Surg Today (2010) 40:757–762DOI 10.1007/s00595-008-4098-7

Reprint requests to: M. Akin, Ayten Sok.12/14, Mebusevler, Tandogan 06580, Ankara, TurkeyReceived: May 7, 2008 / Accepted: December 8, 2008

Original Article

Comparison of the Classic Limberg Flap and Modifi ed Limberg Flap in the Treatment of Pilonidal Sinus Disease: A Retrospective Analysis of 416 Patients

MURAT AKIN1,2, SEZAI LEVENTOGLU

1, B. BULENT MENTES1, HASAN BOSTANCI

1, HAKAN GOKBAYIR2, KADIR KILIC

2, ERSIN OZDEMIR

2, and ZAFER FERAHKOSE1,2

1 Department of General Surgery, Gazi University Medical School, Ankara, Turkey2 Department of General Surgery, Bayindir Medical Center, Ankara, Turkey

AbstractPurpose. Pilonidal sinus disease (PSD) is usually seen on the sacrococcygeal region in adolescent patients. The current study analyzed the outcome of the rhomboid excision and the Limberg fl ap procedure (cLF) in com-parison to the modifi ed Limberg fl ap procedure (mlF) for PSD.Methods. Four hundred and sixteen patients with PSD were operated on under spinal or general anesthesia by cLF and mlF. The patients were divided into two groups. In Group 1, cLF was performed on 211 patients. In Group 2, mlF was performed on 205 patients.Results. No signifi cant difference was detected between Groups 1 and 2 in terms of sex, age, preoperative disease period, follow-up time, the mean hospital stay, and hypoesthesia. The mlF group had better clinical results than the cLF group. The recurrence rate was statistically higher in the cLF group 1 than in the mlF group (P = 0.036). The time to return to work, time to walk without pain, and time to be able to sit on the toilet without pain were longer in the cLF group (P = 0.001). The macera-tion and wound infection rate were statistically higher in the cLF group than in the mlF group (P = 0.020 and P = 0.019, respectively).Conclusion. The mlF is a more effective treatment than cLF for the surgical management of PSD.

Key words Pilonidal sinus · Modifi ed Limberg fl ap · Maceration · Recurrence

Introduction

Pilonidal sinus disease (PSD) is a common condition that affects younger patients, and occurs predominantly

in the sacrococcygeal region. However, it has also been reported to occur in the axilla, suprapubic area, and periumbilical zone.1,2 Rare occurrences such as in a fi n-gertip pulp, penis, and in the ends of amputated extremi-ties have been reported.3–5 Pilonidal sinus disease typically affects young male patients after puberty. It appears to have a higher frequency in males (male/female ratio 3–4 : 1).1,5

Although many surgical and nonsurgical methods have been proposed, no clear consensus as to optimal treatment has been reported so far in the literature.6 Conservative nonsurgical management (including phenol application, cryosurgery, and shaving), a limited excision, excision with marsupialization, wide excision and primary closure, and most recently, fl ap surgery have been utilized in the treatment of this disease.7–11 Different types of fl aps have been used in the treatment of PSD. The rhomboid excision and Limberg fl ap pro-cedure (cLF) was described more than 20 years ago.6 It is an effective surgical method for PSD, associated with a low complication rate, short time for returning to normal activity, and short hospitalization.7,12 However, in the cLF the lower part of the suture line is placed in the intergluteal sulcus. After surgery, recurrences may be caused by the presence of a wound scar and macera-tion in the midline acting as a portal for hair entry.13 Therefore, a simple modifi cation of the Limberg fl ap to eliminate inferior midline maceration and recurrence has been suggested. The modifi ed Limberg fl ap proce-dure (mlF) is easy to design and simple to perform, provided that its placement is correctly chosen.14 The aim of this study was to perform a retrospective analysis to compare the results of cLF with the mlF.

Patients and Methods

In this study, patients who had undergone the two dif-ferent surgical treatment methods due to PSD were

758 M. Akin et al.: Classic and Modifi ed Limberg Flap

retrospectively analyzed. The study was performed by two teams, one of which preferred the Limberg fl ap procedure (cLF), the other claiming that the modifi ed Limberg fl ap procedure (mlF) yields better results.

