Are postoperative drains necessary with the Limberg flap for treatment of pilonidal sinus?

Karydakis procedure versus Limberg flap for treatment of pilonidal sinus: an updated meta-analysis of randomized controlled trials

BACKGROUND

The Karydakis procedure (KP) and Limberg flap (LF) are two commonly performed operations for pilonidal sinus disease (PND). The present meta-analysis aimed to review the outcome of randomized trials that compared KP and LF.

METHODS

Electronic databases were searched in a systematic manner for randomized trials comparing KP and LF through July 2020. This meta-analysis was reported in line with the PRISMA statement. The main outcome measures were failure of healing of PND, complications, time to healing, time to return to work, and cosmetic satisfaction.

RESULTS

Fifteen randomized controlled trials (1943 patients) were included. KP had a significantly shorter operation time than LF with a weighted mean difference (WMD) of -0.788 (95%CI: -11.55 to -4.21, p < 0.0001). Pain scores, hospital stay, and time to healing were similar. There was no significant difference in overall complications (OR= 1.61, 95%CI: 0.9-2.85, p = 0.11) and failure of healing (OR= 1.22, 95%CI: 0.76-1.95, p = 0.41). KP had higher odds of wound infection (OR= 1.87, 95%CI: 1.15-3.04, p = 0.011) and seroma formation (OR= 2.33, 95%CI: 1.39-3.9, p = 0.001). KP was followed by a shorter time to return to work (WMD= -0.182; 95%CI: -3.58 to -0.066, p = 0.04) and a higher satisfaction score than LF (WMD= 2.81, 95%CI: 0.65-3.77, p = 0.01).

CONCLUSIONS

KP and LF were followed by similar rates of complications and failure of healing of PND and comparable stay, pain scores, and time to wound healing. KP was associated with higher rates of seroma and wound infection, shorter time to return to work, and higher cosmetic satisfaction than LF.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of pilonidal disease

Pilonidal disease (PD) is a relatively common, benign but challenging condition of the natal cleft. This consensus statement was drawn up by a panel of surgeons, identified by the Italian Society of Colorectal Surgery (SICCR) as having a “special interest” in PD, with the aim of recommending the best therapeutic options according to currently available scientific evidence. A three-step modified-Delphi process was adopted, implying: (1) choice of the panelists; (2) development of a discussion outline and of target issues; and (3) a detailed systematic review of the current literature. The agreement/disagreement level was scored on a five-point Likert scale as follows: “A + : strongly agree; A–: agree; N: unsure/no opinion; D–: disagree; D + : strongly disagree. Each panelist contributed to the production of this manuscript, and the final recommendations were reviewed by the Clinical Practice Guidelines Committee.

Comparison of the Three Surgical Flap Techniques in Pilonidal Sinus Surgery

We aimed to study the efficacy of three surgical flap techniques in pilonidal surgery. Pilonidal disease is characterized by chronic inflammation and infection in the sacrococcygeal region. Complications and recurrence are common after treatment and optimal treatment for the disease has not been established yet. We enrolled a total of 401 patients in this study. Patients have been treated with Karydakis (n = 113), modified Limberg (n = 179), or Limberg (n = 109) flap techniques. Mean off-work period, time to walk without pain, time to sit on the toilet, time to take the drainage catheter off, maceration rates, recurrence, and hypoesthesia rates were significantly better in the modified Limberg group. In conclusion, we showed the modified Limberg technique is superior than both Limberg and Karydakis techniques.

Impact of geography and surgical approach on recurrence in global pilonidal sinus disease

Pilonidal sinus disease (PSD) is increasing globally. A recent meta-analysis and merged-data analysis showed that recurrence rates in PSD depend essentially on follow-up time and specific surgical procedures. However, the global distribution of surgical approaches and respective recurrence rates have never been studied in PSD. We aimed at studying the impact of geographic distribution of surgical approaches to treat PSD and subsequent geography-specific recurrence rates. We searched relevant databases as described previously. Recurrence rates were then associated with reported follow-up times and geographic origin. We simulated individual patients to enable analogy across data. Globally, recurrence rates range from 0.3% for Limberg/Dufourmentel approaches (95% CI 0.2–0.4) and flaps (95% CI 0.1–0.5) and up to 6.3% for incision (95% CI 3.2–9.3) at 12 months. Recurrence rates range from 0.3% for Karydakis/Bascom approaches (95% CI 0.0–0.8) up to 67.2% for incision (95% CI 7.5–100) in the USA, and 0.0% for primary asymmetric closure in Germany (95% CI 0.0–0.0). Our analysis shows that recurrence rates in PSD not only depend on therapeutic approaches and follow-up time but also on geography. Primary asymmetric closure and various flap techniques remain superior regardless of the geographical region. Some approaches have extraordinarily good outcomes in specific countries.

