Pilonidal sinus disease with especial reference to Limberg flap

Pilonidal sinus disease with especial reference to Limberg
flap

Review Article
Pilonidal sinus disease with especial reference to
Limberg flap
Ajay K. Khanna a,
*, Satyendra K. Tiwary b
a
Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi,
Uttar Pradesh 221005, India
b
Assistant Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University,
Varanasi, India
1. Background
First historical description of pilonidal disease dates back to
1833 by Herbert Mayo as a hair containing sinus1
but the term
'Pilonidal' was coined by Hodge in 1880.2
The disease is a very
common problem affecting middle-aged working population,
and it most often arises in the hair follicles of the natal cleft of
the sacrococcygeal area. Incidence of pilonidal sinus is about
26 cases per 100,000, affecting males thrice as much as
females. Men are thought to be at higher risk because of their
hirsute nature. Pilonidal sinus is also associated with obesity
(37%), sedentary occupation (44%), and local irritation or
trauma (34%).3
It may manifest as pilonidal cyst, sinus, or
abscess, and inflammation may lead to rapid progression of
the disease. During the Second World War, pilonidal disease
very commonly appeared in jeep drivers, so called as ‘‘jeep
disease’’.4
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x
a r t i c l e i n f o
Article history:
Received 30 June 2015
Accepted 28 July 2015
Available online xxx
Keywords:
Pilonidal sinus
Jeep disease
Limberg flap
Epidemiology
Bacterial contamination
a b s t r a c t
This article lays an emphasis on ‘‘Pilonidal Sinus disease’’ along with the historical back-
ground, materials, and methods used. The term 'Pilonidal' was coined by Hodge in 1880. The
disease commonly affects middle-aged working population and most often arises in the hair
follicles of the natal cleft of the sacrococcygeal area. This disease affects males thrice as
much as females because of their hirsute nature. Pilonidal sinus is associated with obesity,
sedentary occupation, and local irritation or trauma. The management of pilonidal disease is
complex and a big burden on hospital and community resource because of the recurrent
nature of the disease. Various surgical methods have been practiced to treat sacrococcygeal
pilonidal sinus disease. Each method is associated with different postoperative complica-
tions, morbidity, and recurrence rates for each of the procedures.
The most simple approach for pilonidal disease is simple incision. It is effective for
simple, superficial, small, and mostly midline tracts. Excision is a simple technique used for
chronic and recurrent pilonidal sinuses. Rhomboid Limberg flap reconstruction plastic
surgery procedure was done after proper preoperative assessment and preparation in all
cases.
# 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.
* Corresponding author. Tel.: +91 9415201954.
E-mail address: akhannabhu@gmail.com (A.K. Khanna).
APME-309; No. of Pages 7
Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med.
(2015), http://dx.doi.org/10.1016/j.apme.2015.07.013
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.07.013
0976-0016/# 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.

