Comparison of the Limberg flap and bilateral gluteus maximus advancing flap following oblique excision for the treatment of pilonidal sinus disease

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  • ORIGINAL ARTICLE

    Comparison of the Limberg flap and bilateral gluteus maximusadvancing flap following oblique excision for the treatmentof pilonidal sinus disease

    Murat Yildar Faruk Cavdar

    Received: 11 June 2013 / Accepted: 22 August 2013

    Springer Japan 2013

    Abstract

    Purpose This study was performed to compare the use of

    a bilateral gluteus maximus advancing flap (BGMAF)

    following oblique incision, which was recently described

    for the surgical treatment of sacrococcygeal pilonidal sinus

    (SPS) disease, with the widely used Limberg flap (LF)

    technique following a rhomboid incision.

    Methods A total of 105 patients treated for SPS were

    evaluated retrospectively. The patients were evaluated in

    terms of their age, body mass index, symptoms, length of

    the operation, complications, postoperative hospital stay,

    time to return to work, postoperative cosmetic satisfaction

    and recurrence rate.

    Results Fifty-six of the patients were treated with

    BGMAF, while 49 were treated with LF. The mean follow-

    up was 20.5 5.4 months. The mean length of the oper-

    ation, hospital stay and time to return to work were shorter,

    while the cosmetic satisfaction score was higher in the

    BGMAF group compared to the LF group. There was no

    statistically significant difference between the groups for

    the other criteria.

    Conclusion The BGMAF appears to be superior to the LF

    in terms of the length of the operation, time to return to

    work and degree of cosmetic satisfaction. It is preferable

    for sinuses not to require wide excision, while the LF is

    more appropriate for sinuses with a large post-excision

    defect.

    Keywords Pilonidal sinus Limberg flap Obliqueexcision Advancing flap Socioeconomic level

    Introduction

    Pilonidal sinus disease is most common in the sacrococ-

    cygeal region and has an incidence of 26/100000. It is

    twice as common in males as in females [1]. A foreign

    body reaction developing as a result of hair follicles

    penetrating the skin following trauma is implicated in the

    pathogenesis of the disease [13]. The disease is generally

    asymptomatic. However, when it becomes symptomatic, it

    has a negative impact on the patients quality of life.

    Due to their high rates of recurrence, conservative

    methods of treating symptomatic sacrococcygeal pilonidal

    sinus (SPS), such as shaving [4], phenol administration [5]

    and cryosurgery [6], have gradually declined in popularity.

    Although surgical techniques such as excision, marsupial-

    ization and primary closure have lower recurrence rates

    than conservative methods, they have gradually given way

    to advancement flap techniques, for reasons such as the

    need for dressings, prolonged wound healing and wound

    infection. The Limberg flap (LF) technique has the lowest

    recurrence rate among the flap techniques currently used to

    treat SPS. However, recent reports have suggested that this

    technique does not achieve good results in terms of the

    cosmetic appearance and wound healing [7].

    The oblique excision and bilateral gluteus maximus

    advancing flap (BGMAF) technique was recently described

    for the treatment of SPS, and provides results similar to the

    LF in terms of recurrence [8]. However, to date, there have

    been no studies comparing this method with other tech-

    niques in terms of the length of the operation and the length

    of the hospital stay.

    M. Yildar (&)Department of General Surgery, Balkesir University MedicalSchool, Balkesir, Turkeye-mail: muratyildar@hotmail.com

    F. Cavdar

    Department of General Surgery, Yalova State Hospital, Yalova,

    Turkey

    123

    Surg Today

    DOI 10.1007/s00595-013-0764-5

  • Therefore, the present study was performed to compare

    the results of the LF, which is widely used for the surgical

    treatment of pilonidal sinus disease, and the recently

    described BMGAF after oblique excision.

    Methods

    The data for 117 patients surgically treated for SPS at the

    Mus and Erzincan State Hospitals in Turkey between

    February 2009 and July 2011 were evaluated retrospec-

    tively. Twelve patients were excluded due to a lack of data.

    The data for the remaining 105 patients who did not have

    massive gluteal involvement (diseased area more than

    5 cm from the intergluteal sulcus) were included. The

    infected sinuses were treated with antibiotics, while

    abscesses were treated with surgical drainage and antibi-

    otics. Surgery was performed 24 weeks after the regres-

    sion of the infection. Patients were informed about the

    operations to be performed, and signed consent was

    obtained. The operations were performed by the authors.

