Modified Limberg Flap for Pilonidal Sinus

Background: Pilonidal sinus disease is a common condition usually seen in young adults. Although several methods of treatment have been described, but all have been associated with high recurrence rates. This study was carried out to evaluate the advantages and results of rhomboid excision and Limberg flap reconstruction in the management of pilonidal sinus disease. Objective: To evaluate the advantages and results of rhomboid excision and Limberg flap reconstruction in the management of pilonidal sinus disease Material and Methods: This was prospective descriptive study conducted in Unit III, Department of Surgery, Kathmandu Medical College Teaching Hospital from August 2013 to August 2015. First 50 patients with diagnosis of pilonidal sinus were included .Exclusion criteria was patients with pilonidal abscess. Results: Total 50 patient were included in 2 years time. Mean age was 23.48 ± 3.9 years with all male patients only. Median duration of surgery was 32 ± 4.4 minutes .Median time for normal activities was 21± 3.9 days and median follow up time was 18±8.5 months. No recurrence was noted till then. Post surgery, patient applied hair removal cream: 44%, hair shaving: 34% and laser therapy for hair follicles: 22%. Conclusion: Modified Limberg flap is better option for pilonidal sinus with least recurrence. However, post surgical counseling for hair removal is very important in order to prevent recurrence and should be multidisciplinary approach along with dermatologist colleagues. Conflict of Interest: No


Introduction
P ilonidal disease is chronic infl amma on of the hair follicles present at natal cle of the sacrococcygeal area.][3] It was termed 'jeep driver's bo om disease' during World War II because many drivers were found to have the condi on 4 .
7][8][9][10] Hence our objec ve is to evaluate the results of modifi ed Limberg fl ap reconstruc on in the management of pilonidal sinus disease.

Material and Methods
Study type, dura on and loca on: This prospec ve cross sec onal descrip ve study was conducted from August 2013 to August 2015 in Unit III, Department of Surgery, Kathmandu Medical College Teaching Hospital, Sinamangal, Nepal.Ethical clearance for the study was obtained from the Ins tute Ethical Commi ee and all provisions of the Declara on of Helsinki were followed in this study.

Inclusion criteria
All pa ents with diagnosis of pilonidal sinus were included in this study.

Modifi ed Limberg fl ap procedure:
Pa ent prepared in prone posi on with bu ocks separated with tape.Superior and inferior points were placed 1.25cm away from midline( Figure 1) and rhomboid ssue excised ll the level of Gluteus muscle fascia.Then lateral subcutaneous fl ap was constructed based upon superior gluteal artery subcutaneous branch.We always tried to preserve subcutaneous branch of superior gluteal artery.
Nega ve suc on drain 10 F was placed and subcutaneous fat sutured with absorbable polygalc n suture and skin was closed with ma ress suture with non absorbable prolene suture.(Figure2) Pa ent was kept in le or right lateral posi on in post op ward and discharged on 2 nd day with drain.Drain was removed on 5 th post opera ve day and sutures were removed on 14 th post opera ve day.
Mean age, wound infec on rate, were calculated.Pa ent was followed on 7 th , 14 th and 30 th post opera ve day.
Post opera ve pa ent were well explained about importance of hair removal either by hair epila on, shaving or permanent laser therapy for hair removal.They were taken care by combined dermatologist colleagues and us during follow ups for further management by hair removal procedures.All pa ents were followed up on 3 rd month, 6 th month, 1 year and 2 years of post opera ve period.

Data Analysis
Descrip ve sta s cs of mean, standard devia on, percentage were obtained from the data.Sta s cal analysis was by SPSS sta s cal package version 10.1.

Results
Total 50 pa ents were included in 2 years period.All were male pa ents:

Demographic characteris cs
Mean age group (years): 23.48 ± 3.971 Median dura on of surgery (minutes) 32 ±4.4 Median me for normal ac vi es (days) 21±3.9 Median Follow Up (months) 18±8.5 Post surgery therapy for hair follicles: Hair removal cream: 44% Hair Shaving : 34% Laser therapy for hair follicles: 22%   Then studies where comparison between excision with primary closure and Limberg fl aps have shown that Limberg fl ap have be er results in terms of recurrence rate .While Holmebakk and Nesbakken 18 reported a recurrence rate of approximately 20% a er excision and primary closure .On the other hand, Ertan et al. 19 determined a recurrence rate of 2% in the Limberg fl ap method and 12% in the primary closure method, and stated that the Limberg method resulted in a be er outcome with respect to recurrence, complica ons, me required for wound healing, me required to return to work, and general health condi ons.
Similarly, study by Ahmet et al 20 have shown recurrence rate was 7.1% in classical Limberg fl ap than 9.2 % in excision with primary closure (p value: 1.00).
High recurrence rate a er treatment have been a ributed to scar line at midline where movement is constant.Hence modifi ca on of classical Limberg fl ap was done into lateraliza on of midline incision which has demonstrated low recurrence rate 21,22 .In retrospec ve study done by Akin M et al 23 have shown that the recurrence rate was sta s cally higher in the classical group than in the modifi ed Limberg fl ap group (P = 0.036).
Our study showed lesser wound complica on with modifi ed Limberg fl ap .One pa ent had seroma a er removal of drain on 5 th day and three pa ents had lower wound gapping due to poor hygiene of lower edge.No case of fl ap necrosis was no ced in our study.However 30 pa ents complain of numbness over fl ap a er 2 years of follow up.
We emphasis that post surgical pa ent counseling regarding hair removal is more important for preven on of recurrence and hence we recommend that it should be standard prac ce to refer to dermatologist colleagues as a part of mul disciplinary approach for post opera ve management of pilonidal sinus.

Conclusion
Modifi ed Limberg fl ap is be er op on for pilonidal sinus with least recurrence.However, post surgical counseling for hair removal is very important in order to prevent recurrence and should be mul disciplinary approach along with dermatologist colleagues.

Figure 1 :
Figure 1: Marking of Rhomboid fl ap with lateraliza on from midline.

Figure 2 :
Figure 2: Wound a er fl ap closure