|Year : 2014 | Volume
| Issue : 4 | Page : 623-628
Direct closure versus local flaps in management of pilonidal sinus
Mohamed Leithy Ahmed Alam El-Dein1, Tarek Fouad Abd El-Hameed Keshk2, Magdy Ahmed Loulah1, Ehab Abd El-Fattah Mohamed El-Ariny MBBCh 2
1 Department of General Surgery, Menoufia University Hospital, Menoufia, Egypt
2 Department of Plastic and Reconstructive Surgery, Menoufia University Hospital, Menoufia, Egypt
|Date of Submission||08-Sep-2013|
|Date of Acceptance||08-Dec-2014|
|Date of Web Publication||22-Jan-2015|
Ehab Abd El-Fattah Mohamed El-Ariny
Shobrabkhoum, Quesna, Menoufia
Source of Support: None, Conflict of Interest: None
The aim of this randomized prospective trial was to compare both the results of direct closure and local flaps in management of pilonidal sinus.
The best surgical technique for sacrococcygeal pilonidal disease is still controversial in terms of minimizing disease recurrence and patient discomfort. The present study analyzes the results of excision with primary closure and excision with flap reconstruction in the surgical treatment of sacrococcygeal pilonidal disease.
Materials and methods
From February 2012 to February 2013, 30 consecutive patients with chronic pilonidal sinus disease received surgical treatment in the form of either excision and primary closure (group 1, n = 15 patients) or excision and flap reconstruction [group 2, n = 15 patients; classic Limberg flap ( n = 5), modified Limberg flap ( n = 5), and V-Y advancement flap ( n = 5)]. Demographic data, operative time, postoperative pain, hospital stay, duration of incapacity for work, postoperative complications (infection, flap edema, wound dehiscence), patient satisfaction, and postoperative recurrence were recorded.
The mean follow-up was 12 months. A significant difference was observed between the two groups in terms of operative time (min), postoperative complications, and patient satisfaction (P < 0.05) for all comparisons. There were no significant differences among the two groups with respect to age, sex distribution, postoperative pain, length of hospital stay (in days), duration of incapacity for work (in days), and frequency of recurrent disease (P>0.05) for all comparisons. In the modified Limberg flap, no wound infection or recurrence of the disease occurred.
Flap reconstructions were superior to primary closure after excision of pilonidal sinus, and modified Limberg flap was superior with respect to wound infection and recurrence.
Keywords: Flap reconstruction, pilonidal disease, primary closure, surgical treatment
|How to cite this article:|
Ahmed Alam El-Dein ML, Keshk TA, Loulah MA, Mohamed El-Ariny EA. Direct closure versus local flaps in management of pilonidal sinus. Menoufia Med J 2014;27:623-8
|How to cite this URL:|
Ahmed Alam El-Dein ML, Keshk TA, Loulah MA, Mohamed El-Ariny EA. Direct closure versus local flaps in management of pilonidal sinus. Menoufia Med J [serial online] 2014 [cited 2017 Dec 13];27:623-8. Available from: http://www.mmj.eg.net/text.asp?2014/27/4/623/149616
| Introduction|| |
Pilonidal sinus is an acquired disease of young adults characterized by infected sinus in the natal cleft associated with tuft of hairs . Exact etiology is unknown, but some factors are deep natal cleft, prolong sitting, travelling or driving, excessive body hairs, folliculitis, obesity, and poor local hygiene . The pathophysiology is dead hairs being pushed into skin abrasion by movement of buttocks, which causes a foreign body reaction within presacral subcutaneous tissue, resulting into acute and chronic abscess formation . Pilonidal sinus typically appears as an abscess or a persistently discharging, tender sinus tract . The best treatment would be a rapid one that permits patients to resume early their normal daily life activity, with least morbidity and a low risk for complications . The treatment of chronic pilonidal disease is variable, debatable, and challenging .