Postoperative Drain Use in Cranial Vault Remodeling: A Survey of Craniofacial Surgeon Practices and a Review of the Literature

BACKGROUND

The use of subgaleal drains following primary cranioplasty for craniosynostosis has undergone limited investigation. Proposed benefits include prevention of seroma, detection of postoperative bleeding, and cerebrospinal fluid leak. We conducted a systematic review of the literature and surveyed craniofacial surgeons to ascertain the current evidence pertaining to drain use following primary cranioplasty for craniosynostosis and to determine surgical practice patterns.

METHODS

PubMed and Embase databases were searched to identify relevant articles. Abstracts were reviewed by 2 investigators, and a Cohen κ statistic was calculated. Patient demographic and outcome data were extracted and compared. A 9-question survey was e-mailed to active and associate members of the American Society of Craniofacial Surgeons.

RESULTS

A total of 7395 unique citations were identified. Only 2 retrospective chart reviews met inclusion criteria. All objective parameters demonstrated no difference between patients with and without drains. A subjective benefit of limiting facial swelling was proposed without objective analysis. Fifty (32.5%) of the 154 craniofacial surgeons responded to the survey. Forty-two percent used postoperative drains. A significant association (P = .01) was found between the belief that drains limited facial swelling and their use.

CONCLUSIONS

The literature examining postoperative drain use in primary cranioplasty for craniosynostosis is restricted. The current studies show no definite benefit to drain use but are limited in their assessment of key outcomes. There is wide variability among surgeons regarding drain use, and this seems to be motivated by belief and tradition.

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.

Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence

We systematically searched available databases. We reviewed 6,143 studies published from 1833 to 2017. Reports in English, French, German, Italian, and Spanish were considered, as were publications in other languages if definitive treatment and recurrence at specific follow-up times were described in an English abstract. We assessed data in the manner of a meta-analysis of RCTs; further we assessed non-RCTs in the manner of a merged data analysis. In the RCT analysis including 11,730 patients, Limberg & Dufourmentel operations were associated with low recurrence of 0.6% (95%CI 0.3-0.9%) 12 months and 1.8% (95%CI 1.1-2.4%) respectively 24 months postoperatively. Analysing 89,583 patients from RCTs and non-RCTs, the Karydakis & Bascom approaches were associated with recurrence of only 0.2% (95%CI 0.1-0.3%) 12 months and 0.6% (95%CI 0.5-0.8%) 24 months postoperatively. Primary midline closure exhibited long-term recurrence up to 67.9% (95%CI 53.3-82.4%) 240 months post-surgery. For most procedures, only a few RCTs without long term follow up data exist, but substitute data from numerous non-RCTs are available. Recurrence in PSD is highly dependent on surgical procedure and by follow-up time; both must be considered when drawing conclusions regarding the efficacy of a procedure.

Comparative analysis of the same technique-the same surgeon approach in the surgical treatment of pilonidal sinus disease: a retrospective cohort study

Purpose

Although there are several surgical methods for treatment of sacrococcygeal pilonidal sinus, there is no widespread consensus. In this study, we aimed to compare primary closure, Limberg, and modified Limberg flap techniques, with each performed by each of 3 surgeons.

Methods

A total of 802 patients who were operated on for pilonidal sinus disease were included in this retrospective cohort study. Patients were evaluated in 3 groups: group 1 (limited excision + primary closure), group 2 (large excision + Limberg flap technique), and group 3 (large excision + modified Limberg technique). Development of early or late period complications was accepted as primary outcome.

Results

Mean patient age was 28.1 ± 6.7 years. Operation time in group 1 was 44.0 ± 14.5 minutes, and was shorter in comparison to other 2 groups (P < 0.001). One or more complications developed in 171 patients (21.3%) within study group. Highest complication rate was in group 1, with a rate of 30.7% (P < 0.001). Rate of wound dehiscence and recurrence in group 1 were differed significantly from other groups (P < 0.001 and P = 0.001, respectively).

Conclusion

Based on the same technique-the same surgeon approach, comparison of surgical methods for treatment of pilonidal sinus showed that modified Limberg and Limberg techniques are superior to primary closure technique in terms of general complication, wound dehiscence, and recurrence rates.

Retrospective review of pilonidal sinus patients with early discharge after Limberg flap procedure

The aim of this study was to evaluate the results of cases with pilonidal sinus (PS) disease that underwent Limberg flap (LF) transposition and to compare the short and long-term results of early discharge cases with those in the literature. A total of 345 patients who underwent rhomboid excision and LF transposition for PS were evaluated retrospectively. No major anesthetic or surgical complications occurred. Partial wound dehiscence, localized flap necrosis, hematoma, wound infection, and seroma rates were determined as 4.0, 2.1, 1.5, 3.3, and 3.7% respectively. All patients other than those with a hematoma or localized necrosis were discharged with a drain in place 24 hours after the operation. The recurrence rate was 3.9% after a mean 33.1-month follow-up (range, 6-72 months). As a result, we found that short and long-term results of patients who underwent LF and were discharged 24 hours after the operation were similar to those in the literature. We suggest that patients without postoperative complications, such as hematoma or flap necrosis, can be discharged early.

