The Limberg transposition flap in surgical therapy of chronic pilonidal sinus

The operative treatment of pilonidal sinus is characterized by an increased rate of wound healing complications and late recurrences. The Limberg transposition flap is an easy method for covering the defect after excision of the pilonidal sinus. The flap smooths out the deep skin fold of the rima ani and counteracts in this manner an important pathogenetic factor of pilonidal sinus recurrence. Between 6/96 and 7/99 we treated 42 patients using this method without complications of wound healing or recurrences. Comparison of literature results of different operative treatments (open granulation, primary suture, Z-plasty) shows lessened complication and recurrence rates for the Limberg transposition flap, which is the method of choice for chronic pilonidal sinus nowadays.     

Adipo-fascio-cutaneous flaps in the treatment of pilonidal sinus: experience with 50 cases

OBJECTIVE: To retrospectively analyse the results of pilonidal sinus managed using wide excision with primary eccentric closure with various adipo-fascio-cutaneous flaps. METHODS: Data from 50 consecutive patients who had elective surgery for chronic pilonidal sinus with wide excision of all the sinuses and primary eccentric closure with various adipo-fascio-cutaneous flaps (40 lateral advancements, 4 Z-plasties, four rotations, 1 rhomboid and 1 V-Y advancement) were retrospectively analysed. Special emphasis was placed on partial obliteration of the natal cleft, duration of wound healing, postoperative morbidity and hospital stay, loss of work days, cosmetic outcome and recurrence. RESULTS: In all patients, partial obliteration of the natal cleft was achieved by eccentric primary wound closure, with good cosmesis. Superficial necrosis of the flaps occurred in five patients (3 Z-plasties, 2 rotation flaps). None had collection, haematoma, infection or recurrence. CONCLUSION: Complete eccentric excision and partial obliteration of the natal cleft using various adipo-fascio-cutaneous flaps ensured reliable wound healing with fewer dressings and morbidity, shortened hospital stay and early resumption of work, good cosmesis and prevention of early and late recurrence. The lateral advancement flap is a viable option in the treatment of chronic pilonidal sinus.     

Therapy of the pilonidal sinus--Primary wound closure or open wound after excision

The postoperative follow up of 177 operations in 162 patients with pilonidal sinus was investigated. After excision of the sinus a primary wound closure was performed in 80 cases; in 83 cases the wound was left open. After primary wound closure 40 % of the patients showed a primary healing of the wound. Although the remaining 60 % of the wounds healed secondarily the patients were not disabled longer and did not demonstrate more frequently recurrences than those with open wound management. As a consequence we recommend a primary wound closure after excision of a pilonidal sinus.     

Influence of failure of primary wound healing on subsequent recurrence of pilonidal sinus. combined prospective study and randomised controlled trial.

OBJECTIVE: To find out whether failure of primary wound healing after excision and primary suture for chronic pilonidal sinus predicts recurrence. DESIGN: Follow-up of one prospective study and one subsequent randomised, multicentre study. SETTING: Three teaching hospitals in WesternNorway. SUBJECTS: A total of 197 consecutive patients operated on for chronic pilonidal sinus. INTERVENTIONS: Fifty two patients in the prospective group were given cloxacillin perioperatively. In the randomised study, 145 patients were randomised to have either a single preoperative dose of cefoxitin 2 g intravenously (n = 73) or no prophylaxis (n = 72). Patients were followed up for a median of 7 years. MAIN OUTCOME MEASURES: Recurrence of pilonidal sinus. RESULTS: In the prospective group there were 10 recurrences (19%). In the randomised study 6 patients (8%) who had been given antibiotic prophylaxis had a recurrence compared with 14 patients (19%) who had not been given prophylaxis (p = 0.09). In both groups, failure of primary normal healing was significantly associated with early recurrence (p = 0.0002). Neither the use of antibiotics nor sex had any significant influence on the incidence of recurrences. Most recurrences occurred within the first year. CONCLUSION: Wound complications significantly influenced the recurrence rate whereas antibiotics did not. Most recurrences were seen early.     