Principles of management need eradication of the sinus tracts, complete healing of the overlying skin, and prevention of reappearance . Different modalities of management are there; in acute stage, incision and drainage under local anesthesia is followed by secondary intention granulation healing . Another method described is chemical phenolization with injection of phenolic acid in the incised abscess . In chronic stage, many surgical and nonsurgical treatment modalities have been tried for the treatment of this chronic disease, including shaving, phenol application, cryosurgery, incision and drainage, excision with primary closure, excision with open packing, excision with marsupialization, and flaps surgery .
The main problems with the primary closure techniques seem to be high recurrence and infection rates. In contrast, patients generally complain about open packing or marsupialization methods because of painful wound management and dressing changes . If the defect size is large enough to close primarily, reconstructive procedures are typically required in these cases to close the defect . These procedures not only cover the wound, but also, in theory, flatten the natal cleft, reducing hair accumulation, mechanical irritation, and risk for recurrence. Complications, including flap necrosis, wound dehiscence, and infection, are a considerable risk .
The techniques available in reconstructive procedures include the cleft closure, advancement flap (Karydakis procedure), local advancement flaps (Limberg, Z-plasty, V-Y advancement flap), modified V-Y advancement flap, modified Limberg flap, and rotational flap (gluteus maximus myocutaneous flap) .
In this prospective study, the results of primary closure and flaps reconstruction (classic Limberg flap, modified Limberg flap, and V-Y advancement flap) after wide excision of sacrococcygeal pilonidal disease were compared and analyzed with the evaluation of patients' satisfaction and comfort toward surgical techniques.
| Materials and methods|| |
This was a prospective descriptive study on 30 cases of chronic pilonidal sinus. Excision and reconstruction were performed at Department of General, Plastic and Reconstructive Surgery at Menoufia University and El-Monera General Hospital between February 2012 and February 2013. Informed consent was obtained from all patients included in the study, which was approved by the local ethics committee. All patients were subjected to thorough history taking, clinical examination, and laboratory tests. ECG and chest radiography were requested when indicated. The patients were then randomized into two groups: group 1 patients (n0 = 15) were treated with excision and primary closure, whereas group 2 patients (n = 15) were treated with excision and flaps reconstruction [classic Limberg flap (n0 = 5), modified Limberg flap (n = 5), and V-Y advancement flap (n0 = 5)].
Patients were admitted to hospital on the day of operation; the patients were shaved from gluteal skin areas to the lumbar region extending laterally to midaxillary line. All patients were operated on under spinal or general anesthesia in prone Jack-knife position with two adhesive straps in each gluteal region to pull them laterally and cleaning the area with povidone iodine. A prophylactic antibiotic in the form of a third-generation cephalosporin was administered 30 min before the operation.
Excision and primary closure
A symmetrical elliptical incision around the midline natal cleft is made to enclose the sinus and its tracts. With continuous sharp dissection, the incision is carried down to the sacrococcygeal fascia. Hemostasis is achieved by electrocautery without using any ligature. The subcutaneous fat is undermined and lifted as a flap from the gluteal fascia. A suction drainage is inserted and externated through a separate stab incision. The wound is closed by polypropylene deep full-thickness tension sutures including the postsacral fascia and crossing symmetrically through both sides of the elliptical defect [Figure 1]. A roll of dressing gauze is placed over the wound and then is covered by dressing pad and adhesive plaster.
Limberg flap procedure
The rhomboid flap starts by excising all sinuses down to the presacral fascia using a rhombic incision. The flap consists of skin and fat and is constructed by extending the incision to the gluteal muscle fascia. The flap was completely mobilized from the gluteus maximus muscle to prevent tension. Hemostasis was achieved by electrocautery. Adhesive tapes were removed before suturing. After mobilizing the flap, a suction drainage was inserted and a single-layer polypropylene mattress sutures was used to close the defect and the wound was covered by dressing pad and adhesive plaster.
Modified Limberg flap procedure
In modified Limberg flap procedure, we marked and placed the inferior apex of the rhomboid excision asymmetrically 1-2 cm lateral to the midline on the side opposite to the donor area [Figure 2]. The flap consists of skin and fat and is constructed by extending the incision to the gluteal muscle fascia. The flap was completely mobilized from the gluteus maximus muscle to prevent tension. The subsequent steps were identical to those in the classic Limberg flap.