Pilonidal sinus surgery: could we predict postoperative complications?

Pilonidal sinus surgery could, as of now, be considered a surgery tailored more to the surgeon than to the patient. In an attempt to give to surgeons an objective instrument of decision, we have evaluated which variables could be considered predictive of postoperative complications after pilonidal sinus surgery. A prospective electronic database of all patients treated for sacrococcygeal pilonidal disease was analysed. Sex, age, obesity, smoking, recurrent disease, the presence of multiple orifices and the distance between the most lateral orifice and midline were recorded and correlated with the occurrence of postoperative complications (infection and recurrence); 1006 patients were evaluated. Excision with primary mid-line closure was performed on all the patients. Mean follow-up was 7·3 ± 3·6 years. A total of 158 patients with postoperative complications (infection and/or recurrence) were recorded during this period. A multivariate analysis showed that, after adjusting for major clinical and demographic characteristics, only a recurrent disease [odds ratio (OR): 3·41, 95% confidence interval (CI): 1·89-6·15, P < 0·001] and the distance of lateral orifice from midline (OR: 26·3, 95% CI: 12·2-56·7, P < 0·001) were independent predictors of overall postoperative complications. Focussing on the distance from midline, the receiver operative characteristic (ROC) analysis showed that the distance of lateral orifice from midline predicted 79·2% of complications and the Youden's test identified the best cut-off as 2·0 cm for this variable. An evidence-based tool for deciding on the type of surgical intervention could be developed and validated by further ad hoc prospective studies evaluating our results in comparison to other different types of surgical techniques. Our results support the use of these variables as an effective way to tailor pilonidal sinus surgery to the patient, so as to obtain the best results in patient care.

Comparison of surgical Limberg flap technique and crystallized phenol application in the treatment of pilonidal sinus disease: a retrospective study

OBJECTIVE

This study was designed to compare the efficacy of crystallized phenol method with Limberg flap in pilonidal sinus treatment.

MATERIAL AND METHODS

Patients with a diagnosis of pilonidal sinus disease treated with surgical excision + Limberg rhomboid flap technique and crystallized phenol method between 2010-2011 in the Şevket Yılmaz Training and Research Hospital, Department of General Surgery were evaluated retrospectively. Patients' age, sex, length of hospital stay, complications and recurrence rates were evaluated.

RESULTS

Eighty eight percent of patients were male and mean age was 26.84±6.41 in the Limberg group, and 24.72±5.00 in the crystallized phenol group. Sinus orifice locations and nature, and duration of symptoms before surgery were similar in the two groups. Length of hospital stay in the Limberg group was 1.46±0.61 days; whereas all patients in the crystallized phenol group were discharged on the same day. Infection, hematoma, wound dehiscence, and cosmetic problems were significantly higher in the Limberg group. There was no difference between the two groups in terms of recurrence and seroma formation.

CONCLUSION

The less invasive method of crystallized phenol application may be an alternative approach to rhomboid excision and Limberg flap in patients with non-complicated pilonidal sinus disease, yielding acceptable recurrence rates.

The role of drainage after excision and primary closure of pilonidal sinus: a meta-analysis

We carried out a systematic review of the literature to identify the association between the use of drain and the incidence of infections and recurrences after surgery. MEDLINE, SCOPUS and ISI databases were searched up to September 2012. The two outcomes of this meta-analysis were wound infection and recurrence. Postoperative wound infection occurred in 50 of the 604 (8.28 %) patients who underwent drainage and in 68 of the 598 (11.4 %) patients who did not, with a resulting odds ratio (OR) of 0.71 (95 % CI: 0.48-1.03). Recurrence of pilonidal sinus occurred in 41 of the 604 (6.79 %) patients who underwent drainage and in 50 of the 598 (8.36 %) patients who did not, with a resulting OR of 0.80 (95 % CI: 0.52-1.23). The results suggest that, despite a trend toward a reduction in infectious complications and recurrence, drainage was not associated with a better outcome. However, because of the present literature's limitations, further studies are needed to address this issue.

Effectiveness of a drain in surgical treatment of sacrococcygeal pilonidal disease. Results of a randomized and controlled clinical trial on 803 consecutive patients

PURPOSE

The aim of this study was to evaluate the influence of cavity drainage in the surgical treatment of sacrococcygeal pilonidal sinuses.

METHODS

The study was prospectively carried out in 803 patients randomized into two groups of respectively 401 and 402 patients. In the first group, primary excision and closure were associated with drainage of the wound; in the second group, the wound was not drained. We have analyzed time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, and wound infections. We have also evaluated the satisfaction rate and esthetic results.