Pilonidal disease can appear as an acute abscess along
with sinus tract formation. There have been a lot of debate on
whether pilonidal disease is congenital or acquired, but now it
is beyond doubt that it is an acquired condition.5,6
A more
complex manifestation usually after episode of inflammation
can be characterized by chronic or recurrent abscesses with
extensive branching sinus tracts. The commonest presenta-
tion for which a patient seeks medical advice is in the form of
an acute abscess characterized by the existence of a midline
pit in the natal cleft typically identified 4–8 cm from the anus.
A deep natal cleft serves favorable atmosphere for bacterial
colonization due to anaerobic environment, sweating, hair in
growth, close proximity to bacteria leading to contamination.
This primary tract leads into a subcutaneous cavity, which
contains granulation tissue and usually a nest of hairs that are
present in two thirds of cases in men and in one third of those
in women and may be seen projecting from the skin opening.
Many patients have secondary lateral openings 2–5 cm above
the midline pit. The skin opening and the superficial portion
of the tract are lined with squamous cell epithelium, but the
deep cavity and its extensions are not. Maximum number of
cases of pilonidal sinus are present in postsacral area, but it
may be seen in other regions such as interdigital, axillary,
umbilical, peri-anal, para-anal, intra-anal, and cervical
region.7,8
The management of pilonidal disease is complex and a big
burden on hospital and community resource because of the
recurrent nature of the disease.9,10
Treatment and prevention
are successful, if causative factors such as deep natal cleft and
presence of hair are taken care or minimized to prevent
sweating, maceration, bacterial contamination, and penetra-
tion of hairs.11,12
Proper decision making is based on the type
of presentation and treatment modality that range from
antibiotics, shaving, simple incision and drainage, phenol
application, cryosurgery, excision with primary closure,
excision with open packing, and excision with marsupializa-
tion to a wide excision with reconstructive surgical proce-
dures.13–16
There is no clinical consensus on the optimal management
of the pilonidal sinus but low recurrence, low morbidity,
acceptable cosmesis, insignificant tissue loss, and minimal
economic loss should be the goal in management. Our
experiences are mostly with reconstructive procedure of
Limberg flap in 180 patients of pilonidal disease from year
2004 to 2014.
2. Materials and methods
Retrospective data analysis of 180 patients during 2004–2014
was done. Detailed demographics, epidemiology, and clinical
presentations were analyzed. Only cases with surgical inter-
ventions were considered for study. Conservative manage-
ment by antibiotics and drainage of pus was carried out in
abscess, and these patients were later subjected to rhomboid
excision Limberg flap reconstruction.
Age, sex, duration, co-morbidity, presentation, number of
openings, number of surgical interventions in past, treatment,
duration of hospital stay, complications, and follow-up were
recorded and analyzed (Table 1).
3. Results
In 180 patients, males were 126 (70%), and females were 54
(30%). Mean age of presentation was 24.2 years (15–65 years)
with mean BMI of 22.3 kg/m2
(17.1–30.5). Co-morbidity was
present in 42 patients (23.3%) in the form diabetes, renal
failure, and immunocompromised patient. Recurrent disease
with history of past surgical intervention was noticed in 36
patients (20%). Most significant finding was history of
previous infection or abscess in 171 patients (95%). Single
tract was in 153 patients (85%) and multiple tract in 27 (15%).
All patients underwent surgical intervention by Limberg flap
reconstruction. Mean hospital stay was 3.2 days (1–9 days)
and mean follow-up of 38.4 months (6–60 months). Recur-
rence was noticed in only 6 cases (3.3%). Outcome and follow-
up in pilonidal disease treated by Limberg Flap is shown in
Table 2.
Surgical excision and rhomboid Limberg flap reconstruc-
tion plastic surgery procedure (Figs. 1–4) were done after
proper preoperative assessment and preparation in all cases.
First and foremost measure was control of inflammation and
infection in all cases with antibiotics and drainage with
incision and debridement. Anatomical mapping with fistulo-
gram preoperatively in all cases was done to plan reconstruc-
tive procedures. Fistulogram delineated the number of tract,
depth of cavity and lateral extension leading to proper
planning of extent of rhomboid flap excision for curative
intent. Hairs over the region were shaved preoperatively in all
cases. Spinal anesthesia was used in 171 cases (95%) and local
anesthesia in 9 cases (5%). Position was jackknife prone in all
Table 1 – Demographics of pilonidal disease (n = 180).
Total, n, % 180 (100%)
Male, n, % 126 (70%)
Female, n, % 54 (54%)
Age, years Mean 24.2 (15–65)
BMI Mean 22.3 (17.1–30.5)
Comorbidity (Diabetes,
Immuno compromised,
Renal failure), n, %
42 (23.3%)
Recurrent disease, n, % 36 (20%)
Previous infection or abscess, n, % 171 (95%)
Single tract, n, % 153 (85%)
Multiple tracts, n, % 27 (15%)
Hospital stay Mean, 3.2 days (1–9 days)
Follow-up Mean 38.4 months
(6 months to 60 months)
Recurrence, n, % 6 (3.3%)
Table 2 – Outcome and follow up in pilonidal disease
(n = 180).
Seroma 2 (1.1%)
Hematoma 6 (3.3%)
Wound dehiscence 8 (4.4%)
Flap necrosis 1 (0.5%)
Wound infection 4 (2.2%)
Residual pain and heaviness 9 (5%)
Recurrence 6 (3.3%)
Hypoasthesia 8 (4.4%)
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2

