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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 21-26

Comparison between VY flap and rhomboid flap in the treatment of pilonidal sinus


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menufia, Egypt
2 Department of General Surgery Tala Hospital, Ministry of Health, Egypt

Date of Submission26-Jan-2014
Date of Acceptance01-Apr-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Ibrahim Ayman Ibrahim Saadeldin
Tala-Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155916

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  Abstract 

Objective
The present work was designed to compare a VY flap and a rhombiod flap in the treatment of pilonidal sinus.
Background
The pilonidal sinus is a tract that usually contains hair. It occurs under the skin between the buttocks (the natal cleft) a short distance above the anus. The sinus track traverses in a vertical direction between the buttocks. Rarely, a pilonidal sinus occurs in other sites of the body such as the axilla, groin, interdigital webs, or the feet. The exact cause is not clear. There are various theories. For example, one theory states that the problem may develop from a minor congenital or hereditary abnormality in the skin of the natal cleft, in which the hair grows into the skin rather than outwards.
Materials and methods
We studied 30 patients aged 19-47 years (average, 30 ± 10 years) presenting to the outpatient clinic of El-Menoufia university hospital and El-Helal insurance hospital at Shebin El-Kom with pilonidal sinus from December 2012 and May 2013. The patients were followed up until July 2013.
A total of 15 patients (50%) were treated with a VY flap and 15 (50%) were treated with a dufourmentel flap.
Results
The outcome was successful in 14 of 15 patients who received a VY flap and 15 of 15 patients who received a dufourmentel flap. The operative time is shorter in the VY method than the dufourmentel method (P < 0.05). Hospital stay was shorter in the dufourmentel group than the VY group. The duration of follow-up was 6 months in both groups. Recurrence developed in only one patient from the VY group. Excellent results were more commonly observed in younger patients.
Conclusion
Recovery following treatment with a dufourmentel flap is better than with the other method.

Keywords: Dufourmentel flap, pilonidal disease, VY flap


How to cite this article:
Zeineldin AA, Moustafa AF, Saadeldin IA. Comparison between VY flap and rhomboid flap in the treatment of pilonidal sinus. Menoufia Med J 2015;28:21-6

How to cite this URL:
Zeineldin AA, Moustafa AF, Saadeldin IA. Comparison between VY flap and rhomboid flap in the treatment of pilonidal sinus. Menoufia Med J [serial online] 2015 [cited 2019 Jun 17];28:21-6. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/21/155916


  Introduction Top


In 1833, Herbert Mayo described a cyst that contained hair just below the coccyx. In 1880, Hodge coined the name 'pilonidal' from the Latin words (pilus), which means hair, and (nidus), which means nest. Pilonidal disease includes a spectrum of entities ranging from asymptomatic hair-containing cysts and sinuses to a large abscess in the sacrococcygeal area [1].

A pilonidal sinus may not cause any early symptoms, but some individuals notice a painless lump at first in the affected area. However, in most cases, symptoms develop at some stage in the form of acute or chronic symptoms such as redness, hotness, induration, throbbing pain in acute form or pus formation, and discharge with chronicity [2].

Different techniques have been described for the treatment of pilonidal sinus such as phenol injection, cryosurgery, diathermy coagulation. and simple incision and drainage. Excision either without suture or combined with one of several methods of primary closure is a major alternative. Wide excision and healing by secondary intention is one of the methods of treatment. This operation involves cutting out the sinus but also cutting out a wide margin of skin that surrounds the sinus. The wound is not stitched but just left to heal by a normal healing process (healing by 'secondary intention'). This means that the wound can take several weeks to heal and requires regular dressing until it heals [3].

The dufourmentel flap is a fasciocutaneous flap used to fill rhomboid-like defects. The V-Y advancement flap was originally described by Tranquilli-Leali in 1935, but was first reported in the USA by Atasoy in 1970. Conservative therapy (meticulous hair control by natal cleft shaving and perineal hygiene) effectively controls pilonidal sinus disease (PSD) in nonoperative outpatients [4].

This study reviews the results of the treatment of pilonidal sinus using a VY flap and a dufourmentel flap.


  Materials and methods Top


This is a prospective study that included 30 patients with pilonidal sinus disease who were treated between December 2012 and May 2013 and were followed up until July 2013. They were divided into two groups: VY group included 15 patients and the dufourmentel group includes 15 patients.

Inclusion criteria

  1. Patients of all ages, sexes, and occupations were included.
  2. Only patients with primary pilonidal sinus that was nonrecurrent or uncomplicated were included in the study.


All patients were subjected to the following:

(1) Complete assessment of history:

  1. Personal data (age, sex, occupation, residence, marital status, and habits).
  2. Complaints (in the patient's own words).
  3. Present history (onset, course, and duration of the complaints).
  4. Previous history (the patient was asked about any history of diseases, drugs, and operations).