These teams worked in different polyclinics. The patients were treated by the team that was chosen by the patients. During the application, the patients were free to choose the team they wanted. The medical records of 476 patients who underwent surgery between March 2001 and August 2006 for PSD at the General Surgery Departments of Gazi University Medical School and Bayindir Hospital were reviewed for the treatment option, the mean hospital stay (days), mac-eration rate, wound infection rate, hypoesthesia, time to return to work, time to walk without pain (days), time to sitting on the toilet without pain (days), and recurrence rate. A follow-up period of at least 12 months was included. Sixty of the 476 patients could not be fully followed up so they were excluded. There-fore, 416 patients were eventually enrolled in this study. The patients were divided into two groups. In Group 1, a cLF was performed on 211 patients. In Group 2, an mlF was performed on 205 patients. Clinical pre-sentation included in Group 1 and Group 2, respec-tively: pilonidal abscess (8% and 9%), sinus with chronic suppurative discharge (55% and 58%), a more complex disease with lateral sinuses (25% and 22%), recurrent disease (4% and 5%), and a simple nonin-fected sinus with minimal discharge (8% and 6%). Preoperatively, the infected pilonidal abscesses under-went a simple incision and were treated with antibiotics before the surgical procedure. All patients were oper-

ated on either by or under the supervision of the same surgeon (Z.F.)

Operative Technique

Following medical evaluation, the patients were admit-ted to the hospital the night before operation. Rectal cleansing with an enema was performed 4 h preopera-tively. All patients received sulbactam–ampicillin (1 g intravenously) for prophylaxis immediately before the operation. Under general (81 cases) or spinal (335) anesthesia (the types of anesthesia were chosen accord-ing to the patient’s request), the patients were placed in a jack-knife position. The area was exposed by lateral traction of the buttocks with adhesive tape. Appropriate cleansing of the surgical area was performed with povi-done–iodine solution. Methylene blue, 1–3 ml, was injected through the sinus tracts to mark all branches of the sinus. All sinus tracts were resected en bloc with a rhomboid excision (Fig. 1A). Next, a Limberg fl ap was prepared from the right or left gluteal region. The fl ap included the skin, subcutaneous tissue, and fascia of the gluteal muscle. After careful hemostasis, a suction drain was placed on the presacral fascia. The Limberg fl ap was secured with deep, interrupted 2-0 Vicryl sutures passing through the fl ap and the edges of the defect. The subcu-taneous layer was approximated with 3-0 Vicryl inter-rupted sutures (Fig. 1B). In the mlF, the excision is extended laterally 2–2.5 cm to the level of the postsacral area (Fig. 2). All sinus tracts and diseased area were resected en bloc with a rhomboid excision. The con-

Fig. 1. A, B Classical rhomboid excision and the Limberg fl ap (cLF). C, D Modi-fi ed rhomboid excision and the Limberg fl ap (mlF)

M. Akin et al.: Classic and Modifi ed Limberg Flap 759

structed fl ap, incorporating the gluteal fascia, and the anatomic bands between the rectum and dermis of the lower midline sulcus were fully mobilized on the infe-rior edge and transposed medially to fi ll the Limberg defect. To remove the midline gap and to transpose the fl ap to the contralateral side rather than to the midline, the lower pole of the incision was placed on the contra-lateral side of the elevated fl ap. This way there was no incision on the lower intergluteal sulcus.7,13 The skin was closed with polypropylene sutures or skin staplers (Fig. 1C,D). The drains were removed after drainage decreased to less than 30 ml/day. In the case of wound infection or hematoma, the wound was drained by the removal of a few sutures, covered with daily dressings, and oral sulbactam–ampicillin was given for 7 days. On the 5th postoperative day, patients were called for control and on the 10th postoperative day, the sutures were removed. Follow-up examinations were made at the end of the 1, 6, 12, and 24 months after surgery. After the second year, patients were contacted by phone and asked whether they had any problems. Finally, all patients were interviewed by phone in August 2007. Sixty of the 476 patients could not be fully followed up so they were excluded. Follow-up phone calls were suc-cessful in 87.3% of the patients.

Statistical Analysis

The statistical software package SPSS (Statistical Package for the Social Science) v. 11.0 for Windows (SPSS, Chicago, IL, USA) was used for all analyses. The signifi cances of differences between the groups were compared using the chi-squared test, Fisher’s exact test, and Student’s t-test. Probabilities of less than 0.05 were considered to be signifi cant.