RESULTS

On comparing time off work, time to walk without pain, and time to sitting on toilet without pain postoperatively, there were no significant differences between the two groups. A significant difference between the two groups with regard to wound infection rates (p = 0.5) and recurrence rates (p = 0.6) was not observed. In order to prevent prolonged inpatient stay and social intolerance, this study suggests that the post-operative period is tolerated by a few when a drain was used. The visual analog scale (VAS) in the drained group was 3.2 ± 0.9, and VAS in the non-drained group was 3.5 ± 0.9 with a significant statistical difference (p = 0.0001). As regards the cosmetic appearance of the scar after surgery, we achieved a high satisfaction rate among patients in either group with 82.9% good cosmetic results.

CONCLUSIONS

The use of a drain, in our experience, appears to be useless in achieving a quick healing of the sacral wound; in addition, it has a low satisfaction rate.

Day-Case Limberg Flap for Recurrent Pilonidal Sinus: Does Obesity Complicate the Issue?

The purpose of this study was to analyze the long-term outcome of rhomboid excision with Limberg flap reconstruction (LF) as one-day surgery in treatment of recurrent pilonidal sinus (RPS). The effect of obesity on outcome will be addressed. Forty-nine patients with RPS were treated by rhomboid excision and LF as one-day surgery. Data collected included demographics, body mass index, operative time, flap ischemia, wound infection, length of hospital stay, time of complete healing, and recurrence. Patients’ mean age was 33.4 years and mean number of previous operations was 3.4. Operative time ranged from 40 to 70 minutes. Two patients developed sterile seroma (4.1%) and two patients (4.1%) had wound infections. No wound dehiscence or flap ischemia was reported. All patients returned to normal activity within 7 days. No recurrences were reported after a mean follow-up of 32.1 months. Obesity significantly increased the operative time, however, it affected neither the postoperative outcome nor the long-term recurrence. Rhomboid excision and LF as one-day surgery is a safe and reliable method for treatment of RPS. It guarantees low morbidity, short hospital stay, short time off work, and carries low risk of recurrence, even in obese patients.

Are postoperative drains necessary with the Karydakis flap for treatment of pilonidal sinus? (Can fibrin glue be replaced to drains?) A prospective randomized trial

PURPOSE

Different surgical techniques for pilonidal disease have been described in the literature. In this study, our aim was to evaluate the influence of routine cavity drainage in the Karydakis flap technique.

METHODS

As much as 50 male patients with pilonidal sinus who underwent the Karydakis flap operation were evaluated prospectively.The patients were assigned randomly into two groups (Group 1 with suction drain; Group 2 fibrin glue).

RESULTS

Fluid collection was encountered in 8 out of 50 patients (6.25%): 6 in Group 2 (24%) of which 4 experienced superficial, healed with simple dressing, the other 2 with substantial dehiscence healed with wound dressing; 2 in Group 1 (8%) were treated with wound punctures.There has been no recurrence in any of the patients during the follow-up period.The Karydakis flap operations can be performed with a near zero recurrence rate with the use of drains.

CONCLUSION

We recommend the use of fibrin sealant with Karydakis flap procedure, but further studies are needed to confirm this conclusion.

Dufourmentel rhomboid flap in the radical treatment of primary and recurrent sacrococcygeal pilonidal disease

PURPOSE

The aim of this study was to assess early and late results of the Dufourmentel procedure in patients with primary and recurrent sacrococcygeal pilonidal disease.

METHODS

Consecutive patients who underwent surgical treatment for pilonidal disease from November 1993 through July 2009 at the Second Department of General Surgery of the Second University of Naples were entered into the study. All patients underwent epidural anesthesia and radical excision followed by reconstruction with a Dufourmentel rhomboid flap. Study variables included preoperative body mass index, hospital stay, time to walking, sitting, and return to work, and pain score (visual analog scale) for evaluation early results and patient comfort. Time to complete wound healing, wound complications, and recurrence rates were recorded to assess late results.

RESULTS

A total of 310 patients with pilonidal disease entered the study. Of these, 24 patients were asymptomatic (incidental diagnosis) and 55 had recurrent sinus. Obese patients had a significantly worse clinical presentation than patients with normal weight (P < .001). All operations were uneventful, with a mean operative time of 40 (range, 30-55) minutes after the surgeons' learning period, and no flap necrosis occurred. The median hospital stay was 1 day (range, 1-11 days), median time to return to work was 7 (range 5-30) days, and pain was minimal. Wound complications were experienced by 33 patients (10.6%). All but 2 patients were managed conservatively; in 2 patients (0.6%), the wound was resutured under local anesthesia and healed within 15 days. No patient was lost to follow-up. Recurrence was observed in 7 patients (2.3%). All relapses occurred in 25 months after the operation; no late recurrences were seen (5-, 10-, and 16-year recurrence-free rates were all 97.6%). The recurrence rate was significantly higher in obese than in normal-weight patients (6% vs. 0.5%; P = .0029). Permanent hypoesthesia was negligible (0.9%), and no patient complained about the cosmetic outcome.

CONCLUSIONS

The Dufourmentel flap is associated with minimal discomfort and excellent results. This technique can be considered in the first- and second-line management of pilonidal disease.

