International Surgery Journal

Singh PK et al. Int Surg J. 2017 Jul;4(7):2238-2242

http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

DOI: http://dx.doi.org/10.18203/2349-2902.isj20172773
Original Research Article

Limberg flap procedure for sacrococcygeal pilonidal sinus:

a prospective study
Prashant Kumar Singh*, Rohit Kumar Gohil, Neeraj Saxena

Department of Surgery, PGIMER and Dr. Ram Manohar Lohia Hospital, New Delhi, India

Received: 15 May 2017

Accepted: 08 June 2017

*Correspondence:
Dr. Prashant Kumar Singh,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Sacrococcygeal pilonidal sinus is a common and morbid disease associated with high recurrence rate
after surgery. Many conventional surgical procedures have been described for its management with their merits and
demerits. The present study aims to evaluate the efficacy and complications of Limberg flap reconstruction surgery.
Methods: 32 consecutive patients underwent Limberg flap reconstruction between January 2015 to November 2016
and were evaluated for various parameters.
Results: All patients successfully underwent surgery, with very minimal postoperative pain, average hospital stay for
5 days, returned to work after 19 days, with 2 patients having seroma, 1 having flap necrosis, 1 developed wound
infection and no recurrences so far. Patients with complications were managed conservatively.
Conclusions: Limberg flap for reconstruction of the defect after excision of recurrent sacrococcygeal pilonidal sinus
is an effective and reliable technique, easily performed, with high patient satisfaction, associated with complete cure
and low incidence of post-operative complications.

Keywords: Limberg flap, Pilonidal sinus, Sacrococcygeal

INTRODUCTION cells. Now the view widely shifted toward acquired

theory5 and is based on the observations that congenital
Chronic pilonidal sinus is common disease and is usually tracts do not contain hair and are lined by cuboidal
found in the midline of the sacrococcygeal region of epithelium. Karydakis proposed three main factors
young hirsute men. It is an acquired condition with high causing the disease, namely high quantity of hair,
morbidity and patient discomfort. The name pilonidal is extreme force, and vulnerability to infection. 6 The
taken from Latin meaning “nest of hairs.” The estimated presence of hair in the gluteal cleft seems to play a
incidence is 26 per 1, 00,000 population.1,2 It generally significant role in the pathogenesis of this disease. A deep
presents as a cyst, abscess or sinus tracts with or without natal cleft is a favourable environment for sweating,
discharge.3 Men affected more often than women, rare maceration, bacterial contamination and penetration of
both before puberty and after the age of 40 years. 4 hairs. Other risk factors include obesity, local trauma or
irritation, sedentary life style, family history, poor
The aetiology of the pilonidal sinus is a matter of debate. hygiene and excessive hairiness.
Initially congenital origin was suggested that it was
secondary to a remnant of an epithelial lined tract from It is widely accepted that a pilonidal sinus results from
post coccygeal epidermal cell rests or vestigial scent the penetration of shed hair shafts through the skin, which

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 Singh PK et al. Int Surg J. 2017 Jul;4(7):2238-2242

ultimately leads to an acute or chronically infected site, were male. The median ages of patients were 21 years. 7
and the disease can be treated effectively by appropriate patients (23%) had previous history of abscess drainage
surgery.7 However, extensive disease with numerous due to pilonidal sinus. The main outcome of this study
pilonidal openings, branching tracts, and overt symptoms was to evaluate the surgical procedure with respect to the
may require wide excision of the diseased region. surgical area related complications and recurrence rates.

