This study compared outcomes of patients undergoing either laser ablation (PiLaT technique) or Limberg flap (LF) surgery for primary pilonidal sinus. 200 patients were randomized to each group. Results showed PiLaT had significantly shorter surgery time, less post-op pain, earlier return to daily activities, higher patient satisfaction, and no recurrences at 2-month follow-up compared to LF surgery. The authors conclude PiLaT is an effective treatment that may be preferred over LF due to benefits of less pain/tissue loss.

1. 148
Analytical and Quantitative Cytopathology and Histopathology®
0884-6812/20/4205-0148/$18.00/0 © Science Printers and Publishers, Inc.
Analytical and Quantitative Cytopathology and Histopathology®
OBJECTIVE: The success of surgical treatment of pilo-
nidal sinus disease is measured by parameters such as
recovery time, return time to daily activities, analgesic
need, and complication and recurrence rates. We com-
pared the rates of surgery, analgesic need, daily life re­
turn times, patient satisfaction, and complication and
recurrence rates of patients treated with laser ablation to
those treated with the Limberg flap (LF) technique.
STUDY DESIGN: Between January 2017 and January
2019, 200 patients diagnosed with primary pilonidal
sinus were randomized into 2 groups: LF surgery (n=
100) and pilonidal sinus tract ablation therapy (PiLaT)
with a 1,470-nm diode laser (n=100).
RESULTS: Average surgery time was 17.4±1.9 (14–
21) minutes in the PiLaT group and 33.4±6.5 (28–40)
minutes in the LF group. Duration of surgery was
noticeably shorter in the PiLaT group (p<0.001). After
surgery the early visual analog scale pain score was
2.4±0.5 (1–4) in the PiLaT group and 5.3±1.4 (3–6)
in the LF group (p<0.001). The average time to re-
turn to daily activities was significantly shorter in the
PiLaT group, with an average of 2.3±0.5 (1–4) days in
the PiLaT group and 11.5±1.3 (8–15) days in the LF
group (p<0.000). The satisfaction score was 4.4±0.6
in the PiLaT group and 3.2±0.8 in the LF group
(p<0.001).
CONCLUSION: If a disease is to be treated surgically,
pain and tissue loss should be kept as low as possible.
For this reason we believe that the PiLaT technique is
an effective and reliable method that will be preferred
by more patients and surgeons as the results of more
controlled and comparative studies are reported. (Anal
Quant Cytopathol Histpathol 2020;42:148–154)
Keywords: anal canal/surgery, diode laser, Lim-
berg flap, pilonidal cyst, pilonidal sinus, pilonidal
sinus disease, rectal fistula, surgical flaps, tract
ablation.
Pilonidal sinus disease (PSD) is an infectious, be­
nign disease associated with the skin and subcu-
taneous tissues in the posterior of the sacrum. It is
located on the surface of the sacral periosteum and
can have one or more extensions.1 PSD occurs most
often in young adult men. Its incidence is around
25/100,000.2 Although PSD was first described as
a congenital disease by Herbert Mayo, M.D., it is
widely believed to be an acquired disease today.3
Tissue tension already present in the presacral
area, which is the embryological closure region,
increases with hormonal activity in puberty. This
tension causes the hair follicle orifices to expand.
Comparison of Limberg Flap and PiLaT
Procedure in Primary Pilonidal Sinus
Treatment
Results from a Single Center
Erkan Dalbaşı, M.D., and Ömer Lütfi Akgül, M.D.
From the Department of General Surgery, Memorial Hospital, Diyarbakır; and the Department of General Surgery, Genesis Hospital,
Diyarbakır, Turkey.
Erkan Dalbaşı is Physician, Department of General Surgery, Memorial Hospital (ORCID ID: 0000-0002-4652-1747).
Ömer Lütfi Akgül is Physician, Department of General Surgery, Genesis Hospital (ORCID ID: 0000-0002-7858-454X).
Address correspondence to: Erkan Dalbaşı, M.D., Department of General Surgery, Memorial Hospital, Diyarbakır, Turkey (erkandal
basi144@gmail.com).
Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.