Use of drains in surgery: a review

Drains have been used in surgery for several years to remove body fluids thereby preventing the accumulation of serous fluid and improving wound healing. Drains may be classified as closed or open systems, and active or passive depending on their intended function. Closed vacuum drains apply negative suction in a sealed environment, producing apposition of tissues and thus promoting healing. Correct assessment of clinical indications might reduce unnecessary usage. This article will introduce the principles and practice of various types of drains and highlight the importance of understanding how surgical drains promote quality patient care.

Surgical treatment of sacrococcygeal pilonidal sinus with rhomboid flap

In this review, we summarized the general characteristics of pilonidal sinus disease and details of rhomboid flap (RF) technique used in its treatment, and discussed the results of RF methods and its comparison with other techniques, principally with flap technique available in the literature. When performed studies are examined, RF technique has come into prominence nowadays with low recurrence and infection rates, and with a comfortable surgical technique. Recently, it has been anticipated that with the modification of this technique, the recurrence rate would be lower.

Surgical treatment of pilonidal sinus with a fasciocutaneous rotation flap based on an inferior pedicle

Pilonidal sinus is a common disorder of the sacrococcygeal region and several surgical treatments have been described. However, rates of recurrences and complications vary, so there is no consensus on one specific approach. In this prospective study from 1 August 2000 to 1 August 2003, 60 patients with pilonidal sinus were treated by our new surgical technique. All patients were operated on by the first author or under his supervision. A vertical elliptical excision was made, and the defect repaired by a fasciocutaneous rotation flap based on the inferior pedicle under general anaesthesia. All patients were discharged from hospital on the first postoperative day. By the 12th day, the wound had healed completely. There were no recurrences during one years' follow-up. Postoperative pain was negligible and the scar was cosmetically acceptable. The inferiorly-based rotation flap is an ideal technique for treatment of pilonidal sinus, cures the disease, has low recurrence rates, little postoperative pain, and few complications. Stay in hospital was short and patients returned to their regular activities in a short time.

Management of pilonidal sinus disease with oblique excision and bilateral gluteus maximus fascia advancing flap: result of 278 patients

PURPOSE

Excision followed by natal cleft depth reduction should be performed, with no leftover midline scar tissue, to prevent recurrence of pilonidal sinus, which is the main problem in the treatment of this disease. We investigated the potential advantages of this advancing flap technique, which we developed.

METHOD

An S-type incision together with a bilateral gluteus maximus fascia advancing flap was applied on 278 (89 percent) patients, who did not have extensive gluteal involvement, of the 312 patients who had pilonidal sinus disease, between January 1997 and January 2007. No drainage was performed on any patient.

RESULTS

All patients were discharged within 24 hours. Total complication rate was 7.2 percent and recurrence rate was 0.7 percent. The mean time off from work was 12 +/- 2 days (range, 10 to 22). The mean follow-up period was 66 +/- 32 months (range, 12 to 120).

CONCLUSION

We suggest that this surgical procedure may successfully be applied to a large majority of the patients. It does not lead to unnecessary excision of healthy tissue because of its significantly simpler nature compared with the full-layer flap technique and its S-type incision, it does not create a midline scar tissue, and it is able to flatten the gluteal sulcus.

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.

Sacrococcygeal pilonidal disease

BACKGROUND

Sacrococcygeal pilonidal is a common disease in active young adults. Many surgical methods have been proposed, although no clear consensus as to the optimal treatment has been reported. This review looks at the different surgical techniques available and examines the reported results of primary healing, recurrent disease and complications (including delayed healing).

METHOD

A literature search using the Medline database was performed to locate English language articles on surgery for pilonidal disease. Further articles were obtained from the references cited in the literature initially reviewed.

RESULTS

Management should be tailored according to the individual and whether the disease is acute or chronic. Treatment should take into consideration hospital stay and return to work. Simple excision, curettage, partial lateral wall excision, or marsupialisation, are simple techniques with good results. They can be used for the initial surgery but their use is not recommended for recurrent disease. The modified rhomboid flap for recurrent disease has consistently shown positive results in terms of complication rates and recurrence.

CONCLUSION

We would recommend tailored treatment with simple excision for initial presentation and the modified rhomboid flap for recurrent disease.

Short-term and long-term outcomes of the cleft lift procedure in the management of nonacute pilonidal disorders

PURPOSE

We report the results of the cleft lift procedure in the management of nonacute pilonidal sinus disorders.

METHODS

Seventy consecutive patients who underwent a cleft lift for nonacute pilonidal sinus were evaluated prospectively. Responses to a postal questionnaire were analyzed for long-term outcome.

RESULTS

All patients who fulfilled the criteria for day-case were operated on as such. Sixty-six patients achieved complete wound healing within six weeks. Delayed wound healing occurred in three patients and nonhealing occurred in one. Fourteen patients had one or more complications: wound breakdown, superficial (n = 7) and deep (n = 1); wound infection (n = 5); wound seroma (n = 4); and early recurrence (n = 1). The median time off work and to return to normal activities was two and four weeks, respectively (range, 0.5-12). Forty-seven patients completed the questionnaire at a median follow-up of 24 months: five patients reported minimal tenderness in the sacral region; none reported recurrence of pilonidal symptoms; and all were satisfied.