V-Y advancement flap procedure
The diseased tissue is excised and then the defect is closed with a V-shaped full-thickness flap extending down to the gluteal fascia, which is completely mobilized from the gluteus maximus muscle to prevent tension [Figure 3]. Hemostasis is achieved by electrocautery. Adhesive tapes are removed before suturing. After mobilizing the flap, a suction drainage is inserted and the space that is left after advancing the flap is closed with simple sutures. The suture line is in the shape of a Y; hence, the name is V-Y advancement flap.
Follow-up and data analysis
Postoperatively, regular diet was allowed and patients were encouraged to walk after 8 h but not to exercise until removal of stitches. Closed suction drains were removed when 24-h suction output was less than 30 ml. The patients were advised to shave the hair for 3-4 cm from the surrounding edges of the wound and to keep the natal cleft free of hair for 3-6 months after healing. Patients were discharged when clinically free after the operation. Instructions on discharge included avoidance of prolonged sitting, riding bicycles or scooters until 6 weeks postoperatively to prevent wound disruption, and improving local hygiene. All patients were advised to visit outpatient clinic every week for 1 month and then every 3 months for at least 12 months during the follow-up period. Stitches were removed 14 days postoperative. The duration of operation, postoperative pain, length of hospital stay, duration of incapacity for work, postoperative complications (infection, flap edema, wound dehiscence), patient satisfaction, and postoperative recurrence were recorded for both groups. Thereafter, the two groups were compared. Duration of operation was defined as the length of time between the first incision and placement of the last suture. Postoperative pain was assessed using visual analogue scale (VAS) from 0 (no pain) to 10 (worst pain imaginable) on the first postoperative day. Duration of incapacity for work was defined as the time from the date of surgery to the date on which the patient returned to normal activities including employment and leisure activities. Infection was considered as leakage of purulent secretion through the surgical wound and not only peri-incisional hyperemia. At 6 months, we evaluated patient satisfaction with the treatment modality used with a questionnaire including a score ranging from 0 (not satisfied) to 12 (greatly satisfied).
The data collected were tabulated and analyzed by SPSS (Statistical Package for Social Sciences) version 11 on IBM compatible computer. Quantitative data were expressed as mean and SD (X ± SD) and analyzed by applying the Student t-test for comparison of two groups of normally distributed variables. Qualitative data were expressed as number (N) and percentage (%) and analyzed by applying the c2 -test. All these tests were used as tests of significance at P value less than 0.05.
| Results|| |
The study consisted of 30 patients divided into two groups. Patients were followed up for a period of 12 months. The collected results were statistically analyzed as seen in [Table 1] and show significant differences between group 1 and group 2 in terms of duration of operative procedure (min), as group 2 recorded longer operative time than group 1; postoperative complications (infection, flap edema, wound dehiscence), as group 1 recorded postoperative complications more than group 2; and patient satisfaction, as patients in group 2 were more satisfied than patients in group 1 (P < 0.05). No significant differences were found between both groups regarding age and sex distribution, postoperative pain (VAS), length of hospital stay (in days), and duration of incapacity for work (in days) (P > 0.05). Although there was a lower incidence of recurrent disease in the local flaps group approached, they did not quite reach statistical significance compared with the primary direct closure group, and the recurrence rate in the modified Limberg flap group was lower than the recurrence rate in the other flap techniques.
| Discussion|| |
Pilonidal disease is an infection under the skin in the gluteal cleft, which is a common source of morbidity and loss of work productivity in healthy young adults . The origin of pilonidal sinus has been a subject of interest for many years. It was thought to be of congenital origin, but most authors now believe that the majority of pilonidal disease cases are acquired and the result of a foreign body response to entrapped hair . Natal cleft pilonidal disease is prevalent worldwide, although it is probably more common in hot humid regions such as the Middle East and Mediterranean basin. Patients may present after months and even years of repeated episodes of infection, resulting in deep branching tracks and multiple skin pits .
