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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 539-544

Comparative study between the Karydakis technique and the Limberg flap in pilonidal sinus


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Shebin El-Kom Teaching Hospital, Shebin Elkom, Egypt

Date of Submission05-Jun-2014
Date of Acceptance02-Nov-2014
Date of Web Publication23-Jan-2017

Correspondence Address:
Mahmoud A Abo Zaid
43 Anwar El-Sadat St., El-Helw, Tanta, Gharbia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.198696

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  Abstract 

Objective
A comparative study was carried out between the Karydakis technique and the Limberg flap in the management of sacrococcygeal pilonidal disease.
Background
Pilonidal sinus is a sinus tract that commonly contains hairs under the skin between the buttocks a short distance above the anus, but can occur elsewhere in the body. The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare the results of both the Karydakis technique and the Limberg flap.
Patients and methods
This study included 13 patients with sacrococcygeal pilonidal sinus disease who were assigned randomly. Fifteen patients were subjected to the Karydakis technique and 15 patients received the Limberg flap.
Results
Our study showed that the time to removal of stitch in the Karydakis group was 12.26 ± 1.66, whereas in the Limberg group, it was 13.66 ± 1.29 (longer in group that received the Limberg flap; P = 0.016). The percentage of complete healing in the Karydakis group was 80%, whereas that in the Limberg group was 66.7% (no significant difference; P ≥ 0.05). Postoperative wound breakdown in the Karydakis group was 13.3%, whereas that in the Limberg group was 26.7% (no significant difference; P ≥ 0.05). Recurrence was 6.7% in the Karydakis group, whereas it was 6.7% in the Limberg group (no significant difference; P ≥ 0.05). The time to return to work was 21.73 ± 6.49 in the Karydakis group, whereas in the Limberg group, it was 28.66 ± 7.50 (longer in the Limberg flap group; P = 0.012), and the duration of surgery in the Karydakis group was 37.73 ± 12.98, whereas that in the Limberg group was 61.60 ± 11.11 (longer in the Limberg flap group; P ≤ 0.001).
Conclusion
The Karydakis flap procedure had many advantages over the Limberg flap for the treatment of uncomplicated pilonidal sinus because of its lower postoperative complication rate, time to removal of stitches, time to return to work, and duration of surgery. However, there was no difference between the two surgical procedures in terms of prevention of recurrence.

Keywords: complication, Karydakis technique, Limberg flap, recurrence, sacrococcygeal pilonidal sinus


How to cite this article:
Kohla SM, Alsesy AA, Abd El-Aziz TF, Mohammed MA, Abo Zaid MA. Comparative study between the Karydakis technique and the Limberg flap in pilonidal sinus. Menoufia Med J 2016;29:539-44

How to cite this URL:
Kohla SM, Alsesy AA, Abd El-Aziz TF, Mohammed MA, Abo Zaid MA. Comparative study between the Karydakis technique and the Limberg flap in pilonidal sinus. Menoufia Med J [serial online] 2016 [cited 2020 Mar 29];29:539-44. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/539/198696


  Introduction Top


Sacrococcygeal pilonidal disease is a chronic inflammation and infection of the sacrococcygeal region. It is a common condition that occurs mostly among young adults after puberty and usually presents as an abscess or a painful sinus tract on the natal cleft with chronic seropurulent discharge [1] .

Although many surgical and nonsurgical treatment methods have been described for the treatment of the disease, from phenol application to complex advanced flap mobilization, an optimal treatment has not been established because of the high complication and recurrence rates [2] . Most authors have accepted that pilonidal sinus is an acquired condition that cannot be treated by traditional surgical and nonsurgical interventions. In this respect, modification of the natal cleft and lateralization of the scar from the midline are the most important factors to eliminate the essential causative factors of pilonidal sinus disease. Thus, the aim of the present study is to compare the Karydakis technique and the Limberg flap.


  Patients and methods Top


Thirty patients with pilonidal disease were included in this prospective study from April 2012 to December 2013 and were divided randomly into two groups:

Group 1: this group included 15 patients who were subjected to the Karydakis flap technique.

Group 2: this group included 15 patients who were subjected to the Limberg flap technique.