Evaluation of the Outcome of Complete Sinus Excision with Reconstruction of the Umbilicus in Patients with Umbilical Pilonidal Sinus

Umbilical pilonidal sinus is a cause of umbilical discharge. In this study, the outcome of complete excision of the umbilical sinus with umbilical reconstruction is considered. Adult patients with umbilical pilonidal sinus who had not undergone any previous surgeries were operated on using a technique that involves complete excision of the sinus after eversion of the umbilicus followed by reconstruction of the umbilicus. Patients were then followed; and wound complications, recurrence, and patient satisfaction were evaluated at postoperative visits. A total of 45 patients underwent the operation; 39 (86.5%) were male, and 6 (13.5%) were female. The mean age was 22.6 years (18-27 years). Six male patients had synchronous sacrococcygeal pilonidal disease. The mean follow-up period was 34 months (3-62 months). Only four patients had wound drainage after operation, and all required drainage of the wound. No recurrence was observed during the follow-up period, and all patients were satisfied with the appearance of their umbilicus. The technique of complete sinus excision and umbilical reconstruction is an effective and acceptable method for treating umbilical pilonidal sinus and may be recommended for primary treatment of this disease.     

Erhöhtes Rezidivrisiko nach primärem medianem Wundverschluss bei Patienten mit Pilonidalsinus

BACKGROUND: There is a high incidence of postoperative complications and late recurrences after operative therapy of a pilonidal sinus.The optimal treatment strategy is still matter of discussion.We studied the long-term results after excision of a pilonidal sinus and primary midline closure compared with the open surgical procedure. MATERIALS AND METHODS: A total of 73 patients (62 male and 11 female, mean age 26.6 years) underwent a total of 79 operations between 1992 and 2001.Thirty patients (38%) were previously operated on because of a pilonidal sinus.Twenty-four were treated in our institution by an open procedure (five after simple abscess incision, 19 after sinus excision) and 52 by primary midline closure. Another three patients received skin flap procedures. RESULTS: Follow-up was possible for 65 patients (82%) for a median of 50 months.Recurrent pilonidal sinus occurred in 22 cases: 18 after primary midline closure (42%) and four after open procedure (21%, P=0.4).We found no relapse following the three skin flap procedures. There was a significantly higher relapse rate in patients operated with recurrent disease (12/25 vs 10/40; P<0.05). CONCLUSIONS: Despite of numerous previously operated patients (38%), there was a high recurrence rate (42%) after excision of a pilonidal sinus and primary midline closure. Alternative operative techniques creating a lateral wound or the various skin flap procedures may be promising alternatives.We are in the process of changing our treatment strategy for patients suffering from a pilonidal sinus.     

Comparative study between radiofrequency sinus excision and open excision in sacro-coccygeal pilonidal sinus disease

AIM: Evaluation of outcome of pilonidal sinus excision using a radiofrequency device and comparing its results with excision and open granulation procedure. METHODS: Patients with sacro-coccygeal pilonidal sinus disease (n=44) were randomly assigned to undergo either a wide excision and healing by open granulation procedure [WEG] (n=23) or a radiofrequency sinus excision [RSE] (n=21). An Ellman radiofrequency generator was used for RSE. Intra- and postoperative events and outcome data were evaluated and analyzed by Student's unpaired t test and chi(2) test. RESULTS: The significant differences in the two groups WEG and RSE were as follows: mean hospital stay (47 vs. 10 h, p< 0.05), period off work (29 vs. 8 days, p< 0.05), mean analgesic requirement (39 vs. 15 tablets, p< 0.05), time for complete wound healing (84 vs. 49 days, p< 0.05). At the mean follow-up of 30 months, 2 patients from the wide excision and open granulation group and one patient from the radiofrequency sinus excision group developed recurrence. CONCLUSION: These findings suggest that sinus excision with radiofrequency is a simple and swift procedure. It needs a short hospital stay and is associated with less postoperative pain and early resumption to work. As compared to excision and healing by granulation technique, the radiofrequency sinus excision procedure achieves faster wound healing and a better outcome.     

Excision and simple primary closure of chronic pilonidal sinus.

OBJECTIVE: To evaluate the outcome of asymmetrical complete excision of pilonidal sinus with simple primary closure without using drains or tension sutures. DESIGN: Prospective study. SETTING: Teaching hospital, Jordan. SUBJECTS: 46 patients with chronic pilonidal sinus treated between November 1994 and October 1998 by excision of the sinus down to the sacrococcygeal fascia and simple primary closure of the wound without tension sutures or drains. RESULTS: Patients stayed in hospital for 48 hours and postoperative pain was minimal. Complete healing was achieved in 41 patients (89%) after a mean follow up period of 36 months (range 12-60). Two patients (4%) developed recurrent sinuses and in three (7%) the wound broke down. All the patients who healed completely were back to work within three weeks of the operation. CONCLUSION: Excision and simple primary closure is a cost-effective way of treating chronic pilonidal sinus.     