CONCLUSIONS

The cleft lift procedure is easy to perform as a day-case procedure. It is associated with high rates of primary healing, durable low recurrence rates, and early functional recovery. This technique may be the procedure of choice in the surgical management of nonacute pilonidal disorders.

Sacrococcygeal pilonidal sinus treated by a new fascio-cutaneous flap

PURPOSE

This study reported the technical details and preliminary clinical outcomes of a new fascio-cutaneous transposition flap for the surgical treatment of pilonidal sinus.

METHODS

Fifty-two patients with pilonidal sinus were surgically treated. During the surgical procedure, an inferiorly pedicled, fascio-cutaneous flap with specific geometric characteristics was prepared and transposed. Postoperative pain, complications, duration of hospital stay, and time off worked were assessed. Patients were followed for eighteen months after surgery.

RESULTS

The mean hospital stay was 2 days. Drains and sutures were removed after 3 and 12 days, respectively. No flap ischemia, wound dehiscence or major complications were observed. Tension on suture lines and pain after surgery were negligible. Wound infections occurred in 4 patients (7.7 percent) and were managed by removing a few sutures. Seroma was detected in 6 patients (11.5 percent). The mean time patients missed work was 7 days. No recurrence was observed during the follow-up period of 18 months.

CONCLUSIONS

With no disease recurrence, minimal complication rate, time off work, and acceptable aesthetic outcome, this fascio-cutaneous transposition flap technique is a safe and effective method for surgically treating pilonidal sinus.

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.

Outcome of treatment of primary and recurrent pilonidal sinuses with the Limberg flap

BACKGROUND

Surgical treatment of pilonidal sinus disease has a significant morbidity and recurrence rate. The rhomboid flap of Limberg is a transposition flap that has been advocated for treatment of this condition. We present our experience with the Limberg technique for both primary and recurrent pilonidal sinuses.

PATIENTS AND METHODS

In a three-year period, 25 patients with chronic pilonidal sinus disease were treated with this method. Twelve patients had recurrent disease and were previously treated with other types of surgery. The sinuses were excised in a rhomboid fashion and the defect closed using a transposition flap designed to obliterate the midline cleft. Patients were treated with prophylactic antibiotics and the wound drained with a vacuum drain.

RESULTS

Median post-operative hospital stay was four days. There were four (16%) wound complications. The mean follow-up period was 20 months. There was a single recurrence (4%) of a pilonidal sinus, which required further surgical excision.

CONCLUSIONS

Despite the risk of wound complications, this method is particularly useful for complex sinuses with extended tracts where radical excision leaves a large defect. It is also suitable for cases where simpler operations have failed and carries a low risk for recurrence.

Superiority of asymmetric modified Limberg flap for surgical treatment of pilonidal disease

PURPOSE

Cases treated surgically using wide excision plus classic Limberg flap or wide excision plus asymmetric modified Limberg flap were compared with respect to complications and patient comfort in the postoperative period.

METHODS

In this prospective, randomized study, 68 of 70 patients were followed for a mean of 29.22 (range, 6-44) months after wide excision plus classic Limberg flap (Group 1, n=35) and after asymmetric modified Limberg flap closure (Group 2, n=33).

RESULTS

There were significantly more macerations in Group 1 (P<0.001). All macerations were detected on the lower part of the incision left on the intergluteal sulcus, and infections occurred subsequent to maceration. The infection rate was statistically higher in Group 1 than in Group 2 (P=0.028). We noted that as a result of these complications, time to suture removal (P=0.001), discharge from hospital (P=0.001), and time off from work (P=0.001) were significantly longer for Group 1 than for Group 2. There were two recurrences in the inferior part of the suture line in Group 1 and none in Group 2, which showed no statistical difference (P=0.493).

CONCLUSIONS

The deep intergluteal sulcus and midline gap were slightly flattened over the anococcygeal region. The vacuum effect was decreased, and there were less macerations and fewer infections. Time off from work and discharge time from hospital were shortened by eliminating the moisture effect and reducing complications by lateralizing the lower part of the suture line.

Does technique alter quality of life after pilonidal sinus surgery?

BACKGROUND

Pilonidal sinus is a common disease in young adults that carries high postoperative morbidity and patient discomfort. Controversy still exists about the best surgical technique for the treatment of the disease in terms of recurrence rate and patient discomfort.

METHODS

From January 2000 to November 2003, 100 consecutive age- and sex-matched patients with chronic pilonidal sinus disease were randomized to receive surgical treatment in the forms of either excision and primary closure or rhomboid excision and Limberg flap. Time to return to work and to complete healing were recorded. To evaluate quality of life and patient comfort, all patients were asked to complete a questionnaire including short form 36, Visual Analogue Scale, time to sitting on toilet without pain, and time to walking without pain 3 months after surgery.