(2) Complete examination:

  1. General data (weight, height, vital signs, head, chest, heart, abdomen, and pelvis).
  2. Local examination of the site of pilonidal sinus.


(3) Investigations (pretreatment):

  1. Routine laboratory investigations (complete blood count, liver function tests, kidney function tests, coagulation profile, random blood glucose level, chest radiography, and ECG).
  2. Blood grouping, cross-matching.
  3. Fistulogram.


(4) Surgical techniques:

(a) Gluteal V-Y advancement flap:

  1. General or spinal anesthesia can be used. With the patient in a prone jack-knife position, shaving and preparation of the area is carried out. The elliptical excision line is marked with its long axis oriented sagittally. Sinus tracks, side fistulas, cyst walls, and scarified tissue are resected radically; a unilateral V-Y flap is used to cover defects 8-10 cm in diameter. This enables a radical excision with adequate margins of healthy tissue in defects larger than 10 cm.
  2. The flap should be composed of skin, subcutaneous fat tissue, and the underlying gluteal fascia to enable sufficient mobilization of the V-Y advancement flap and wound closure without tension. This part of the flap is undermined and the free end is folded under, creating a double layer of de-epithelized tissue. The double-layered flap area is sutured subcutaneous to the contralateral buttock a few centimeters away from the midline, therefore creating two layers of tissue in the midline and transforming the natal cleft into a shallow groove. After the placement of a suction drain, the wound is closed in layers using nonabsorbable monofilament sutures.


(b) Dufourmentel flap (rhomboid flap of Limberg):

  1. The procedure is performed under general or spinal anesthesia with antibiotic prophylaxis of 1 g third-generation cephalosporin administered intravenously on induction of anesthesia and for 48 h subsequently. Patients are placed in the prone position and the operative area is shaved and prepped. The area to be excised, as well as the flap, is marked out on the skin, as described previously.
  2. An arhomboid incision including the sinus and its extensions is made down to the presacral fascia. The flap is constructed by extending the incision laterally and down to the fascia of the gluteus maximus muscle. The use of the diathermy facilitates the dissection and achieves good hemostasis. The flap is then transposed and the defect is covered. A close-suction drain is placed and the skin is closed with nonabsorbable monofilament interrupted sutures.


(5) Follow-up:

(a) By serial clinical examinations, as a general rule, the patient was seen postoperatively at first 4 weeks, and then at 1-month intervals for 6 months.


  Results Top


In this study, we found that the following.

Demography of patients

There were a total of 30 patients ranging in age between 19 and 47 years, divided into two groups.

The V-Y group included 15 patients (11 men and four women). The dufourmentel group included 15 patients (11 men and four women) [Figure 1],[Figure 2],[Figure 3],[Figure 4] and [Figure 5].

[Table 1] shows a comparison between the VY and dufourmentel groups in terms of sex and age.
Table 1: Age and sex in both groups

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There was no significant difference between the two groups in age and sex (P > 0.05).

Clinical features in both groups

Patients in both groups presented with different clinical features such as multiple sinuses, single sinus, blood-stained discharge, sacrococcygeal swelling, and sacrococcygeal swelling and sinus(s).

[Table 2] shows a comparison between the VY and dufourmentel groups in clinical features.
Table 2: Preoperative presentations

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There was no significant difference between the two groups in preoperative presentations (multiple sinuses, single sinus, blood-stained discharge, sacrococcygeal swelling, and sacrococcygeal swelling and sinus(s) (P > 0.05).

Operative time and hospital stay in both groups

The mean operative time in the V-Y group was 25-30 min compared with 35-40 min in the dufourmentel group. In the dufourmentel group, the range of hospital stay was 2-3 days compared with 2-4 days in the V-Y group.[

[Table 3] shows a comparison between the VY and dufourmentel groups in operative time and hospital stay.
Table 3: Operative time and hospital stay in relation to the type of operation

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It was found that the operative time was significantly shorter in the V-Y group than the dufourmentel group (P < 0.05). The hospital stay was significantly shorter in the dufourmentel group than in the VY group (P < 0.05).

Postoperative complications in both groups

In the dufourmentel group, no patients developed postoperative hemorrhage, whereas one patient had hematoma and wound dehiscence and one patient had wound infection, compared with two patients who had postoperative hemorrhage; no patient developed hematoma and wound dehiscence and one patient had wound infection in the V-Y group.

[Table 4] shows a comparison between the VY and dufourmentel groups in postoperative complications.
Table 4: Postoperative complications in both groups

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There was no significant difference between the two groups in postoperative hemorrhage, hematoma, wound dehiscence, and wound infection (P > 0.05).