Risk factors for wound complication in pilonidal sinus procedures

BACKGROUND: Pilonidal disease is a common condition among young people. Complicated pilonidal surgical wounds are associated with considerable morbidity, including chronic sacral wound, loss of work time, and lifestyle limitation. The aim of our study is to report our experience with Karydakis procedure and explore the risk factors associated with infection and poor healing in pilonidal operation. STUDY DESIGN: A 3-year experience of a Joint-Commission International accredited tertiary center in patients with pilonidal sinus operations is reported. We retrospectively reviewed the charts of unselected patients with pilonidal sinus who underwent excision and primary closure on elective basis in terms of wound healing, surgical site infection, and return to work. Variables predictive of surgical site infection and disruption were assessed by multiple logistic analyses. RESULTS: From January 2004 to December 2006, 94 patients with pilonidal disease underwent excision and primary closure on elective basis. Incidence of surgical site infection was 12.8%. No recurrence was observed after median followup of 6 months, with interquartile range of 4 to 9 months. Smoking (p = 0.027) and obesity (p = 0.047) were independent risk factors for wound infections. CONCLUSIONS: Excision and primary closure is an acceptable modality of treatment in nonobese and nonsmoker patients with pilonidal sinus disease. Infection rate in obese patients and smokers is unacceptably high, and active preoperative weight loss and smoking cessation or simple laid open procedure is recommended in these patients.     

两种手术方法治疗骶尾部藏毛窦 43例的临床分析

目的:评价切开引流囊壁搔刮术与切除袋形缝合术治疗骶尾部藏毛窦的疗效。方法:回顾性分析43例骶尾部藏毛窦患者的临床资料,其中行切开引流囊壁搔刮术治疗(切口开放搔刮组)20例,行切除袋形缝合术治疗(切除袋形缝合组)23例。结果:切口开放搔刮组、切除袋形缝合组的手术时间分别为(30.40±5.22)min、(43.49±7.45)min,住院时间分别为(7.70±1.42)d、(8.17±1.47)d,愈合时间分别为(34.45±7.72)d、(24.48±5.96)d,术后疼痛NRS评分分别为(4.15±1.09)、(4.74±0.96)。两组手术时间、切口愈合时间的差异具有统计学意义(P<0.05),住院时间、术后疼痛的差异无统计学意义(P>0.05)。随访1~6年,两组均无复发。结论:彻底切除病变组织是治愈骶尾部藏毛窦的关键,急性感染期选择切开引流囊壁搔刮术、慢性窦道期选择切除袋形缝合术均可治愈骶尾部藏毛窦。     

Ambulatory treatment of chronic pilonidal sinuses with lateral incision and primary suture

Background

Outpatient management is appropriate for chronic pilonidal sinuses. Even though there are different surgical treatments for pilonidal sinuses, the outcome may not be uniformly satisfactory. The aim of this paper was to examine the ambulatory treatment of chronic pilonidal sinuses with lateral incision and primary suture.

Methods

We present our experience with outpatient management of asymptomatic chronic pilonidal disease. We prospectively studied patients presenting with pilonidal disease from Mar. 20, 2005, to Mar. 20, 2008. All were managed as outpatients. We reviewed presentation, treatment, healing, time off work and recurrences.

Results

In all, 150 patients (131 men and 19 women) with chronic pilonidal sinuses underwent ambulatory plain lateral excision and primary repair during the study period. The mean age of patients was 22.1 years. The mean duration of surgery was 18.4 minutes. No general complications occurred. Local complications consisted of 3 wound infections and 4 wound hematomas. No sinus recurrence occurred. The healing rate was fast in all patients.

Conclusion

Advantages of ambulatory plain lateral excision and primary repair include immediate treatment, minimal pain and a quick return to normal activities. This method is a simple and effective procedure in the treatment of uncomplicated pilonidal sinuses.     

