4 days. 30 patients (81.0%) healed in stage one and 7 (16.3%) had postoperative complications. Only 1 patient (2.7%) had a recurrence while others were healed after dressing-changing. There was no significant difference in age, BMI, preoperative debridement history, preoperative sinus classification, Wound area, Negative pressure drainage tube, prone time (<3d) and treatment effect. Squat defecate and premature defecation were associated with treatment effect, and they were independent predictors of treatment effect in the multivariate analysis. LFR has a stable therapeutic outcome. Compared with other skin flaps, the therapeutic effect of this flap is not significantly different, but the design is simple and is not affected by the known risk factors before operation. However, it is necessary to avoid the influence of two independent risk factors, squatting defecation and premature defecation, on the therapeutic effect.     

Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease

Background

There is still no consensus as to the optimal treatment for sacrococcygeal pilonidal disease (SPD). Many recommend off-midline closure, if any excisional procedure is to be selected.

Methods

The authors prospectively studied 145 patients with SPD who presented at 3 hospitals. Patients were randomly assigned to undergo either modified Limberg flap (MLF) transposition (n = 72) or Karydakis flap reconstruction (n = 73). Surgical findings, complications, recurrence rates, and degree of patient satisfaction, evaluated via a standardized telephone interview, were compared.

Results

Operation time was longer in the MLF group. There were no significant differences between the two groups in terms of complication rate, length of stay, or recurrence rate. Patients in the Karydakis group reported feeling completely healed more quickly postoperatively. The two groups reported similar rates of satisfaction. Mandatory patient withdrawal from a given study arm because of the orifice straying from the midline occurred more frequently in the Karydakis group.

Conclusions

The MLF technique and the Karydakis procedure appear to generate comparable outcomes. With laterally situated orifices, however, the applicability of the Karydakis method may be limited.     

Pilonidal sinus: experience with the Limberg flap

A personal series of 162 patients with chronic pilonidal disease was treated by rhombic excision and Limberg transposition flap. Each sinus was totally excised and covered primarily by a fasciocutaneous Limberg flap. Full primary healing was obtained in 161 out of 162 patients. One patient had ischaemia which resulted in necrosis of the flap tips that healed later with a scar. Minor infection occurred in 12 patients (7%). The average hospital stay was 4.2 days, and no patient remained in hospital more than 12 days. The mean follow-up period was 18 months, and three recurrences (2%) have occurred. Surgery for pilonidal sinus should not only eradicate the presenting sinus formation but should also aim to eliminate factors that predispose to formation of another sinus. This can be achieved using a Limberg flap which reduces the depth of the cleft and ensures that all parts of the wound and all suture holes are away from the midline.     

Suture granuloma mimicking a recurrent sacro‐coccygeal pilonidal sinus after Limberg flap

Sacro‐coccygeal pilonidal sinus disease is classified as an asymptomatic, acutely abscess‐forming or chronic subcutaneous inflammation in the sacro‐coccygeal region featuring characteristic pits in the bottom cleft. Due to high rates of recurrence, two flap techniques have been established in the course of the past three decades. One of them is the Karydakis operation, the other option is a rotation flap named Limberg procedure. We report about a case of suture granuloma in the area of a Limberg flap after recurrent pilonidal sinus with extrusion of the suture material, thus mimicking recurrence. In case of recurrent pilonidal sinus following plastic coverage or primary closure, respectively, the differential diagnosis of suture granuloma should be considered.     

Comparison of the short-term results after Limberg and Karydakis procedures for pilonidal disease: randomized prospective analysis of 100 patients

Objective  The study was designed to compare the early postoperative results of the commonly used two surgical flap procedures in pilonidal disease: Karydakis and Limberg.
Method  One hundred patients were randomized into two groups and standard Limberg or Karydakis procedures were performed. All had primary sinus orifices. Infected cases and the ones with secondary orifices over 2 cm distant from primary were excluded. Data were recorded concerning complications, need for analgesia and wound dressing, periods of time off work and off driving. Patients were asked to classify their first defecation manner after the operation and also pain according to a Visual Analogue Scale with range of 1–10.
Results  There was a significantly higher wound infection rate in the Karydakis group than in the Limberg group (13/50 and 4/50 respectively). This also resulted in significantly higher values for wound dressings and need for analgesia. The time off work and off driving and also the Visual Analogue Scale scores were not significantly different between the two groups.
Conclusion  Both procedures can be safely performed in pilonidal disease with a standard length of stay in hospital and a similar loss of productive power. However, the Karydakis flap seems to have a significant higher infection rate and this probably increases the cost.