cases. After prepping and draping, lesion was marked and
included in rhomboid area to be excised. Limberg ﬂap was
raised as per the dimensions to cover the defect. The ﬂap was
raised along with the fascia over the gluteus maximus. Two-
layered closure was done with vicryl 2-0 for adipofacial
approximation and prolene 3-0 for skin closure. Minivac
suction drain was placed after hemostasis in 160 cases (88.1%).
The patient was nursed in prone position or lateral position for
initial 24 h. The dressing was changed after 48 h and the drain
was removed if contents were less than 10–15 ml.
Fig. 1 – Planning of Rhomboid or Limberg Flap
Fig. 2 – Marking, incision and excision
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3

4. Discussion
Various surgical methods have been practiced to treat
sacrococcygeal pilonidal sinus disease; each is associated
with different postoperative complications, morbidity, and
recurrence rates for each of the procedures. Excision of the
infected tissue and sinuses is not considered a major technical
problem but healing is cumbersome and expensive for both
the patient and physician due to its long duration and the
Fig. 3 – Incision and mobilization of Limberg Flap
Fig. 4 – Closure in Limberg Flap

requirement for daily wound dressings using the open-
packing technique.17
Although the primary closure method
results in rapid recovery and quick resumption of daily
activities, high complication and recurrence rates have been
reported.18,19
Pilonidal disease affects men20,21
between 16 and 25 years
of age. Usually it is associated with obesity22,23
and hirsute
individuals, who experience profuse sweating and have a
sedentary lifestyle.24,25
High morbidity and chronicity of the
disease leads to significant economic burden. In acute phases
of inflammation, an antibiotic and conservative approach is
the choice. There is almost always history of inflammation or
abscess formation. Definitive and curative approach always
includes some type of surgical intervention. The treatment of
pilonidal disease is mostly surgical. The most commonly used
procedures today are simple incision, excision, marsupializa-
tion, fistulotomy, and various plastic surgery techniques.
Most simple approach for pilonidal disease is simple
incision. It is basically a limited intervention in acute
inflammatory stage and is most important for relieving pain
and rapid recovery for subsequent definitive excision and flap
reconstruction surgery. A midline incision through the
mouths of the pits carried out and is effective in those cases
of so-called raphe cannulization where infection spreads from
pit to pit.26,27
It is effective for simple, superficial, small, and
mostly midline tracts. After unroofing the tract, it is debrided,
cleaned, and drained.28,29
Recurrence is frequent, and defini-
tive plastic reconstructive procedure is planned for final cure.
Excision is a simple technique used for chronic and
recurrent pilonidal sinuses. Excision of all involved skin and
subcutaneous tissue is must for definitive treatment. Wounds
may be left open with healing by secondary intention, allowing
the wound to granulate, or is closed by primary intention with
immediate suturing.30,31
Various types of silastic dressing and
negative pressure therapy are used to fasten the healing of
wound. Laying the sinus open permits adequate drainage of
secretions, pus, or debris. The healing by secondary intention
requires more time, but has lower recurrence rate.32
In healing
by primary intention, the pilonidal sinus is excised and the
wound sutured by using deep tension sutures tied over a gauze
dressing. The advantages are quicker healing, less hospital
stay, and an early return to work, albeit with higher recurrence
when compared to the open technique.33,34
Plastic surgery techniques that include these procedures do
not only cover the wound but also, in theory, flatten the natal
cleft, as well as reduce hair accumulation, mechanical
irritation and risk of recurrence.20,35
Various kinds of flaps
have been used: 1–2 skin flaps, fasciocutaneous flaps like the
V-Y flap (for recurrent and complicated sinus disease) and
rhomboid excision and the Limberg flap.6
The Karydakis flap36
achieves asymmetric closure of the pilonidal wounds by
avoiding to place the wound in the midline at the depth of the
natal cleft and also flattens the cleft, reducing hair accumula-
tion and mechanical irritation36,37
resulting in decreased
recurrence.
A tendency toward using flap reconstruction techniques to
treat pilonidal sinus has been established, as they provide the
desired results, such as flattening of the natal cleft, providing
tissue healing without tension, short duration of healing