A comparison of flap reconstruction vs the laying open technique or excision and direct suture for pilonidal sinus disease: A meta‐analysis of randomised studies

Many treatments have been described for pilonidal disease, but recurrence cannot be completely eliminated. The aim of this study was to perform a meta‐analysis of randomised, controlled trials comparing flap repair vs the laying open technique and/or excision and direct closure techniques in the treatment of chronic pilonidal sinus disease. The primary outcome measure was the recurrence rate. Secondary outcomes were complete wound‐healing time, duration of the incapacity to work, quality of life and patient satisfaction, postoperative pain, wound infection, bleeding or haematoma, skin wound complications, and duration of hospital stay. Seventeen studies were included. The meta‐analysis demonstrated a lower risk of recurrence, a shorter duration of incapacity to work, a lower risk of wound infections, a lower risk of skin wound complications, and a shorter duration of hospitalisation in favour of flap vs direct closure. A shorter time to complete wound healing and a shorter duration of incapacity to work for flap vs the laying open technique were observed. Superiority of flap repair vs direct closure in pilonidal sinus treatment was demonstrated in this meta‐analysis. These results suggest avoiding primary direct closure in clinical practice. Compared with the laying open technique, flaps result in faster healing and a shorter time to return to activities.     

Treatment of pilonidal sinus with excision and primary suture using a local, resorbable antibiotic carrier. Results of a prospective randomized study]

The excision of a pilonidal sinus with wound healing by second intention, often results in a long duration of treatment. On the other hand, primary suture after excision has a high rate of abscess formation. In a randomized study we treated 40 patients with excision of pilonidal sinus, insertion of a collagen sponge containing Gentamicin and primary suture (group 1) to prevent this abscess formation. Another 40 patients were treated in the same way but without applying the Gentamicin-collagen sponge (group 2). There had been no significant differences as to the history and duration of the disease, the wound size, the degree of inflammation, the weight of the patients or the amount of hair near the sinus. In group 1 only 7.5% of the patients had a postoperative abscess formation, in contrast to group 2, with an abscess rate of 52.5% and consecutive surgery (p less than 0.001). One year after the operation the recurrence rate was 0 in both groups. Considering the results mentioned, surgical excision of the pilonidal sinus in combination with insertion of a resorbable antibiotic sponge we recommend this therapy.     

Surgery for pilonidal disease.

BACKGROUND AND AIMS: Surgery for pilonidal disease carries a considerable risk of complications, recurrence, and cosmetic sequelae. The present study evaluates the four procedures performed in our institution. MATERIAL AND METHODS: Operations from 1999 through 2002 were retrospectively assessed. Cosmetic result and overall satisfaction were reported on visual analogue scales. RESULTS: Seventy-three procedures were performed in 71 patients: excision with open granulation in nine; excision and primary suture in 25; rhomboid plasty in 23; and lay-open in 16 patients. Infections were as frequent after rhomboid plasty (40%) as after excision and primary suture (43%). Nineteen recurrences (26%) were observed during a median follow-up of 20 months, and the estimated five-year actuarial recurrence rate was 44%. Recurrence occurred in 1/9 (11%) after excision with granulation, in 4/23 (17%) after excision and suture, in 5/25 (20%) after rhomboid plasty, and in 9/16 patients (56%) after lay-open. The cosmetic result was satisfactory only in 22/53 (42%) patients; the result was poor in 16/53 (30%) patients. CONCLUSION: Results after surgery for pilonidal disease are modest and should be compared to conservative management in a randomised trial.     

Outcomes in the repair of pilonidal sinus disease excision wounds using a parasacral perforator flap

INTRODUCTION

The ideal treatment for pilonidal sinus disease has yet to be defined. There are many approaches described in the literature.

METHODS

Thirty-five consecutive patients who underwent wide excision of pilonidal sinus disease had the wound repaired using a parasacral perforator flap. Outcomes were assessed by case notes analysis and follow-up telephone and postal questionnaires.

RESULTS

There were ten minor complications including six minor wound edge dehiscences. There were two ischaemic complications, with one flap loss. There were 3 recurrences of pilonidal disease at a mean follow-up of 33 months, giving a 5-year recurrence free rate of 86%. Of the patients questioned, all would recommend the procedure to someone else despite 69% being dissatisfied with the cosmetic outcome.

CONCLUSIONS

This series indicates that the parasacral perforator flap technique is able to repair pilonidal sinus excision wounds successfully with minimal morbidity and a low recurrence rate at a mean of follow-up of 33 months. The study suggests that it may be a technique best reserved for recurrent cases of pilonidal sinus disease. Patients feel the procedure is successful despite reservations regarding the cosmetic outcome.     