Group 1: the Karydakis flap

An asymmetrical elliptical incision was made. The cranial and caudal tips of the incision were placed at opposite sides of the perianal opening. The ellipse was based only on the pits in the vicinity of the midline. The incision covered lateral secondary openings. Under the guidance of methylene blue, both sides of the elliptical incision were deepened into the gluteal fascia. The flap was prepared as described by Karydakis. The flap was then sutured with polyglycolic acid sutures in two layers, and a suction drain was placed. Finally, the perianal incisions were closed separately with a 3-0 polypropylene suture.

Group 2: the Limberg flap

A rhombus, including the pilonidal sinus and the flap line, was marked on the skin using a sterile skin-marking pen. Under the guidance of methylene blue, the rhombus was excised down to the presacral fascia and the fasciocutaneous flap was transposed medially so that the defect would be covered without any tension. The size of the prepared flap was equal to that of the rhomboid area. A suction drain was placed beneath the flap through a separate stab incision, and subcutaneous tissue was approximated with polyglycolic acid sutures. The skin was closed separately using 3-0 polypropylene sutures. For both procedures, the suction drain was removed on the third or the fourth postoperative day depending on the amount and duration of drainage. The duration of surgical drainage was the same as the period of stay in the hospital. The sutures were removed between the 10 th and 13 th postoperative day.

Patient age, sex, symptoms, type of procedure, operation time, length of hospital stay, access to normal daily activity, time of wound healing, postoperative complications, cosmetic dissatisfaction (postoperative third month) pain when sitting (postoperative 15 th and 30 th days), time of recurrence (months), and the mean follow-up period (months) were recorded.

The results obtained were analyzed statistically and the two groups were compared taking the following into consideration: obesity (BMI), clinical features, preoperative imaging studies (sinogram), duration of operative procedure, patients' activities postoperatively, postoperative hospital stay, and time to removal of stitch. The required time for complete healing, postoperative complications, and time off work were also recorded.

Statistical analysis

Results were collected, tabulated, and analyzed statistically using an IBM, NY, USA personal computer and SPSS (version 16; SPSS Inc., Chicago, Illinois, USA). Two types of statistics were calculated:

  1. Descriptive: for example, percentage, mean, and SD
  2. Analytical:
    1. Mann-Whitney test: This is a nonparametric test of Student's t-test. It is used to collectively indicate the presence of any significant difference between two groups for a non-normally distributed quantitative variable
    2. Fisher's exact test: This is used to compare between two groups or more for one qualitative variable in a 2 × 2 contingency table.


P value

A P value of less than 0.05 was considered significant, a P value was more than 0.05 was considered nonsignificant, and a P value was less than 0.001 was considered highly significant.


  Results Top


This study included 30 patients who had sacrococcygeal pilonidal sinus; they were divided into two groups and each group included 15 patients.

Our study showed that the duration of surgery in the Karydakis group was 37.73 ± 12.98, whereas in the Limberg group, it was 61.60 ± 11.11; this was a significant difference as shown in [Table 1].
Table 1 Comparison between two methods of closure in terms of duration of surgery and time to return to work


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For wound healing, the time of healing in the Karydakis group was 31.26 ± 15.31, whereas in the Limberg group, it was 32.20 ± 14.64; this was not a significant difference as shown in [Table 2].
Table 2 Comparison between two methods of closure in terms of wound healing


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The time taken to remove stitches in the Karydakis group was 12.26 ± 1.66, whereas that in the Limberg group was 13.66 ± 1.29; this was a significant difference as shown in [Table 2].

In terms of return to work, the time in the Karydakis group was 21.73 ± 6.49, whereas that in the Limberg group was 28.66 ± 7.50; this was a significant difference as shown in [Table 1].

In terms of postoperative complications, complete healing was achieved in the Karydakis group in 80% of patients, whereas in the Limberg group, complete healing was achieved in 66.7% of patients; the prevalence of wound breakdown in the Karydakis group was 13.3%, whereas that in the Limberg group was 26.7%. The rate of recurrence in the Karydakis group was 6.7%, whereas that in the Limberg group was 6.7%; this was not a significant difference as shown in [Table 3].
Table 3 Comparison between two methods of closure in terms of postoperative complications


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In this study, no significant difference was found between both methods in age, sex, obesity, clinical presentation, preoperative sonogram, first time to mobilization following surgery, hospital stay, time of wound healing, recurrence, postoperative complications, and percentage of complete healing.