and return to work, acceptable cosmetic results, and low
recurrence rates.38
The problem, related to a continuing deep
natal cleft after surgery, leads surgeons to find techniques in
order to minimize or flatten natal cleft. Infection starts in hair
follicles due to open orifices leading to sinus as hypothesized
by Bascom and excision of midline pits with lateral open
drainage of any associated abscess essential for cure. Natal
cleft effect, wound tension, and complete excision are three
key factors that prompted various plastic reconstructive
procedures such as Z plasty, W plasty, V-Y plasty, and various
flap techniques. Various techniques have been described that
attempt to eliminate factors that cause negative primary
closure results such as a midline incision scar and tissue
tension resulting in lower recurrence rates.12,20,39–42
One of
the most commonly used techniques is Limberg flap
reconstruction.
The flap necrosis after Limberg flap is rare, and it varies from
0 to 3.3% of cases in literature.43
In our study, only one patient
out of 180 had partial flap necrosis, which is acceptable and
comparable to various studies in past. The rate of development
of seroma after Limberg flap is 0–14.5% of cases in various
studies. Mentes et al. reported a seroma rate of 2.2% without
placing a drain and a mean duration of hospitalization of 4.51
Æ 2.85 days in their series of 353 patients.44
Kirkil et al. reported
the rates of seroma development in groups with and without
drains to be 10.7 and 18.5%, respectively (total, 14.5%), in their
series of 55 patients who were randomized for drain placement
with a mean 3.2 days of hospitalization.45
They reported that all
such patients were treated by repeated aspiration of seroma.
Okuş et al. reported a mean duration of hospitalization of 1.85
days and that no seroma developed in any patient treated with
Limberg flap in their prospective study of 49 patients in an
Limberg flap group in which drains were placed in all patients.46
Therefore, these studies suggest no relationship between
development of a seroma and duration of hospitalization. We
discharged our patients 24–48 h after surgery with a mean of 3.2
days (1–9 days). The rates of hematoma and wound dehiscence
after Limberg flap are 0–4% and 0–10.4%, respectively, and in our
patients, such were 3.3 and 4.4%. Although hematomas have
been treated with repeated aspiration in some studies, but good
hemostasis is the key to prevent hematoma.45
The rate of wound infection after the Limberg flap
procedure varies from 0–8% of cases.43
Different rates of
infection in studies with similar numbers of patients and
duration of hospitalization have been reported, suggesting
that there is no direct relationship between the duration of
hospitalization and the development of infection. The rate of
infection was 2.2% (4 patients) in our series of 180 patients.
The most commonly reported result in long-term studies is
the recurrence rate. The reported rates of recurrence following
Limberg flap vary between 0 and 9%.43
Two other long-term
problems with Limberg flap are hypoesthesia at the operative
site and cosmetic dissatisfaction. Mentes et al. reported a
recurrence rate of 2.2%.44
The rates of recurrence and
hypoesthesia in our study agree with those in the literature
(3.3 and 4.4%, respectively).
Short- and long-term postoperative results are in agree-
ment with the literature data in patients treated with the
Limberg flap procedure in our study. The duration of
hospitalization varies from 1.7 to 5.9 days43,44
in studies in
which Limberg flap was performed.

5. Conclusion
Pilonidal sinus is a benign disorder but two serious issues are
associated with it; those are significant economic loss and
significant morbidity. It affects the working middle-aged
population and individuals receiving their education or those
in early phases of their job. The time spent in the hospital
continues to result in significant economic issues. The Limberg
flap procedure has minimal postoperative complications and
very low recurrence in long-term follow-up with minimal time
to be spent in hospital. Though it requires a good geometric
calculation for raising the flap, the flap never fails with an
advantage of flattening natal cleft so to have the low
recurrence of the disease.
Conflicts of interest
The authors have none to declare.
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Pilonidal sinus disease with especial reference to Limberg flap

Pilonidal sinus disease with especial reference to Limberg flap

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Pilonidal sinus disease with especial reference to Limberg flap