Long-term outcome in both groups

Patients in both groups were followed up for 1 year. In the dufourmentel group, two patients had scar pain compared with five patients in the V-Y group. Two patients had local numbness in the dufourmentel group compared with one patient in the V-Y group. One patient developed recurrence in the V-Y group, whereas no patient developed recurrence in the dufourmentel group.

There was no significant difference between the two groups in scar pain, numbness, and recurrence (P > 0.05).

[Table 5] shows a comparison between the VY and dufourmentel groups in terms of long-term outcome.
Table 5: Long-term outcome in both groups

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There was no significant difference between the two groups in scar pain, numbness, and recurrence (P > 0.05).


  Discussion Top


The present work aimed to perform a comparison between VY and dufourmentel flaps in the treatment of PSD and the factors affecting the outcome.

Many authors have discussed the treatment of PSD and the factors affecting the outcome, and most of them reported similar findings.

The various surgical approaches for chronic PSD include curettage of the tract, incision and laying open, wide excision with healing by secondary intention, wide excision with closure of the defect by full-thickness plasty techniques (VY plasty, dufourmentel, or myocutaneous advancement flap, Z plasty), recovery in marsupilization of the skin edges after excision, phenol injection (phenolization), cryosurgery, electrocauterization, and procedures using Nd-YAG or ruby lasers [2].

Several modalities have been implicated in the treatment of pilonidal disease. Surgical treatment should be limited in extent to the least necessary to heal the sinus. Surgical procedures that keep the main wound away from the midline are more successful. Both a V-Y flap and a dufourmentel flap have been suggested and have been favored by surgeons for the management of pilonidal sinus among different operative procedures [5].

A study by Cihan et al. [6] included 40 patients ranging in age between 21 and 50 years, divided into groups. The V-Y group included 18 patients and the dufourmentel group included 22 patients; there were more men in this study (25 : 1) than women. There was no significant difference between the two groups in age and sex.

In our study, there were a total of 30 patients ranging in age between 19 and 47 years, divided into two groups.

The V-Y group included 15 patients (11 men and four women). The dufourmentel group included 15 patients (11 men and four women). There was no significant difference between the two groups in age and sex because of the low number of cases.

Eryilmaz et al. [7] noted that the mean operative time was 25 min in the V-Y group and 45 min in the dufourmentel group. In our study, the mean operative time was 35-40 min in the dufourmentel group compared with 25-30 min in the V-Y group. It is found that the operative time was significantly shorter with the V-Y method.

Wound disruption after the V-Y method has been reported to be ~10% by Giordano in 2003 [4] and 6% by Ertan et al. [5]. Bradley [8] noted that postoperative hemorrhage (4%) and postoperative infection were (10%) encountered with the V-Y method, whereas with the dufourmentel method, a 6% complication rate (infection, disruption, and seroma formation) was observed in patients. Eryilmaz et al. [7] reported that partial stitch disruption occurred in 2.2% of patients and wound seroma in 4.4% of patients with the dufourmentel method, whereas with the V-Y method, postoperative hemorrhage was observed in 7% and wound infection in 25% of the patients. In our study, none of the patients in the dufourmentel group developed postoperative hemorrhage, whereas 1 (6.7%) patient had hematoma and wound dehiscence and 1 (6.7%) patient had wound infection, compared with 2 (13.3%) patients. The level of injury was a very important factor.

Postoperative hemorrhage, no patient had hematoma and wound dehiscence and 1 (6.7%) patient had wound infection in the V-Y group.

Sakarya et al. [9] noted that the mean duration of hospital stay was 6.3 days, duration of healing was 6.7 weeks, and time off work was 25-40 days in the V-Y group. However, in the dufourmentel group, duration of hospital stay was 2-3 days, duration of healing was 2.5 weeks, and time off work was 30-40 days. A shorter duration of hospital stay was documented by Malik et al. [10]: 4-5 days in the V-Y group and 3 days in the dufourmentel group. In our study, in the dufourmentel group, the duration of hospital stay was 2-3 days compared with 3-4 days in the V-Y group; duration of healing showed no difference between the two groups and duration of time off work was 30-45 days compared with 25-35 days in the V-Y group.

A recurrence rate of 13% was recorded by Ertan et al. [5]. However, Al Jaberi [1] recorded a lower recurrence rate (4.3 and 3%, respectively) in the dufourmentel group. Karydakis in 2007 [3] reported a 2.2% recurrence rate and Marzouk et al. [11] reported a 5% recurrence rate with the dufourmentel method. In our study, patients in both groups were followed up for 6 months. In the dufourmentel group, 2 (13.3%) patients developed scar pain compared with 5 (33.3%) patients in the V-Y group. Two (13.3%) patients developed local numbness in the dufourmentel group compared with 1 (6.7%) patient in the V-Y group. One (6.7%) patient developed recurrence in the V-Y group, whereas no patient developed recurrence in the dufourmentel group.

