Treatment  of recurrent pilonidal sinus  by flap technique(Limberg  flap)

Abdulkarem Omer Mohamed salih¹

Hazem Sadeq Ahmed²

Nissan Khaleel  Abdulla Alazawi³

 ¹General Surgeon, FICMS,CABS. Department of Surgery, Kirkuk General Hospital. Iraq (Telephone: 07701346432 email: abdulkaremomer1970@gmail.com)

²General Surgeon, FICMS,CABS. Department of Surgery, Kirkuk General Hospital. Iraq (Telephone:07715188801    email:hazimmm2000@yahoo.com)     

³General Surgeon, FICMS. Department of Surgery, Kirkuk General Hospital. Iraq (Telephone:07706672821,07700351987   email: Nissan_azawi@yahoo.com, azawinissan@gmail.com

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Abstract

Background: pilonidal sinus (PNS) is a chronic disease that mostly affects young adults. describes a hair-filled cavity in the subcutaneous fat of the post sacral intergluteal region, known as the natal cleft , its name arises from the Latin terms “pilus” and “nidus” meaning  a nest of hair  PNS can be asymptomatic, or may be present  as a recurrent  abscess or as  chronic  inflamed cavity and local  discharge from sinus or sinuses and local pain and discomfort .

Materials and Methods: retrospective  study was done  from (November 2017 to November   2018) at surgical department in  Kirkuk General Hospital in 50 patients with  recurrent PNS all will be treated with  Limberg  flap then follow up for one year  this surgery done  by excision of PNS till  we reach  fascia overlying  sacrum inferiorly  and laterally till  we reach gluteal fascia and dissection was performed with electro cautery and  reconstruction done by  flap (Limberg flap) from gluteal area.

Results: in 50  patient  with recurrent PNS   we have 45 (90%) were male and 5 (10%) were female ,30 patient  (60%) patients had a familial history of PNS and 42 patients(84%) with etiology-related risk factors to develop PNS then  we divided them according first time surgery done either, by excision and primary closure 30 patient(60%) or excision and healing by granulation tissue and secondary intension 20patient (40%)

Discussion: pilonidal sinus not classified as  dangerous condition but any  patients  with PNS live in  non-comfortable   state and may have complications such as abscess formation   or discharging sinus even  severe  pain  therefore Limberg flap is  commonly used method to treat  recurrent PNS and this good  result with  healing in short period  also satisfactory results   in long duration but this method  with  Sacrococcygeal area  disfigure mentation  as one long duration complications  but   less  recurrence rates and  short stay in hospital and better patient  tolerability  in this way if we  compare it  to all other methods even  with  surgical challenge  to create a flap  but it less wound infection,  hematoma ,edema , wound separation  if we compare it  to  other surgical techniques but fluid accumulation in close space under flap is one of important complications in this method and we decrease it   by  using a  drain  and putted  in site until fluid drainage in area  decreased to be less than 50 ml/day .

In this method recurrence rate in our study is 2%  but  reported recurrence rate for Limberg flap are from 0.8 to 2.7% if we compare to 12% recurrent rate   in  primary closure therefore we have very good recurrence rate

Conclusions: the approach for recurrent PNS should be differ  from  primary PNS flap reconstruction methods in treatment for recurrent PNS  is very good  and efficient method even with surgical challenge procedure  to create flap, personal hygiene are the keystones for preventing recurrence.

Keywords: pilonidal sinus, recurrence, Limberg  flap.   

INTRODUCTION

   Sacrococcygeal pilonidal sinus (PNS) is a chronic disease that mostly affects young adults. describes a hair-filled cavity in the subcutaneous fat of the post sacral intergluteal region, known as the natal cleft and

this pathology was first described in 1833 but PNS usually occurs in healthy young men (Male/Female = 4-5/1)(1) and its  arises from the Latin terms “pilus” and “nidus” meaning “a nest of hair.”  (2)

 Clinically, PNS in any patient  may be asymptomatic or present as  recurrent  abscess or  may be as  inflamed cavity with local fluid discharge and variable discomfort(2,3)

 PNS  can be seen  at any age groups although  high incidence will be seen in   second  or third decades .

  the incidence of PNS  in the general population is about 26 cases per 100,000 people (0.026%)(4)

The PNS may present as chronic cutaneous infection   or abscess  with or without  sinus or  may be present as  recurrent  sinuses 

This disease may classify as acquired disease but  still not well defined it's etiopathogeny .

 Many etiologic factors, like  hirsutism, repeated local trauma, obesity with deep natal cleft and  familial predisposition with  smoking  and lifestyle have been a role in it as sedentary one, all will be  suggested as predisposing factors .(5)

 There are many  non-surgical or surgical methods describe for management  PNS cases  in all methods the wound healing of PNS depends many  factors such as the stage of disease , medical conditions for  patient, method of  used to treat patient (medical/surgical line ) ,also experience of the surgeon. When surgical way is chosen to treat  PNS , all methods depend on  total excision of the pilonidal cavity and its tracts(6). Then  wounds left  can be sutured (primary suture of wound ) or we deal with it by creating a flap or we  left  wound open to healed by secondary intension.(7,8)

  In this research we will representing  retrospective study  for recurrent  pilonidal disease in  50 cases, all treated  by surgical method with Limberg flap tech. 