2. Volume 42, Number 5/October 2020 149
Comparison of Limberg Flap and PiLaT
Foreign bodies such as hair, clothing fibers, etc.,
can more easily enter through the enlarged orif-
ices with increased friction due to walking, wear-
ing tight clothing, and sitting for prolonged peri-
ods, on the interlocking surfaces of the intergluteal
sulcus. The resulting stasis causes infection and
suppuration in the follicle. This suppuration usu-
ally continues in a silent and chronic form, but
it can also manifest itself in the form of an
acute abscess. Chronic infection proceeds in low-
resistant areas under the skin, opening secondary
orifices. Despite this information, the actual patho-
genesis is still unclear. Obesity, family history,
oily skin, deep intergluteal sulcus, and poor hy-
giene are factors that facilitate the formation of
the disease. PSD clinically consists of 3 compo-
nents. One or more orifices located in the mid-
line are also called pits. It consists of midline
acute or chronic abscess cavities that extend to
the sides and secondary orifice or orifices.4,5 There
are many surgical methods to treat PSD, but none
has become the gold standard.6 In patients con-
sulting with acute abscess, the abscess is drained
with unroofing and the skin is closed with a
dressing after the skin is ex­
cised. It resolves the
acute problem and provides up to 70% defini-
tive treatment.7 In surgical treatment of chronic
PSD, primary closure of the defect was widely
used after excision. However, due to reasons such
as wound separation and high recurrence rate,
tension-reducing flap techniques are used today.5,8
Different techniques such as Karydakis flap and
Bascom procedure can be performed using asym-
metric shifting technique. Limberg flap (LF), which
is used successfully and widely in the treatment
of PSD, is a rhomboid flap. In the LF technique,
recurrence occurs most often in the distal corner
near the anus. To avoid this problem, Akin et al
modified the LF technique and shifted the distal
corner from the midline to the left lateral.9 We
also applied the modified method in our clinic.9
Today, laser ablation of the sinus tract comes to
the fore as a minimally invasive method. There
are studies reporting that this easy-to-apply meth-
od is safe and has a low recurrence rate. The suc-
cess criteria of surgical treatment of PSD are pa-
rameters such as recovery time, return time to
daily activity, analgesic requirement, and complica-
tion and recurrence rates.
In this study we aimed to compare the opera-
tive times, need for analgesics, time to return to
daily life, patient satisfaction, and complication
and recurrence rates of patients treated with laser
ablation of the sinus tract to those of patients treat-
ed with Limberg flap technique.
Materials and Methods
Patients
Between January 2017 and January 2019, 200 pa­
tients diagnosed with primary pilonidal sinus were
randomized into 2 groups. Limberg flap (LF) sur-
gery was performed on 100 patients for treatment,
while the other 100 patients were treated with
pilonidal sinus tract ablation therapy (PiLaT) with
a 1,470-nm diode laser. This study was a retrospec­
tive analysis of prospectively collected data. All
patients signed a consent form that provided in­
formation about the procedure and explained pos-
sible complications. This research was approved
by Memorial Hospital, Diyarbakır, Turkey (Proto-
col No. 2020/141).
Patients presenting with acute abscess and pre-
viously treated by any means and who developed
recurrence were excluded from the study. At the
end of the second month of follow-up the proce-
dure was considered to be unsuccessful and was
defined as recurrence in the presence of an ori-
fice with discharge, suppuration, hair, and debris.
Prophylactically, a single dose of 1 g of cefuro­
xime was administered intravenously to patients
in both groups. Age, gender, pit numbers, dura-
tion of operation, postoperative pain severity and
analgesic need, return times to daily activities,
processing satisfaction, and recurrence rates were
recorded in both groups. Patient satisfaction was
determined using the Likert scoring scale at the
6th month after surgery (1=totally unsatisfied,
2=unsatisfied, 3=neutral, 4=satisfied, and 5=very
satisfied). Postoperative pain evaluation was per-
formed 24 hours after the operation using a visual
analog scale (VAS). According to this scale, 0=no
pain up to 10=very severe pain.
Surgical Technique
All patients were cleaned at the area from the
proximal border of the sacrum to the distal of the
gluteal region with the help of a depilatory cream
the day before the procedure. The patients were
operated on in the prone position after spinal
anesthesia. The surgical area was cleaned with 10%
povidone iodine.
An ALFA (Advanced Laser Fistula Ablation) di-
ode laser (NeoLaser, Israel) was used in this study
(Figure 1). The diode laser emits 30–50 joules/cm

3. 150 Analytical and Quantitative Cytopathology and Histopathology®
Dalbaşı and Akgül
of energy at a wave of 1,470 nm. Energy used is
10 W. First, the outer mouths of all orifices were
expanded to 5 mm with a clamp. With the help
of a mosquito clamp, hair lumps in the tracts
were removed (Figure 2). Then, the debris was
cleaned out with the help of a curette of suitable
size. Oxygenated water diluted with isotonic was
injected into the tract from the orifice, then NaCl
was irrigated with 0.9% saline and the remaining
hair and debris residues were cleaned out. The
laser probe was then advanced from the outside
mouth to the top of the sinus tract. Energy was
applied at 10 W. The laser probe emitted 360
degrees of energy, retracting 1 cm in 5 seconds,
making the entire tract homogeneously sealed off.