Pilonidal disease presents many therapeutic challenges to surgeons throughout the world. Its varied clinical presentations necessitate a wide range of treatments .
Principles of management need eradication of the sinus tracts, complete healing of the overlying skin, and prevention of reappearance .
A large number of surgical techniques (with varying complexity) have been described in the literature for the treatment of this disease, many of which are unfamiliar to general surgeons. Such diversity suggests that no single technique has emerged as the favorite to prevent recurrence of this condition. These include conservative nonexcisional care, phenol injection, pit excision and tract brushing (Millar-Lord procedure), Bascom procedure, excision and leaving the wound to granulate, excision and marsupialization, excision and primary closure with midline or asymmetric incisions, or excision and closure using local flaps. The latter include Karydakis procedure, rhomboid and Limberg flaps, modified Limberg flap, Z-plasty, V-Y flaps, or other reconstructions. Each method has its own advocates .
In this study, regarding the sex of patients treated with primary direct closure technique, male patients are predominant, nine male patients (60%) and six female patients (40%), which is relatively similar to results reported by Mahdy  in which there were 16 male patients (70%) and six female patients (30%). The mean age in the primary direct closure group was 26.07 ± 5.42 years ranging from 20 to 38 years, which is closely similar to results reported by Mahdy  in which the mean age was 26.3 ± 6.8 years. Regarding the sex of patients treated with local flaps, there are eight male patients (53.3%) and seven female patients (46.7%) with age ranged between 19 and 35 years (23.93 ± 4.85 years), which is different from the results reported by Mahdy  in which there were 28 male patients (70%) and 12 female patients (30%) with a mean age about 28.0 ± 7.7 years.
The duration of surgery in patients treated with primary direct closure was 25-35 min (30.13 ± 4.09 min), which is shorter than that reported in the study by Akca et al.  in which the time was 40-60 min (45 min) but is closely similar to the results reported by Inan et al. , which was 20-45 min (32 min). The duration of surgery in patients treated with local flaps ranged from 30-60 min (40.67 ± 8.21 min), which is relatively similar to results reported by Madbouly  in which the duration of surgery ranged from 40-70 min but is in disagreement with the results by Akca et al.  in which the duration of surgery ranged from 60-73 min (60 min).
The postoperative pain assessed by VAS among group 1 ranged between 3 and 5° (4.2 ± 0.77), which is closely similar to results reported by Akca et al.  in which the postoperative pain (VAS) ranged between 3 and 6°  but is in disagreement with results reported by Mahdy , which was 6.1 (1.2). The postoperative pain (VAS) among group 2 ranged between 3 and 6° (3.8 ± 0.94), which is relatively similar to results reported by Elshazly and Said  in which the postoperative pain (VAS) was 2.1 ± 1.2 but is in disagreement with the results reported by Mahdy , which was 7.4 (1.3).
The mean length of hospital stay in the primary direct closure group ranged between 4 and 5 days (4.4 ± 0.51 days), which is closely similar to results reported by Akca et al.  in which the range was 4-6 days  but is shorter than results reported by Mahdy , which was 3-11 days (4.8 days), relatively longer than that documented by Elshazly and Said  (3.8 ± 1.6), and significantly longer than that documented by Khaira and Brown  (1 day). The mean length of hospital stay following treatment of pilonidal sinus by local flaps ranged between 3 and 12 days (4.13 ± 2.23 days). This is similar to results reported by Akin et al.  of 1-10 days but longer than results reported by Elshazly and Said  in which length of hospital stay was 2.1 ± 1.2 and those reported by Mahdy , which was 2-6 days (2.9 days).
The time off work in patients treated with primary direct closure was 25-40 days (30.67 ± 4.16 days), which is closely similar to results reported by Mentes et al.  (28.6 ± 3.11) and is relatively similar to results reported by Mahdy  of 15-50 days (25.5 days) but is more than results reported by Elshazly and Said  (21.6 ± 3.5). The time to return to work in patients treated with local flaps was 20-45 days (28.67 ± 7.18 days), which is in disagreement with results reported by Mahdy  in which the time was 7-24 days (14.8 days) and by Aslam et al.  in which the time was 21 days.