Results

Group 1 included 185 male and 26 female patients with a mean age of 29.95 ± 6.73 (range 17–46), and Group 2 had 180 male and 25 female patients with a mean age of 28.59 ± 6.47 (range 17–50) years. There was no distinc-tion in the selection between the patients for obesity (body mass index), excessive hairiness, perspiration, adiposity, insuffi cient body hygiene, deep natal cleft, or excessive exercise. All patients were followed up for longer than 12 months, the mean follow-up period being 42.25 ± 1.4 months (range 12–60 months). There were neither anesthetic or surgical deaths nor major compli-cations. There were no statistically signifi cant differ-ences between the groups with respect to sex distribution, age, preoperative disease period, follow-up time, mean hospital stay, and hypoesthesia. The results are shown in Tables 1 and 2. The time to return to work, time to walk without pain, and time to be able to sit on the toilet without pain were longer in Group 1 (P = 0.001). The maceration and wound infection rate were statistically higher in Group 1 than in Group 2 (P = 0.020, P = 0.019, respectively). All of the macerations were detected on the lower part of the incision left on the intergluteal sulcus, and infections appeared subsequent to macera-tion (Fig. 3). The recurrence rate was statistically higher in Group 1 than in Group 2 (P = 0.036). Recurrence was detected in 10 patients (4.73%) in group 1, with time to recurrence of between 5 and 10 months. In 80% (8/10) of the patients, recurrences were detected in the inferior part of the suture line. Recurrence was detected in 2 patients (0.97%) in Group 2, with time to recurrence of between 18 and 26 months, and no recurrences were detected in the inferior part of the suture line.Fig. 2. Drawing of the classic and modifi ed Limberg fl aps

Table 1. Baseline characteristics of the patients

Limberg fl ap(Group 1, n = 211)

Modifi ed Limberg fl ap(Group 2, n = 205) P value

Age (years) 29.95 ± 6.73 28.59 ± 6.47 0.831Male/female ratio 185/26 180/25 0.968Disease duration (months) 23.32 ± 4.12 21.45 ± 4.31 0.240Follow-up (months) 37.93 ± 13.49 45.07 ± 13.34 0.729Mean hospital stay (days) 2.74 ± 0.8 2.18 ± 0.9 0.350

760 M. Akin et al.: Classic and Modifi ed Limberg Flap

Discussion

Pilonidal sinus disease is a common and well-recognized entity. In 1833 Herbert Mayo described a hair-contain-ing sinus but not until 1880 did Hodge suggest the term pilonidal, to indicate a disease consisting of hair-con-taining sinus in the sacrococcygeal area.1 The etiology of PSD is uncertain. It was thought to be of congenital origin, but now most experts believe it to be mainly the result of acquired conditions.15 Risk factors include adi-posity, insuffi cient body hygiene, excessive hairiness, and perspiration. Absence of a clear understating of the exact etiology explains the diversity and failure of the current treatment options. Pilonidal sinus disease and its recurrences most commonly occur in the midline. Factors related to the development of the disease include puberty, hirsuteness, moderate obesity, vacuum effect, and deep intergluteal sulcus.13,16

Pilonidal sinus disease is usually associated with fre-quent inability to work and discomfort. Patients with PSD frequently present with symptomatic pits or holes in the natal cleft. The most common presentation is of

a chronic or recurrent sinus. Sondenaa et al. noted dis-charge in 66%, swelling in 50%, and pain in 35% of chronic PSD presentations.17 Half of all patients present with an abscess and can present with progressive dis-comfort or pain after physical activity or a period of prolonged sitting.18

Management of PSD remains controversial. Different surgical and nonsurgical methods have been tried for the treatment of PSD and no “gold standard” treatment has yet been described.2 Conservative approaches such as weekly shaving of the involved areas may control the progression of PSD, but surgical treatment is often required since supervening infections are inevitable in most of the cases.19 Marsupialization provides a smaller wound to granulate. It is also associated with a low recurrence rate, but the healing time is as long as 4–5 weeks, and patients need to change multiple wound dressings.11,20 The most effective treatment modality is a wide excision of the sinus tract. Excision and primary closure have both advantages and disadvantages, includ-ing rapid healing and short time off from work, and increased risk of wound dehiscence and considerable pain at the surgical site. In addition, high recurrence rates of up to 15%–25% have been reported.21 There-fore, asymmetric or oblique incision and excision tech-niques have been introduced during last 2–3 decades to avoid the problems believed to be associated with a midline scar.19 Bascom22 advocated placing a lateral inci-sion 2.5 cm from the midline and cutting a 1.0-cm button of skin to prevent premature resealing. Furthermore, in 7 days he continues with a defi nitive excision of the midline pits, which become visible at this time. Bascom’s suggested technique is an attractive, safe, and easily per-formed operation with minimal morbidity, and can be reliably used as a second-line surgical option for recur-rent pilonidal sinus disease. However, because of the use of a limited excision, both of these techniques seem to be inappropriate for patients with complex and exten-sive involvement.1,22,23

An ideal operation should minimize the fi nancial cost to the community as well as the patient (e.g., treatment effi ciency, earlier return to work), should not require a

Table 2. Postoperative outcomes and complications

Limberg fl ap(Group 1, n = 211)