This procedure was applied for all sinus and sinus
tracts, and all tracts were closed. Then, the probe
was attempted to be moved again and it was
checked whether the tract was closing. After the
treatment the area was cooled with ice. External
orifices were left open. The surgical area was cov-
ered with a sponge by applying cream containing
silver sulfadiazine.
In the LF group the pilonidal sinus pouch was
excised up to the presacral fascia, including all the
pits and tracts. This area was then washed with
oxygenated water and isotonic. The distal corner,
where the most common separation, infection, and
recurrence were seen, was shifted to the lateral as
described by Akin and colleagues.9 A Hemovac
drain was attached to all patients in this group.
The subcutaneous layer was closed with Vicryl
sutures (Ethicon). The skin was closed with skin
staples (Figure 3). The staples were removed on
postoperative day 13. When the amount of fluid
drained fell below 25 cc in the follow-up of the
patients, the drainage was withdrawn.
In the early postoperative period, all patients
were given 10 mg/mL paracetamol intravenously
as analgesia if needed. In both groups, patients
were discharged a day later. After discharge, all
patients received 1 g cefuroxime axetil and 500 mg
of paracetamol orally for 5 days if needed. Patients
were allowed to take a standing shower from the
second day after the operation. Patients in both
groups were checked at the outpatient clinic on
Figure 1 An ALFA (Advanced Laser Fistula Ablation) diode laser
(NeoLaser, Israel).
Figure 2 Outer mouths of all orifices have been expanded and
hair lumps in the tracts were removed. Figure 3 Limberg flap technique.

4. Volume 42, Number 5/October 2020 151
Comparison of Limberg Flap and PiLaT
days 7, 15, 30, 45, and 60 after surgery. In the
6th and 12th months patients were evaluated by
phone, and patients with problems were invited
to the hospital. Laser hair removal was recom­
mended to prevent future recurrences 3 months
after the operation.
Statistical Method
IBM SPSS Statistics for Windows was used for
cross-group comparisons (version 20.0; IBM Corp.,
Armonk, New York, USA). The results are shown
as percentages, means with standard deviations,
or means with ranges. The unmatched Student’s
t test was used to evaluate surgical time, pain
score, return to daily life, recurrence, and com-
plication variables of analgesic need. P<0.05 was
considered to be statistically significant.
Results
A total of 200 patients were treated in the LF and
PiLaT groups (100 patients in each group). Of the
patients in the PiLaT group, 83 (83%) were male
and 17 (17%) were female. The average age was
26.9±7.9 years (range, 14–43). In the LF group,
80 (80%) of the patients were male and 20 (20%)
were female and the mean age was 29.7±7.3 years
(range, 18–48). There was no statistically signifi-
cant difference between groups in age and gender
distribution (p=0.355, p=0.310). The demographic
characteristics of the groups are summarized in
Table I.
The average surgery time was 17.4±1.9 (14–
21) minutes in the PiLaT group, while in the LF
group it was 33.4±6.5 (28–40) minutes. The dura-
tion of the surgery was noticeably shorter in the
PiLaT group (p<0.001). Pit numbers were 3.3±
0.7 (1–6) and 3.6±0.8 (2–7) in the PiLaT and LF
groups, respectively (p=0.745). After the surgery,
the early VAS pain score in the PiLaT group was
2.4±0.5 (1–4), while in the LF group it was 5.3±
1.4 (3–6). The difference in VAS score between
groups was statistically significant (p<0.001). In
the PiLaT group a single dose of painkillers was
enough, to 500 mg of paracetamol, and was used
for an average of 2.3±1.7 (1–4) days. In the LF
group paracetamol dose was used daily at 1,000
mg, and painkillers were used for an average of
6.5±2.4 (4–8) days (p<0.001). The average time it
took to return to daily activities was significantly
shorter in the PiLaT group than it was in the LF
group. The average was 2.3±0.5 (1–4) days in the
PiLaT group, while in the LF group it was 11.5±
1.3 (8–15) days (p<0.000). The number of pa-
tients considered to have recurrence at the end
of 8 weeks was 4 in the PilaT group and 3 in the
LF group. All patients with recurrence had 1 pit,
and they were treated by PiLaT. There was no
difference between the 2 methods in terms of re-
currence ratios (p=0.654). In patients in the PiLaT
group, a small amount of serous discharge from
the expanded orifice stopped spontaneously with-
in 72 hours. No complications such as hematoma
and abscess were observed in any patient in this
group. In the LF group, abscess developed in 3
patients. The sutures in this area were removed
and drained and healed with dressings. In 1 patient
all sutures were opened due to a reaction to the
Vicryl and the wound was left to heal secondary.