In this comparable study, there was no significant difference among the two groups with the V-Y method and the dufourmentel method with respect to age and sex distribution (P > 0.05). The dufourmentel method has been reported to have a lower recurrence rate, shorter hospital stay, and better esthetic result. With this technique, we can obliterate the natal cleft at the site of the sinus disease and by making the suture line away from the midline, it yields a better result than V-Y methods, especially in terms of postoperative pain and hospital staying. The dufourmentel group showed better clinical results than the V-Y group. The hospital stay for the dufourmentel group was shorter than that of the V-Y group, and the difference was significant (P < 0.05). The duration of operation was also significantly (P < 0.05) shorter in the V-Y group, but time off work was not significant (P > 0.05).

There was no significant difference between the two groups in postoperative hemorrhage, hematoma, and wound dehiscence and wound infection (P > 0.05).

Over a mean follow-up period of 6 months, recurrence developed in one patient treated by the V-Y method; in contrast, there was no recurrence in patients treated by the dufourmentel method. There was no significant difference between the two groups (P > 0.05).

In agreement with our result, Sakarya et al. [9] studied 100 patients with chronic pilonideal sinus who were randomized to receive surgical treatment by the dufourmentel and V-Y method. Each group included 50 patients. The mean duration of follow-up was 15 months. There were significant differences between the two groups in terms of length of hospital stay (P < 0.03) and operative time, but there were no significant differences between the two groups in terms of duration of complete healing, time off work, postoperative infection, and postoperative pain. Shorter hospital stay, low ratio of complications (infection, seroma, disruption), lower pain perception, and improved general health are the main advantages with the use of the dufourmentel method. These parameters contribute toward the patient comfort and satisfaction after surgical treatment.

Similarly, Karydakis in 2007 [3] concluded that the dufourmentel method can be used for the management of primary and recurrent with a low complications rate, short hospital stay (2.5 days), short time to return to normal activity (5 days), low recurrence rate (5%), and good long-term result.

Also, significant disadvantages in terms of postoperative infection rate, mobilization time, discharge from hospital, and time off work were noted for the V-Y method compared with the dufourmentel method. Following a median follow-up period of 5 years, a recurrence rate of 15% was observed in the V-Y group compared with 4.5% in the dufourmentel group. Thus, the recurrence rate in the dufourmentel group was not found to differ significantly from that in the V-Y group (P = 0.259) according to the study by Marzouk et al. [11].


  Conclusion Top


It has lower recurrence rate and better esthetic results.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Al Jaberi TM. Excision and simple primary closure of chronic pilonidal sinus. Eur J Surg 2001; 167 :133-135.  Back to cited text no. 1
    
2.
Al-Khamis A, McCallum I, King PM. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev 2010; 336 :868-871.  Back to cited text no. 2
    
3.
Amir MA. Karydakis operation for chronic pilonidal sinus. Pak J Surg 2007; 23 :65-69.   Back to cited text no. 3
    
4.
Blanco G, Giordano M, Torelli I. Surgical treatment of pilonidal sinus with open surgical technique. Minerva Chir 2003; 58 :181-187.   Back to cited text no. 4
    
5.
Ertan T, Koc M, Gocmen E. Does technique alter quality of life after pilonidal sinus surgery?. Am J Surg 2005; 190 :388-392.  Back to cited text no. 5
    
6.
Cihan A, Chintapatla S, Safarani N, Kumar S. Sacrococcygeal pilonidal sinus: pathological insight and surgical options. Tech Coloproctol 2003; 7 :3-8.  Back to cited text no. 6
    
7.
Eryilmaz R, Sahin M, Alimoglu O. Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap. Surgery 2003; 134 :745-749.  Back to cited text no. 7
    
8.
Bradley L. Pilonidal sinus disease: A misunderstood problem. Wounds 2006; 2 :45-50.  Back to cited text no. 8
    
9.
Sakarya A, Dirlik M, Caglikulekci M, Turkmenoglu O. Gluteal V-Y advancement fasciocutaneous flap for treatment of chronic pilondial sinus disease. Scand J plast Reconstr Surg Hand Surg 2001; 36 :80-84.  Back to cited text no. 9
    
10.
Malik AM, Parracha VI, Tamimy MS. Ideal treatment for chronic pilonidal sinus. Pak Armed Forces Med J 2002; 52 :168-173.  Back to cited text no. 10
    
11.
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 2006; 90 :371-376.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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