Diagnosis is generally clinical and patient may present Surgical procedure

with a chronic inflammation or a sinus with persistent
discharge or acutely there may be an abscess or multiple The natal cleft was shaved the day before surgery.
subcutaneous tracts. Cefazolin 1 gram and Metronidazole 500 mg were
administered intravenously prophylactically before
Although pilonidal sinus can be treated using several placing incision. All operations were performed under
defined conservative and surgical methods, recurrence spinal anaesthesia. Patients were placed in prone position
rates remain high.8 Complete removal of the pilonidal and the buttocks strapped apart by adhesive tapes.
sinus or sinuses and appropriate reconstruction can lead
to successful recovery.9 Using a sterile skin-marking pen a rhomboid area of skin
was marked over pilonidal sinus involving all midline
Various techniques for management of sacrococcygeal pits and lateral extension if any. The flap design was
pilonidal sinus have been described which ranges from, mapped on the skin (Figure 1). The long axis of the
clipping of hairs with good hygiene of the area, wide rhomboid in midline was marked as A-C, C being
excision of the area and packing, excision and primary adjacent to perianal skin, A placed so that all diseased
closure, marsupialization and flap techniques like tissues can be included in the excision. The line B-D
Limberg flap,10 modified Limberg transposition flap,11 transected the midpoint of A-C at right angles and is 60
elliptical rotation flap12 and rotation advancement % of its length. D-E was a direct continuation of the line
fasciocutaneous flap.13 B-D and was of equal length to the incision B-A, to
which it was sutured after rotation. E-F was parallel to D-
Among different surgical modalities for treatment of C and of equal length. After rotation, it was sutured to A-
sacrococcygeal pilonidal sinus, flap reconstruction D.16
techniques eradicate the aetiology of the disease by
flattening the inter gluteal sulcus with much less hairy
fasciocutaneous flaps and less perspiration.14 Among
them, the most commonly used is the rhomboid excision
with the Limberg flap. With this technique of flattening
the natal cleft, a tension-free repair is made using a wide,
well-vascularized flap. It is reported as one of the best
treatment methods, with a 0-16 % of surgical area-related
complication and a recurrence rate of 0-5 %.15

This article evaluates the use of Limberg flap, which is

based on the superior gluteal and sacral perforators for
reconstruction of the sacrococcygeal region after excision
of pilonidal sinus.

METHODS
Figure 1: Marking with letters.
Thirty-two consecutive patients who underwent pilonidal
sinus surgery between January 2015 and November 2017
A rhombic-shaped excision of the sinus-bearing skin and
were included in this study. The mean duration of
subcutaneous tissue up to the pre-sacral fascia was done
symptoms was 3.5 years. All patients were subjected to
complete history taking and routine clinical, local by electrocautery (Figure 2) (Figure 3). Then elevation of
examination and laboratory investigations. Written perforator-based Limberg flap (Figure 4) (based on the
consent was obtained from all patients after explanation superior gluteal and sacral perforators according to the
study done by Koshimaetal on a cadaver dissection)17 in
of the procedure and expected results of the flap in this
the same manner and the level of dissection was pre
area. Data of the patients were collected from the forms,
muscular fascia, good haemostasis was achieved and the
which were created preoperatively and used for
postoperative follow up period, for each patient. The adhesive tapes which retracted the buttocks were released
patients having other local pathologies like eczematous, to allow suturing of the flap without tension A right or
fungal or other deforming pathologies were excluded left sided fasciocutaneous Limberg transposition flap,
incorporating the gluteal fascia, was fully mobilized on
from the study. All the patients underwent Limberg flap
reconstruction as the surgical procedure. All the patients

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 Singh PK et al. Int Surg J. 2017 Jul;4(7):2238-2242

its inferior edge and transposed medially to fulfil the

Limberg defect (Figure 5).

Figure 5: Rotation of flap over defect.

Figure 2: Placing skin incision.
The defect thus created was closed in linear fashion
(Figure 6). Interrupted Vicryl 2-0 sutures to include
fascia and fat were placed over a vacuum drain, and then
finally the skin was closed with skin stapler.18The
operation produces a tension-free flap of unscarred skin
in the midline (Figure 6). Antibiotics were given for 7
days initially intravenously, then orally, suction drain
removed after 2 days, staples removed around 10 th day.
The patient was advised not to put pressure on the flap
for 3 weeks. All the patients were evaluated for flap
healing, seroma formation, oedema, flap necrosis,
surgical site infection, pain and length of hospital stay.
The objective grading of pain was done by visual
analogue scale. The patients were followed at 1 and 6
months after surgery.

Figure 3: Excision of pilonidal sinus complex

till deep fascia.

Figure 6: Final outcome after suturing.