When the complications were compared, this rate
was higher in the LF group (4%) as compared
to in the PiLaT group (0%) (p<0.000). In the LF
group drainage continued in patients for an aver-
age of 3 days. Persistent pain and numbness at the
wound site were not seen in any patient. Likert
satisfaction scores of the patients at the 6th month
after surgery were higher in the PiLaT group as
compared to in the LF group. The satisfaction score
was 4.4±0.6 in the PiLaT group and 3.2±0.8 in
the LF group (p<0.001). In the 12th month it was
found that no patient in either group had problems
related to the disease or the operation. The data
obtained are summarized in Table II.
Discussion
Although PSD is a benign disease, it is a disease
that adversely affects the comfort of life, especially
in young people and mostly in men. In our study
the age and gender distribution of the patients
were compatible with those found in the litera-
ture. Even if the disease is controlled with con-
servative approaches, surgical treatment provides
permanent treatment.10,11 Although different sur­
Table I Demographic Features of the Patients
LF PiLaT Total
(n=100) (n=100) (n=200) p Value
Male 80 (80%) 83 (83%) 163 (81.5%)
0.355
Female 20 (20%) 17 (17%) 37 (18.5%)
Age 29.7±7.3 26.9±7.9 28±7.55
0.310
(18–48) (14–43) (14–48)
P<0.05 is considered statistically significant. Continuous variables are
defined as mean±standard deviation (range), categorical variables as
n (%).

5. 152 Analytical and Quantitative Cytopathology and Histopathology®
Dalbaşı and Akgül
gical techniques are used, there is no ideal proce-
dure that eliminates relapse. The surgical proce-
dure for PSD should ideally have the following
characteristics: ease of application, short recovery
(healing) time, safe, minimal pain, short-term
dressing, low recurrence rate, and good cosmet-
ic appearance.3,12 After extensive excision, it was
common to leave the wound open for secondary
healing. Although the recovery period is long and
the necessity of dressing every day is a disad-
vantage, the recurrence rate is low (5%). Primary
closure after sinus excision is an easy and quick
operation, but its recurrence rate of over 30% is
an important drawback. The recurrence rates of
the Karydakis, Bascom, and Limberg flap meth-
ods, which are mostly performed in complicated
patients and are intended to shift the midline
through an asymmetric incision, are low, and
average recurrence rates range from 3–8%. How-
ever, factors such as large incision areas, necessity
of drain placement in some patients, high level
of postoperative pain, and long recovery period
(return to daily life) can be counted as disadvan­
tages of these methods.13-15
In the study conducted by Boshnaq et al, they
found that the early complication rates in patients
undergoing LF were 11% and the recurrence rate
was 7.7%. In the literature review, the recurrence
rate was found to be between 0–7.4% in 22 LF
case series studies. The length of hospital stay
was determined to be between 1 and 15 days. The
rate of complications such as seroma and hema­
toma is between 0–9.6%. In studies comparing
LF with primary closure, the recurrence rate was
between 0 and 8.3% for LF and between 8 and
37% with primary closure. It was observed that
the return to daily life was earlier in the LF group.
In a study of 269 cases by Ates et al, LF and Kary-
dakis flap were compared. They did not notice
any difference in terms of recurrence, but because
of lower pain scores, lower complication rates,
shorter operative times, and shorter hospital stays
they recommended the Karydakis flap in uncom-
plicated PSD. In our study we found the rate of
recurrence in the LF group to be 3% and the
early complication rate, 4%. The average return
to daily life was 11.5 days, and these values are
compatible with those found in the literature.16,17
In their study, Aithal et al did not experience re-
currence in 30 patients treated with LF. Average
hospital stay was 5 days, and return to work be-
gan 3 weeks later.18
Laser sinus tract ablation, an increasingly min-
imally invasive procedure, has been used in the
treatment of PSD in the last decade. Laser treat­
ment was also used for the ablation of the pilo-
nidal sinus tract since the laser closure of the fis­
tula tract gave promising results in the treatment
of perianal fistula. The results of the studies con-
ducted for this purpose are promising.19 It is pre-
ferred by many centers and patients today be-
cause of its positive aspects such as ease of appli­
cation, safety, low recurrence rate, low complica-
tion rates, low pain score levels, short recovery
time enabling return to work and social life, and
absence of tissue loss.