Regarding the postoperative complications (wound dehiscence, wound infection) of treatment of pilonidal sinus in the primary direct closure group, there were six patients with complete healing without complications (40%), six patients developed wound dehiscence (40%), which is in disagreement with the results by Mahdy  in which there were four patients (20%), and three patients developed wound infections (20%), which is closely similar to results reported by Ertan et al. , 10 patients (20%), and is better than results reported by Mahdy  in which there were five patients (25%). Regarding the postoperative complications (wound dehiscence, wound infection) of treatment of pilonidal sinus in the local flaps group, there were 12 patients with complete healing without complications (80%), one patient developed wound dehiscence (6.7%), which is closely similar to results reported by Mahdy  in which there were two patients (5%) but is in disagreement with results reported by Ertan et al. , which was one patient (2%), and two patients developed wound infections (13.3%), which is relatively similar to results reported by Ersoy et al.  in which there were four patients (8%) but is in disagreement with results reported by Mahdy  in which there were two patients (5%).
Although the scars following pilonidal sinus surgery are frequently hidden beneath clothing, pilonidal disease affects the younger population, and the scars may result in considerable embarrassment. Future studies should investigate the impact of pilonidal sinus surgery on patient satisfaction and the quality of life.
In this study regarding patient satisfaction in the primary direct closure group, they had a score ranging between 7 and 10° (8.2 ± 0.86) and in the local flaps group, they had a score ranging between 6 and 10° (9.2 ± 1.17). Hence, patients in group 2 were more satisfied than patients in group 1.
Regarding postoperative recurrence after primary direct closure during a follow-up period of 12 months, five patients developed postoperative recurrence (33.3%). This result is closely similar to results reported by Bissett and Isbister , which is 33.3%, and is relatively similar to results reported by Mahdy , which is 25%, but is more than results reported by Ertan et al. , which is 12%, and is less than that the results reported by Clothier and Haywood  in which the recurrence rate is 40%. Regarding recurrence after local flaps during a follow-up period of 12 months, two patients developed postoperative recurrence (13.3%). This result is more than results reported by Mentes et al. , which was 7.5%, and by Mahdy , which was 5%. These two cases of recurrence developed as follows: one patient in the classic Limberg flap group developed on the inferior midline and the other one in the V-Y advancement group. There was no recurrence in the modified Limberg flap group. The modified Limberg flap technique appears to provide a more efficient flattening of the natal cleft, including the most inferior part that is inclined to invert toward the anal region. Although there is a lower incidence of recurrent disease in the local flaps group approached, they did not quite reach statistical significance compared with the primary direct closure group.
| Conclusion|| |
On the basis of this study, authors conclude that wide excision with a modified Limberg flap reconstruction is a preferred treatment of the disease. The technique can be mastered easily and provides an effective procedure for primary as well as recurrent disease with few complications, and we suggest carrying out more trials on the flap techniques [Figure 4].
|Figure 4: Postoperative complications in patients included in both groups.|
Click here to view
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abdul-Ghani AK, Abdul-Ghani AN, Ingham Clark CL. Day-care surgery for pilonidal sinus. Ann R Coll Surg Engl 2006; 88:656-658.
Arnold JS. Pilonidal sinus. Ann R Coll Surg Engl 2008; 90:87-88.
Khalil PN, Brand D, Siebeck M, Hallfeldt K, Mutschler W, Kanz KG. Aspiration and injection-based technique for incision and drainage of a sacrococcygeal pilonidal abscess. J Emerg Med 2009; 36:60-63.
Kaymakcioglu N, Yagci G, Simsek A, Unlu A, Tekin OF, Cetiner S, Tufan T. Treatment of pilonidal sinus by phenol application and factors affecting the recurrence. Tech Coloproctol 2005; 9:21-24.
Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir M. Limberg flap procedure for pilonidal sinus disease: results of 353 patients. Langenbecks Arch Surg 2008; 393:185-189.
Shafik A. Electrocauterization in the treatment of pilonidal sinus. Int Surg 1996; 81:83-84.