RESULTS

A total of 32 patients came with pilonidal sinus, from

January 2015 to November 2016, underwent Limberg
flap surgery under spinal anaesthesia. The mean operative
Figure 4: Raising of inferior Limberg flap. time was 50 minutes (range-30 to 80 minutes).

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 Singh PK et al. Int Surg J. 2017 Jul;4(7):2238-2242

Table 1: Rate of complications. There are many previous studies on this subject among
which, Katsoulis had 25 patients, with 16 of them having
Complications Number Percentage complications with no recurrences and Aslam had 110
Seroma 2 6.2% patients, with 5 of them having complications and 1
Wound infection 1 3.1% recurrence (19)5.26,27 Mentes and Urhan were other
Flap necrosis 1 3.1% studies.28,29 Several series with the rhomboid or rhombic
flap technique, including more than 50 cases, have
All patients were followed up initially at 2-week interval, reported recurrence rates of1% to7%.30 In our series we
then at 1 month and again at six months. Four patients had a total of 32 patients among which 4 patients had
(12.5%) developed complications two (6.2%) had seroma complications like seroma formation (2), wound infection
formation, 1 (3.1%) had flap necrosis and the other 1 (1) and flap necrosis (1) which were managed
(3.1%) had superficial surgical site infection. subsequently. The mean pain score was 4.5 and there
were fewer needs of additional analgesics apart from the
It took nearly 8 days for seroma to resolve and three standard protocol. None of the patients reported
weeks for the surgical site infection to subside. The recurrence.
patient with flap necrosis underwent multiple
debridement and dressings and took 8 weeks to heal by Iesalnieks studied the long-term results after excision of a
secondary intention. The pain score range was in the pilonidal sinus and primary midline closure compared
range of 2-8 with a mean score of 4.5. The average length with the open surgical procedure in 73 patients.31 There
of stay in hospital was 5 days (range-2 to 14 days). All was a high recurrence rate (42%) after excision of
other patients wound healed primarily with minimal pilonidal sinus and primary midline closure. Present
scarring and less postoperative pain, with no recurrence study shows no recurrence with this procedure. In present
till now. None of the patients needed readmission due to study, the flap is inferiorly based with more anatomical
pilonidal sinus. The mean time to return to work was 19.6 and better cosmetic appearance. In 2008, El-Khatiband
days (range -10 to 30 days). Al-Basti reported a series of 8 cases of pilonidal sinus
reconstructed by bilobed perforator-based flap, the mean
DISCUSSION operative time was 90 minutes so it is time consuming
with a long scar.32 In the study, we performed inferiorly
Sacrococcygeal pilonidal sinus disease is notorious for based flap, the mean operative time was 50 min with
complete cure of the disease and very low incidence of
prolonged morbidity and recurrence and the ideal
treatment should ensure low pain, short hospitalization post-operative complications when compared with the
period, low risk of complications, rapid return to normal previous studies.
activities, better cosmesis, and should have a low
recurrence rate. CONCLUSION

There has been increased realisation of the importance Limberg flap for reconstruction of the defect after
that the midline natal cleft should be avoided for suture excision of recurrent sacrococcygeal pilonidal sinus is an
placement as it is the site for recurrence. To minimise the effective and reliable technique, easily performed,
recurrence, the emphasis should not only be on flattening subjectively high patient satisfaction, associated with
the natal cleft but also of achieving an off-midline closure complete cure and low incidence of post-operative
of the resultant defect in order to minimize wound-related complications.
complications and recurrence.19-21
ACKNOWLEDGMENTS
Flap reconstructions having a midline lower edge or
suture line on intergluteal sulcus are more likely to Authors would like to thank their patients who gave them
increase recurrence rates, wound dehiscence and wound the opportunity to serve and learn.
infection risk. Limberg flap reconstruction achieves an
Funding: No funding sources
off-midline closure and ensures flattening of the natal
Conflict of interest: None declared
cleft.
Ethical approval: The study was approved by the
institutional ethics committee
Reconstruction of the defect with Limberg flap has many
advantages as it is easy to perform and design, and it
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