RESULTS

Each group was composed of 50 patients. Mean follow-up was 19 months. There was a significant difference between the groups in terms of length of hospital stay (P=.005), time to complete healing (P<.001), time off work (P<.001), and wound infection rate (P=.03). Statistically significant differences were noted between the groups in items of general health perception (71.1+/-11.7 vs 78.2+/-14.1; P=.008), social functioning (87.3+/-32.8 vs 110.4+/-33.8; P=.001), and pain (54.5+/-14.0 vs 67.5+/-18.4; P<.001). Times to sitting on toilet and walking without pain showed significant differences between the groups (P=.006 and P<.001, respectively). The mean postoperative Visual Analogue Scale scores were 6.5+or= 1.7 and 7.4+/- 1.4, respectively (P<.001).

CONCLUSIONS

Shorter hospital stay, earlier healing, shorter time off work, lower ratio of complications, lower pain perception, and improved general health perception are the main advantages of te Limberg flap technique in pilonidal sinus surgery. All together, these parameters add to patient comfort and satisfaction after surgical treatment.

Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus: a prospective, randomized clinical trial with a complete two-year follow-up

BACKGROUND AND AIMS

The best surgical technique for treating pilonidal sinus disease is controversial. The aim of this study is to compare the modified lay-open technique with primary closure following excision with respect to operating time, healing time, time before return to work, morbidity rate, and recurrence rate.

PATIENTS AND METHODS

After a pre-study power analysis, 142 patients with chronic sacrococcygeal pilonidal sinus were prospectively and randomly allocated, either to the modified lay-open group (Group A, n=73) or the primary closure group (Group B, n=69). In the former, incision, curettage, partial lateral wall excision, and marsupialization were performed. Single doses of cefazoline (1 g) and metronidazole (500 mg) were given intravenously 15 min before surgery to all patients.

RESULTS

There were no differences with respect to gender, age, body mass index, and mean operating time between the groups. In Group A, healing failure and early bridging occurred in one patient each. In Group B, wound infection occurred in four patients, wound breakdown in three, one healing failure and hematoma in one patient each. Morbidity and recurrence rates were significantly lower in Group A (2.7 vs. 13%, P=0.028 and 1.4 vs. 17.4%, P<0.001 respectively). The median time before return to work in Group A was significantly shorter than in Group B (3 [range 2--8] vs. 21 [range 14--63] days, P<0.001). The median healing time in Group A was significantly longer than in Group B (7 [range 3--16] weeks vs. 2 [range 2--9] weeks; P<0.001).

CONCLUSION

The results of the present study suggest that modified lay-open is superior to excision with primary closure for the surgical treatment of chronic sacrococcygeal pilonidal sinus with regard to morbidity and recurrence rates, and time before return to work, although healing time is longer.

Is routine cavity drainage necessary in Karydakis flap operation? A prospective, randomized trial

PURPOSE

Different surgical techniques for pilonidal disease have been described in the literature. In this study our aim was to evaluate the influence of routine cavity drainage in the Karydakis flap technique.

METHODS

Fifty patients with pilonidal sinus who underwent the Karydakis flap operation were evaluated prospectively. The patients were assigned randomly into two groups-with and without suction drainage of the cavity-and the effects of drains were studied in terms of wound complications, hospital stay, and recurrence rate.

RESULTS

There was no significant difference between groups in term of length of hospital stay. Complication rate was 20 percent and the complications were caused exclusively by fluid collections. Wound infection, dehiscence, or failure was not observed in any of the patients. There has been no recurrence in any of the patients during the follow-up period. There was a significant increase in the number of fluid collections in patents without a suction drain.

CONCLUSION

The present study indicates that routine cavity drainage reduces the incidence of fluid collection after the Karydakis flap operation.

Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap

BACKGROUND

Pilonidal sinus is a common chronic disease of the sacrococcygeal region. Although many surgical methods have been suggested, an ideal method is still lacking because of high recurrence rates.

METHODS

This prospective study was conducted in 63 patients who were treated with the use of a rhomboid excision and Limberg flap closure for sacrococcygeal pilonidal sinus. The follow-up period ranged from 4 to 52 months (mean, 25 months).

RESULTS

The mean hospital stay was 3 days (range, 2-7 days) and the mean time to return to work was 15 days (range, 12-26 days). Early wound complications and recurrence were encountered in 6% and 3%, respectively. Nineteen percent had numbness at the operation site and 63% were not pleased with cosmetic appearance of the scars.

CONCLUSIONS

The results favor rhomboid excision and Limberg flap closure in the treatment of sacrococcygeal pilonidal sinus, especially in recurrent cases and in patients with extensive involvement. Low recurrence rates, shorter hospital stay, and time off from work may outweigh the disadvantages related to unfavorable cosmetic appearance.