Role of simple V-Y advancement flap in the treatment of complicated pilonidal sinus.

OBJECTIVE: To evaluate our short term results of simple V-Y advancement flap for complicated pilonidal sinus. DESIGN: Prospective study. SETTING: Yüzüncü Yyl University hospital, Van, Turkey. SUBJECTS: 23 patients aged 19-47 (mean 31) years with complicated pilonidal sinus treated between October 1994 and December 1996, of whom 9 had had previous operations for pilonidal sinus. INTERVENTIONS: Bilateral V-Y-plasty to close the defect after wide excision (n = 7), and unilateral V-Y-plasty (n = 16) were performed under spinal anaesthesia. RESULTS: There were no complications during the operation. There were 4 minor complications (17%) consisted of seroma (n = 2) and severe wound pain, and wound infection (n = 1 each). All patients were discharged within 10 days of operation and returned to work within 3 weeks. The mean follow up was 18 months (range 10-25) and no recurrences have occurred so far. CONCLUSIONS: Simple V-Y advancement flap may prove to be useful in patients with recurrent and complicated pilonidal sinuses.     

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.     

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.     

Local Administration of Antibiotics by Gentamicin–Collagen Sponge does not Improve Wound Healing or Reduce Recurrence Rate After Pilonidal Excision with Primary Suture: A Prospective Randomized Controlled Trial

Background

Excision and primary suture for pilonidal disease is associated with a high rate of wound infection and recurrences. This randomized, controlled study was designed to analyze the effect of local application of a gentamicin-containing collagen sponge (Collatamp^®) in reducing the wound infection rate and recurrences after excision of pilonidal sinus and wound closure with primary midline suture.

Methods

From March 2003 to November 2005, 161 patients with symptomatic pilonidal disease were operated on at 11 hospitals with traditional wide excision of the sinus and all of its tracts. The patients were randomized to filling of the cavity with a gentamicin-containing collagen sponge (Collatamp^®) before wound closure or to closure with no additional treatment. Information about the treatment allocation was hidden until the end of the study. Information about wound healing was noted at follow-up at the outpatient department after 2–4 days, 2 weeks, 3 months, and 1 year.

Results

No statistically significant differences were observed between the groups during follow-up. Patients who received prophylaxis with Collatamp^® had slightly fewer wounds with exudate at 2–4 days and 2 weeks of follow-up (2% vs. 10%, p = 0.051 and 57% vs. 65%, p = 0.325, respectively), a slightly larger proportion of healed wounds at 3 months follow-up (77% vs. 66%, p = 0.138) but not at 1 year (85% vs. 90%, p = 0.42, respectively), and slightly more reoperations (10% vs. 4%, p = 0.213).

Conclusions

This randomized, controlled study showed no significant differences in the rates of wound infection, wound healing, and recurrences when a gentamicin–collagen sponge was added to the surgical treatment of pilonidal disease with excision and primary midline suture. This does not support the use of gentamicin–collagen sponge for the surgical treatment of pilonidal disease.     

Treatment of pilonidal sinus by primary closure with a transposed rhomboid flap compared with deep suturing: a prospective randomised clinical trial.

OBJECTIVE: To assess two techniques of primary closure after excision of pilonidal sinus. DESIGN: Prospective randomised study. SETTING: University department of surgery, United Arab Emirates. SUBJECTS: 46 patients with chronic pilonidal sinus disease, 24 treated by rhomboid flap transposition, and 22 by deep suturing technique. MAIN OUTCOME: Early mobility and recurrence. RESULTS: All patients in the rhomboid flap transposition group healed their wounds primarily compared with 17 in the primary deep suturing group (77%). (P = 0.02). Five patients wounds broke down as a result of haematoma and infection (23%). The mean hospital stay for the rhomboid flap technique was 6 days compared with 9 days after deep suturing, and the mean follow up for both groups was 18 months, the rhomboid flap group returned to work a mean of nine days earlier than the deep suturing group (23 days). No recurrence has been identified yet in the rhomboid flap group, while 2 recurrences have developed in the deep suturing group (9%). CONCLUSION: Primary closure after excision of pilonidal sinus with a transposed rhomboid flap is successful in the management of pilonidal sinus and is superior to primary closure by deep suturing.