Modifi ed Limberg fl ap(Group 2, n = 205) P value

Maceration 19 (9.04%) 4 (1.95%) 0.020Infection 13 (6.16%) 3 (1.46%) 0.019Hypoesthesia 19 (9.04%) 17 (8.29%) 0.862Mean time off work (days) 9.81 ± 3.34 8.18 ± 2.42 0.001Time to walk without pain (days) 13.47 ± 4.77 9.85 ± 2.89 0.001Time to be able to sit on the toilet without pain (days) 16.15 ± 4.74 12.87 ± 3.76 0.001Recurrence 10 (4.73%) 2 (0.97%) 0.036

Fig. 3. Maceration and recurrence in the lower part of the incision in the classic Limberg fl ap

M. Akin et al.: Classic and Modifi ed Limberg Flap 761

prolonged hospital stay, should have a low recurrence rate, should cause minimal pain, should be associated with a low complication rate, and should be simple. Post-operative morbidity and patient comfort are important considerations. Extensive disease with numerous piloni-dal sinus openings, branching tracts, and overt symp-toms may require wide excision of the diseased region.13 Postoperative recurrences and complications develop in the midline and as the natal cleft become deeper. Simple excisional techniques are associated with high recur-rence and morbidity owing to the continuing presence of the natal cleft. The problems related to continuing natal cleft after pilonidal sinus surgeries have prompted surgeons to discover new techniques to eliminate gluteal furrow. To eliminate the natal cleft, various fl ap tech-niques such as the Limberg fl ap, Z-plasty, W-plasty, V-Y advancement fl ap, and rotating fl ap have been used.12,24 In all kinds of excision plus fl ap procedures for PSD, recurrences rates are between 1% and 7% in the literature.7,12,13 cLF has been reported to have lower infection and recurrence rates. However, longer hospital stays, a high maceration rate, hypoesthesia, and an unat-tractive cosmetic appearance are associated with this technique.

When the midline is lateralized or fl attened, recur-rences are less likely to occur than primary closure or other methods that fail to reconstruct the intergluteal sulcus. The only weak point we can fi nd with cLF is that the lower pole of the fl ap stays within the intergluteal sulcus.7,13 Therefore, this fl ap reconstruction was modi-fi ed by tailoring the rhomboid excision asymmetrically to place the lower pole of the fl ap lateral to the inter-gluteal sulcus. This study compared the cLF to the mlF for the treatment of PSD. The patients were similar in the two groups with respect to age, sex, and duration of PSD. The mlF group (Group 2) had better clinical results than the cLF group (Group 1). The mlF decreased the recurrence rate (0.97%), maceration rate (1.95%), and wound infection rate (1.46%) signifi cantly. mlF caused restriction of activity because of tissue tension and maceration. Most complaints by patients after pilo-nidal sinus surgery are caused by wound tenderness.24 In addition, the present study confi rmed a signifi cantly shorter time to return to work, time to walk without pain, and time to be able to sit on a toilet without pain in patients treated with mlF.

The mean hospital stay in the current study for Group 1 was 2.74 ± 0.8 days (range 1–6) and the mean hospital stay was 2.18 ± 0.9 days (range 1–5) in Group 2, and the difference between the groups was not signifi cant (P = 0.350). The hospital stay was also in accordance with the literature.7,14 In this study, anesthesia or hypoesthesia occurred on the upper portion of fl ap in 36 (8.65%) patients (in Group 1: 19, in Group 2: 17), which was permanent in 6 and 5 patients, respectively. There were

no statistically signifi cant differences between the groups (P = 0.862). This complication was well tolerated by patients with cLF or mlF. Malignant transformation is rare but cases of squamous cell carcinoma and ver-rucous carcinoma have been reported.1 No squamous cell or verrucous carcinoma was detected in the current study.

Sixty-two patients from a previous study25 were included in this study (some of the surgeons work part-time in Bayindir Hospital). The previous study included a larger number of patients and longer follow-up period. The complications occurred in the fi rst and second years. Therefore, in the previous study the complication rate was lower. However, the number of patients was lower (411 vs 211) in the present study and the follow-up period was shorter. This may be the reason for the higher complication rate. Regardless of the results obtained from the previous study, as discussed in the Patients and Methods section, the patients were not guided for the choice of type of operation, thus there was no bias in the patient selection of groups.

In conclusion; preventing a recurrence is a major concern in the surgical treatment of PSD. cLF is a very effective procedure for chronic or recurrent PSD, with a low complication rate, a rapid return to normal activi-ties, and a low recurrence rate. Maceration and wound infection occurred on the lower left part of the incision on the intergluteal sulcus, and infections appeared sub-sequent to maceration. The main advantage of the mlF is to fl atten the natal cleft and to create a new shaped suture line lateral to the intergluteal sulcus. Therefore, this modifi cation will help to reduce the recurrence, maceration, and infection associated with the surgical treatment of PSD.

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