In the study conducted by Dessily et al, they
applied laser ablation therapy to 200 primary
PSD diagnosed patients. The average operation
time lasted 9.4 minutes. Complete recovery rate
was 94%. Recurrence was seen at 15.2%. Compli-
cations were observed in 15%. The proportion of
patients using painkillers for <7 days was 85.5%.6
In our study the rate of recurrence (3%) was found
to be lower. However, the operation time took
longer in our study (17.4 minutes).
Table II Outcomes of Limberg Flap as Compared with PiLaT Technique
Outcome LF (n=100) PiLaT (n=100) p Value
Mean operative time (min) 33.4±6.5 (28–40) 17.4±1.9 (14–21) <0.001*
VAS pain score (0–10) 5.3±1.4 (3–6) 2.4±0.5 (1–4) <0.001*
Satisfaction score (1–5) 3.2±0.8 (1–5) 4.4±0.6 (3–5) <0.001*
Pit score 3.6±0.8 (2–7) 3.3±0.7 (1–6) 0.745
Mean time to return to daily activity, days 11.5±1.3 (8–15) 2.3±0.5 (1–4) <0.000*
Complication rate (%) 4 0 <0.000*
Duration of analgesic therapy, days 6.5±2.4 (4–8) 2.3±1.7 (1–4) <0.000*
Recurrence (%) 3 (3%) 4 (4%) 0.654
*P<0.05 is considered statistically significant.

6. Volume 42, Number 5/October 2020 153
Comparison of Limberg Flap and PiLaT
Yardimci compared the Karydakis flap proce-
dure with the sinus tract ablation procedure com-
bined with pit excision. The laser procedure was
found to be more successful in terms of mean
operative time, pain score, process satisfaction,
and recovery time (return to work) parameters.
However, it was observed that both groups had
equal rates of recurrence. In our study we did not
make pit excision, expanded the orifice inlets with
clamp, and cleaned the sinus inside the bristles
and debris, and we found that the results were
compatible.3
In the study conducted by Pappas and Christo-
doulou involving 237 patients, the patients were
discharged the same day. The average surgery
time lasted 24 minutes, which was longer than
the 14–21 minutes in the PiLaT group in our
study. 92.8% of the patients returned to their
daily activities after leaving the hospital. Approx-
imately 20% of patients experienced moderate
pain between 3 and 8 days. Recurrence was ob­
served at 2.9%, occurring in patients in stages
2 and 3. No relapse was observed in the stage 1
and stage R groups.20
Hair plays a key role in the formation of PSD.
Clearing of the hair by various methods reduces
the risk of recurrence after surgery. Pronk et al
showed that laser epilation is more effective than
razor and depilatory creams in the prevention of
relapse after surgery in their study for this pur-
pose. In our study we recommended laser epil-
ation to patients in both groups 3 months after
surgery.21,22 There are studies showing that laser
epilation may be the first-line treatment option.
An improvement of 75% has been reported. How-
ever, these studies were conducted with small pa­
tient groups.23,24
In a study by Georgiou, PiLaT was applied to
60 patients diagnosed with PSD. The average
processing time took 32.3 minutes. VAS pain score
of 0 was detected in 70% of patients in the first
week. Analgesic requirement was used in 11.6%
of patients for only 2 days, and 92% of patients
healed primarily. This rate was 96% in our study.
Patient satisfaction was determined to be 98%,
and 65% of the patients returned to their daily
activities in the first 24 hours. One patient devel-
oped an abscess (1.6%).25
Conclusion
If a disease is to be treated surgically, the sur-
gery should affect the comfort of the patient at a
minimum, as much as possible. It should cause
minimal pain and as little tissue loss as possible.
It should cure the patient as soon as possible. It
should ensure patient satisfaction at the highest
level. The PiLaT method used in the treatment of
PSD is a minimally invasive method that is easy
to learn and easy to apply. The advantages of the
PiLaT procedure are the absence of stitches, short
duration, low need for dressing, rapid return to
daily life, low pain, fast recovery, low relapse rate,
and easy reapplication when necessary. Howev-
er, studies with a higher number of patients are
needed in order to be able to recommend use of
this minimally invasive method more widely in
the treatment of PSD. The LF procedure is a long-
used technique and has a low recurrence rate
and high success rate. However, it is a difficult
technique to re-apply due to the high tissue loss.
The disadvantages of LF are that the pain is high,
the need for dressing is long, the use of stitches
and drains, and returning to daily life takes a
longer time. We believe that the PiLaT technique
is an effective and reliable method that will be
preferred by more patients and surgeons with the
increase of controlled and comparative studies.
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