Sacrococcygeal local anaesthesia versus general anaesthesia for pilonidal sinus surgery: a prospective randomised trial

Sixty patients scheduled for pilonidal sinus surgery were prospectively randomly assigned to receive general anaesthesia or sacrococcygeal local anaesthesia with a newly-described technique. Patients in the general anaesthesia group spent more time in the operating theatre and recovery room than did those in the local anaesthesia group (p < 0.05). Two thirds (67%) of the patients in the local anaesthesia group left hospital on the day of surgery compared to only 17% of patients in the general anaesthesia group (p < 0.05). Visual analogue scale pain scores performed during the 3-day follow-up period favoured the local anaesthetic technique (p < 0.05). Postoperative analgesia requirements were greater in the general anaesthesia group than in the local anaesthesia group (p < 0.05). The majority of patients and surgeons expressed satisfaction with local anaesthesia. Sacrococcygeal local anaesthesia appears to be a successful alternative to general anaesthesia for pilonidal sinus surgery.

Local anesthesia and midazolam versus spinal anesthesia in ambulatory pilonidal surgery

STUDY OBJECTIVE

To evaluate two anesthetic techniques, namely, local anesthesia with sedation, and spinal anesthesia, with respect to recovery times, postoperative side effects, pain scores, patient satisfaction, and hospital costs for ambulatory pilonidal disease surgery.

DESIGN

Prospective, randomized study.

SETTING

University Hospital of Pamukkale.

PATIENTS

60 consenting patients scheduled for pilonidal disease operation with Limberg flap technique.

INTERVENTION

Patients were randomly allocated into two groups: Group 1 (n = 30) received spinal anesthesia with hyperbaric bupivacaine 1.5 mL 0.5%, and Group 2 (n = 30) received local infiltration with a 50-mL mixture containing 10 mL bupivacaine 0.5%, 10 mL prilocaine HCl 2%, and 30 mL isotonic solution with 1:200,000 epinephrine in combination with intravenous (i.v.) midazolam sedation.

MEASUREMENTS

Perioperative and postoperative side effects, patient satisfaction, preoperative visual analog scale (VAS) pain scores, and VAS scores from the fourth hour postoperatively until the seventh day were assessed. Anesthesia, operation, surgery, and total hospital time, and costs (drug, resources, and labor) were recorded.

MAIN RESULTS

No difference was found between groups in the frequency of side effects. Urinary retention was diagnosed in two patients in the spinal anesthesia group. There was no statistical significant difference seen in satisfaction scores between groups. No statistical significance in VAS pain scores between groups was noted except for the fourth postoperative hour values. The average time spent in the operating room (OR) was greater in the spinal anesthesia group. All Group 2 patients achieved fast-tracking criteria in the OR and were able to bypass the postanesthesia care unit (PACU). Total hospital time and total cost were significantly higher in the spinal anesthesia group than local anesthesia-sedation group (p < 0.05).

CONCLUSION

The use of local anesthesia-sedation for ambulatory anorectal surgery resulted in a shorter hospital time, lower hospital costs, and no side effects compared with spinal anesthesia.

Pilonidal disease

Pilonidal disease is a disease of young people, usually men, which can result in an abscess, draining sinus tracts, and moderate debility for some. It probably results from hair penetration beneath the skin, for reasons that are not totally clear. Therapy should be simple, inflict minimal pain, have a short hospitalization, have a low recurrence rate, require minimal wound care, and allow rapid return to normal activity. No treatment meets all these ideal goals. Therefore, starting with a simple treatment and progressing to other treatments if failure occurs despite meticulous wound care and hair shaving is the logical approach. Table 1 depicts treatments from simple to more complex.

Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches

PURPOSE

Pilonidal sinus is a common disease and surgical removal and subsequent wound closure is crucial for lasting cure. To evaluate the outcome of different primary closure techniques we performed a pooled analysis of data published in the past 35 years.

METHODS

We identified reports on wound infection, early failure, and late recurrence status in relation to treatment modality. Surgical techniques were classified into five groups: simple closure technique in the midline, asymmetric or oblique closure techniques, and full-thickness flap techniques like rhomboid flaps, vy-plasty, and z-plasty. Estimations of the incidences resulted from the quotient of number of responses and the number of patients for each study, and these quotients were summarized over all studies.

RESULTS

The MEDLINE search identified 74 publications including 10,090 patients. Pooled data analysis revealed an inhomogeneous effect of the surgical techniques on the infection rate. In contrast, there was a significantly lower early failure rate and late recurrence rate of both the asymmetric-oblique closure techniques and the full-thickness flap techniques when compared with the midline repair technique. No difference was found between the asymmetric repairs and the full-thickness flap techniques.

CONCLUSION

Beside the various statistical considerations when using a pooled data analysis combining results from the literature, this overview suggests a significant benefit of asymmetric-oblique closure techniques or flap techniques in comparison with simple closure in the midline. Thus, we recommend an asymmetric closure technique for primary closure of a chronic pilonidal sinus. These asymmetric procedures provide better results than the simple closure in the natal midline. Furthermore, they are not as sophisticated as the full-thickness plasty techniques.