Lee SL, Tejirian T, Abbas MA. Current management of adolescent pilonidal disease. J Pediatr Surg 2008; 43:1124-1127.
Dalenbäck J, Magnusson O, Wedel N, Rimbäck G. Prospective follow-up after ambulatory plain midline excision of pilonidal sinus and primary suture under local anaesthesia - efficient, sufficient, and persistent. Colorectal Dis 2004; 6:488-493.
Hull TL, Wu J. Pilonidal disease. Surg Clin North Am 2002; 82:1169-1185.
Can MF, Sevinc MM, Yilmaz M. Comparison of Karydakis flap reconstruction versus primary midline closure in sacrococcygeal pilonidal disease: results of 200 military service members. Surg Today 2009; 39:580-586.
Nelson R, Lalonde D. Treatment of the chronic pilonidal sinus wound with a local perforator-assisted transposition flap. Plast Reconstr Surg 2008; 122:47e-49e.
Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, Oguz M. Modified Limberg transposition flap for sacrococcygeal pilonidal sinus. Surg Today 2004; 34:419-423.
Eryilmaz R, Sahin M, Alimoglu O, Dasiran F. Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap. Surgery 2003; 134:745-749.
Khanna A, Rombeau JL. Pilonidal disease. Clin Colon Rectal Surg 2011; 24:46-53.
Bendewald FP, Cima RR. Pilonidal disease. Clin Colon Rectal Surg 2007; 20:86-95.
Marzouk DM, Abou-Zeid AA, Antoniou A, Haji A, Benziger H. Sinus excision, release of coccycutaneous attachments and dermal-subcuticular closure (XRD procedure): a novel technique in flattening the natal cleft in pilonidal sinus treatment. Ann R Coll Surg Engl 2008; 90:371-376.
Mahdy T. Surgical treatment of the pilonidal disease: primary closure or flap reconstruction after excision. Dis Colon Rectum 2008; 51:1816-1822.
Akca T, Colak T, Ustunsoy B, Kanik A, Aydin S. Randomized clinical trial comparing primary closure with the Limberg flap in the treatment of primary sacrococcygeal pilonidal disease. Br J Surg 2005; 92:1081-1084.
Inan A, Surgit O, Sen M, Bozer M, Dener C. One day surgery for pilonidal disease. Bratisl Lek Listy 2011; 112:572-574.
Madbouly KM. Day-case Limberg flap for recurrent pilonidal sinus: does obesity complicate the issue? Am Surg 2010; 76:995-999.
Elshazly WG, Said K. Clinical trial comparing excision and primary closure with modified Limberg flap in the treatment of uncomplicated sacrococcygeal pilonidal disease. Alexandria J Med 2012; 48:13-18.
Khaira HS, Brown JH. Excision and primary suture of pilonidal sinus. Ann R Coll Surg Engl 1995; 77:242-244.
Akin M, Gokbayir H, Kilic K, Topgul K, Ozdemir E, Ferahkose Z. Rhomboid excision and Limberg flap for managing pilonidal sinus: long-term results in 411 patients. Colorectal Dis 2008; 10:945-948.
Aslam MN, Shoaib S, Choudhry AM. Use of Limberg flap for pilonidal sinus - a viable option. J Ayub Med Coll Abbottabad 2009; 21:31-33.
Ertan T, Koc M, Gocmen E, Aslar AK, Keskek M, Kilic M. Does technique alter quality of life after pilonidal sinus surgery?. Am J Surg 2005; 190:388-392.
Ersoy E, Devay AO, Aktimur R, Doganay B, Ozdoðan M, Gündoðdu RH. Comparison of the short-term results after Limberg and Karydakis procedures for pilonidal disease: randomized prospective analysis of 100 patients. Colorectal Dis 2009; 11:705-710.
Bissett IP, Isbister WH. The management of patients with pilonidal disease - a comparative study. Aust N Z J Surg 1987; 57:939-942.
Clothier PR, Haywood IR. The natural history of the post anal (pilonidal) sinus. Ann R Coll Surg Engl 1984; 66:201-203.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]