A significant difference was found between both groups in duration of surgery, time to removal of stitches, and time to  return to work ([Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]).
Figure 1: Distribution of the studied groups in the duration of operation.

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Figure 2: Distribution of the studied groups in the time to removal of stitches.

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Figure 3: Distribution of the studied groups in time to return to work.

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Figure 4: The previous patient undergoing a rhomboid incision.

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Figure 5: Closure of subcutaneous tissue and skin with drain insertion.

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Figure 6: Assymtrical elliptical incision.

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Figure 7: Closure of wound and insertion of the drain (arrows indicates distance to mid-line).

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  Discussion Top


A comparative study was carried out between two methods of surgical treatment for chronic pilonidal sinus disease.

Pilonidal sinus occurs most commonly in young adult males with dark, dense, and strong hair after puberty aged 15-30 years and is rare in individuals older than 40 years of age [3] .

In this study, in terms of the sex of patients treated with the Karydakis technique, males were predominant, which is in close agreement with the results reported by Akca et al. [4] and Mahdy et al. [5] .

In this study, the mean age of the patients in the Karydakis group ranged from 18 to 25 years, which is similar to the results reported by  Tavassoli et al. [6] , but less than that  reported by Akca et al. [4] and Al Traifi et al. [7] .

In this study, in terms of the sex of the patients treated with rhomboid closure, males were predominant, which is in close agreement with the results reported by Akca et al. [4] and also similar to the results reported by Mahdy et al. [5] .

In this study, the mean age of patients treated with the Limberg flap was 19-32 years, which is higher than the results reported by Mahdy et al. [5] and is similar to the results reported by Al Traifi et al. [7] .

In this study, according to the BMI of patients treated with the Karydakis technique, six patients were obese and four patients were overweight, which is less than the results reported by Cubukcu et al. [8] and Al Traifi et al. [7] , but more than that reported by Akinci et al. [9] .

In this study, in terms of the BMI of the patients treated with the Limberg flap, six patients had normal weights, four patients were overweight, and five patients were obese, which is not in agreement with the results of Cubukcu et al. [8] , Akinci et al. [9] , and Al Traifi et al. [7] .

In this study, in terms of the clinical presentation of patients treated with the Karydakis technique, three patients presented with pain, four patients presented with discharge, two patients presented with fibrous band, and six patients presented with pain and discharge, which is not in agreement with the results of Al Traifi et al. [7] .

In this study, in terms of the clinical presentation of patients treated with the Limberg flap, four patients presented with pain, three patients presented with discharge, one patient presented with fibrous band, and seven patients presented with pain and discharge, which is not in agreement with the results of Al Traifi et al. [7] and Mahdy et al. [5] .

In this study, in terms of the sonogram in patients treated with the Karydakis technique, 15 patients underwent a sinogram that showed a pilonidal sinus in the sacrococcygeal area, which is not in agreement with the result of Al Traifi et al. [7] .

In this study, according to the sinogram in patients treated with the Limberg flap, in 15 patients had a pilonidal sinus in the sacrococcygeal area, which is not in agreement with the result of Al Traifi et al. [7] .

In this study, the duration of surgery in patients treated with the Karydakis technique is similar to that reported by Ates et al.[10] and that reported by Can et al. [11] .

In this study, the duration of surgery in patients treated by the Limberg flap is longer than that reported by Can et al. [11] and longer than that reported by Ates et al. [10] .

In this study, the first time to mobilization following surgery of patients treated with the Karydakis technique is 1-3 days after surgery, similar to the results reported by Mahdy et al. [5] , but longer than the results reported by Ates et al. [10] .

In this study, the first time to mobilization following surgery of patients treated with the Limberg flap was 1-3 days, which is not in agreement with the result reported by Mahdy et al. [5] and by Ates et al. [10] .

In this study, the mean hospital stay with the use of the Karydakis technique is shorter than the results reported by Can et al. [11] and similar to the results reported by Ates et al. [10] .

In this study, the mean hospital stay with the use of the Limberg flap is similar to the results reported by Ates et al. [10] and shorter than the results reported by Can et al. [11] .

In this study, the mean time of wound healing in the treatment of pilonidal sinus with the Karydakis technique is longer than the results reported by Mahdy et al. [5] and Al Traifi et al. [7] .