Materials and methods

The study was done  from November 2017 to November   2018 at surgical department in  Kirkuk General Hospital, A total of 50 patients with  recurrent PNS all will be treated with  Limberg  flap  then follow up for one year all patients undergo this surgery all consent them about this method and its complication and  investigations done which include full blood test and ECG also  echocardiography done to all patients.  

Surgery: done to all patients  under spinal or general anesthesia , in prone position the area exposed in  intergluteal region and by adhesive tape , we do  lateral traction of gluteus  area from its lateral region then Sinuses with branching seen and  marked by methylene blue  injection into tract then  remove of PNS completely done till  we reach  fascia overlying  sacrum  and laterally till  we reach gluteal fascia and  Dissection was performed with electro cautery and reconstruction it done by created by  creating a flap from gluteal area (no matter from right or Left side) (9)as seen in fig 1 then transport it, to fill the defect then only skin suture with Prolene(2. 0) and put vacuum drain ,which done by a separate incision,  about 2 cm away from the original  incision and keep it till  drainage from area  decreased to be less than 50 ml/day as seen in picture(1 and 2). pictures taken after patient permission we need about  3to 5days  to remove vacuum drain (10) and all patient discharged on the same day of surgery and ask them not lie on their buttock for 5  days and stich remove after 15 days then full recovery after 21 days.

Fig1

Picture 1

Picture 2

Results

From the 50 selected patients with  recurrent PNS, we have 45 (90%) were male  and 5 (10%) were female. The average age was 25.3 years (interval between 18 and 42 years old).

 30 patient  (60%)  with positive history  in their family to PNS  and 42 patients(84%) with  risk factors to develop PNS as  deep natal cleft ,hirsute body , obesity and with history such as  local trauma and  sedentary lifestyle.  

 we divided them according first time surgery done either, by excision and primary closure 30 patient(60%) or excision and healing by secondary intension 20patient (40%) .

Table (1) age distribution  in both group

Age (yrs.)

Table 2 Sex  distribution  in both group

Table 3

Clinical comparison, operative characteristics and complications .

Discussion

pilonidal sinus not classified as  dangerous condition but any  patients  with PNS live in  discomfort  state and may have many complications such as abscess  or discharging sinus even  severe  pain in area that interfere life quality . The PNS  recurrence is  most likely due to leave  tract or tracts in first surgery or may be as  wound  infection  or abscess , all will lead to new  tract formation. dead tissue collection  or debris in the cleft, sweating, friction, or even poor hygiene in intergluteal cleft   all  are predisposing factors for recurrence.(6).

PNS can be treated by many surgical ways but in all  we have  high risk  for recurrence  [11].

In Flap techniques  we will get a flat  intergluteal cleft  with repair by  tension-free flap  and  less hair in area also if we reduced sweating [9] all are good factor's to decrease  recurrent rate    .

 Limberg flap is one of good method used to treat recurrent PNS and this method   with good outcomes, healing  in short times and  good results for long time(12). Even  Limberg flap may cause  disfigurement in the Sacrococcygeal region by  creating a flap. This  procedure may not be an appropriate for  all patients as patient with extensive  disease which required a big  flap [12].  

If we compare  Limberg flap  with other surgical techniques  as in Shabbir et al we found it  has less wound infection and recurrence rates, short hospital stay and better patient comfort  when compared with excision and direct primary closure [13] .

 Patients treated with  Limberg flap had short time to heal as seen by our results  and better cosmetic results have been achieved by Limberg flap than seen   Karydakis flap procedure which same result  seen by Sit M et al (14) but  Patients underwent Karydakis flap reported shorter healing time postoperatively than Limberg flap only reported by Can MF et al(15).

In flap method complications seen such  as  infection, collection of  fluid, hematoma and  separation  of  wound can noted as in all  other surgical techniques . but fluid accumulation in close space under flap is one of important complications to this method and we decrease it   by  using a  drain  and putted  in site until fluid drainage in area  decreased to be less than 50 ml/day  same result reported by  Gurer et al. (16) they  reported that fluid accumulation is reduced after the routine use of post-operative drains but Bessa (17) determined that the percentage of cases with fluid retention after drain placement was 2.4%. but in our  study was 10% of patients with this complications  which higher  than other study.

The reported recurrence rate for Limberg flap are from 0.8 to 2.7% in our study only 2%  which is similar or near to other results as Ertan et al.( 18) reported  recurrence rate of 2% same to as in comparison 12% in a primary closure .

Conclusions

       The approach for recurrent PNS should be differ  from  primary PNS but risk factors in recurrence PNS unfortunately   same  in both  therefore we must try to  eliminated  or decrease   factors that lead to increase chance PNS recurrence  apart from the surgical approach that we use but  flap reconstruction methods in treatment for recurrent PNS  is very good  and efficient method even with surgical challenge procedure  to create flap ,  personal hygiene are the keystones for preventing recurrence  and all patients  must be educated about  recurrence in this disease are cornerstone to avoid recurrence.

The study is self-funded

There is no conflict of interest between the authors

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