In this study, the mean time of wound healing in the treatment of pilonidal sinus by the Limberg flap is longer than the results reported by Mahdy et al. [5] and by Akca et al. [4] .

In this study, the time to removal of stitches following the treatment of pilonidal sinus by the Karydakis technique was shorter than the results reported by Mahdy et al. [5] .

In this study, the time to removal of stitches following the treatment of pilonidal sinus by the Limberg flap is shorter than the results reported by Aslam et al. [12] .

In this study, the postoperative complications of the treatment of pilonidal sinus by the Karydakis technique were not in agreement with the results reported by Ates et al. [10] .

In this study, the postoperative complications of the treatment of pilonidal sinus by the Limberg flap were not in agreement with the results reported by Ates et al. [10] and by Madbouly [13] .

In this study, the time off work in patients treated with the Karydakis technique was longer than that reported by Ates et al. [10] and similar to that reported by Akca et al. [4] .

In this study, the time off work in patients treated with the Limberg flap was longer than that reported by Ates et al. [10] , and not in agreement with the results reported by Mahdy et al. [5] .


  Conclusion Top


The Karydakis technique can be used in the successful management of pilonidal sinus and is superior to the Limberg flap in time to removal of stitches, time to return to work, and duration of surgery.

The Karydakis flap is characterized by early removal of stitches, early return to work, and shorter duration of operation.

The Limberg flap is longer in terms of duration of operation, removal of stitches, and return to work.

The results of our study support the Karydakis technique and Limberg flap as a preferred treatment of the disease. The technique can be mastered easily and represents an effective procedure for primary as well as recurrent disease, with few complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Petersen S, Koch R, Stelzner S, Wendlandt TP, Ludwig K. Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Dis Colon Rectum 2002; 45 : 1458-1467.  Back to cited text no. 1
    
2.
Søndenaa K, Nesvik I, Andersen E, Natås O, Søreide JA. Bacteriology and complications of chronic pilonidal sinus treated with excision and primary suture. Int J Colorectal Dis 1995; 10 : 161-166.  Back to cited text no. 2
    
3.
Abu Galala KH, Salam IM, Abu Samaan KR, El Ashaal YI, Chandran VP, Sabastian M, Sim AJ. Treatment of pilonidal sinus by primary closure with a transposed rhomboid flap compared with deep suturing: a prospective randomised clinical trial. Eur J Surg 1999; 165 : 468-472.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
Mahdy T, Mahdy T, Gaertner WB, Hagerman GF, Goldberg SM, Finne CO III. Surgical treatment of the pilonidal disease: primary closure or flap reconstruction after excision. Dis Colon Rectum 2008; 51 : 1816-1822.  Back to cited text no. 5
    
6.
Tavassoli A, Noorshafiee S, Nazarzadeh R. Comparison of excision with primary repair versus Limberg flap. Int J Surg 2011; 9 : 343-346.  Back to cited text no. 6
    
7.
Al Traifi H, Anwar KS, Ashraf M. Clinical features and surgical management of sacrococcygeal pilonidal sinus: experience of a peripheral hospital in Saudi Arabia. World J Colorectal Surg 2008; 1:7.  Back to cited text no. 7
    
8.
Cubukcu A, Carkman S, Alponat A. Lack of evidence that obesity is a cause of pilonidal sinus disease. Eur J Surg 2011; 167 :297-298.  Back to cited text no. 8
    
9.
Akinci OF, Bozer M, Uzunköy A, Düzgün SA, Coºkun A. Incidence and aetiological factors in pilonidal sinus among Turkish soldiers. Eur J Surg 1999; 165 :339-342.  Back to cited text no. 9
    
10.
Ates M, Dirican A, Sarac M, Aslan A, Colak C. Short and long-term results of the Karydakis flap versus the Limberg flap for treating pilonidal sinus disease: a prospective randomized study. Am J Surg 2011; 202 : 568-573.  Back to cited text no. 10
    
11.
Can MF, Sevinc MM. The pilonidal sinus disease. Am J Surg: 2010; 200 :318-327.  Back to cited text no. 11
    
12.
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.  Back to cited text no. 12
    
13.
Madbouly KM. Day-case Limberg flap for recurrent pilonidal sinus: does obesity complicate the issue?. Am Surg 2010; 76 : 995-999.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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