    Postoperatively, the patients were examined clinically at 3,

    5 and 10 days and 6 months after BGMAF and at 5 and

    10 days and 6 months after LF. The final condition of the

    patients was determined by a telephone interview. The

    cosmetic satisfaction with the surgical results was scored

    6 months postoperatively as follows: 1 = poor,

    2 = acceptable, 3 = good or 4 = perfect. Patients were

    compared in terms of age, body mass index (BMI),

    symptoms, length of the operation, complications, post-

    operative hospital stay, time to return to work, the post-

    operative cosmetic satisfaction score and recurrence.

    Statistical analysis

    The data are presented as the means and standard devia-

    tions, medians and percentages (range). t test was used to

    compare normally distributed numerical data between the

    groups, and the MannWhitney U test was used for non-

    normally distributed data. In all analyses, a value of

    P \ 0.05 was considered to indicate statistical significance.

    Surgical techniques and postoperative care

    Following the rectal lavage and shaving of the operation

    area on the morning of surgery, all operations were per-

    formed under spinal anesthesia in the prone-jackknife

    position. One gram of prophylactic cefazolin sodium was

    administered 2060 min before the skin incision.

    The Limberg flap was made following the administra-

    tion of methylene blue through the sinus opening, in the

    classic manner, using a vacuum drainage (Fig. 1). In

    BGMAF, an S-type oblique skin incision was made

    following the administration of methylene blue through the

    sinus opening (Fig. 2a). Diseased tissue, including the

    sinus tract, was excised as far as the postsacral fascia

    (Fig. 2b). The fascia of both gluteus maximus muscles was

    incised vertically from the point of adhesion to the sacrum

    and freed 1.52 cm from the muscle with hemostasis

    established with electrocautery (Fig. 2c). The fascia of

    each gluteus maximus was sutured individually to the

    postsacral fascia with no. 0 polyglactin sutures (Fig. 2d).

    The subcuticular plane was closed with subcutaneous 3-0

    polyglactin sutures, and the cutaneous tissue was closed

    with 3-0 polypropylene sutures (Fig. 3). No drain was used

    in any patient in the BGMAF group. Postoperative pain

    was relieved with nonsteroidal anti-inflammatory drugs as

    needed.

    Patients in both groups were mobilized on the first

    postoperative day and told not to sit for the first 7 days.

    Drains were removed when the drainage level reached

    \20 mL/day. Patients were discharged with appropriateinstructions for wound care and advised to use oral anti-

    biotics (co-amoxicillin 1000 mg, once every 12 h) for

    5 days. The skin sutures were removed 1012 days

    postoperatively.

    Results

    A total of 88 of the 105 patients were male while 17 of

    them were female; 56 patients were treated with BGMAF

    and 49 with LF. Their median age was 25 (range 1549)

    years. There were no significant differences between the

    groups in terms of age or gender. The mean follow-up was

    20.5 5.4 months. The mean BMI was 25.4 1.9 in the

    BGMAF group and 24.5 1.6 in the LF group. Although

    there was a significant difference (P = 0.02) between the

    groups, this was unlikely to have affected the treatment

    results. The patients preoperative symptoms were similar

    in both groups. The patients characteristics and symptoms

    are summarized in Table 1.

    The mean length of the operation was significantly

    shorter in the BGMAF group compared to the LF group

    Fig. 1 The final view of the Limberg flap procedure

    Surg Today

    123

  • (31.1 3.9 vs. 48.3 5.0, P \ 0.001). Wound dehis-cence was seen in seven (12.5 %) patients in the BGMAF

    group and three (6.1 %) patients in the LF group in the

    early postoperative period; there were no significant dif-

    ferences between the groups in terms of dehiscence

    (P = 0.267) or in the total complication (P = 0.154) rates.

    Wound dehiscence was treated conservatively. Seromas

    developed in two (3.6 %) patients in the BGMAF group

    and hematomas developed in two (4.1 %) patients in the

    LF group. The seromas were aspirated, while the hemato-

    mas were drained under local anesthesia.

    The mean hospital stay and time to return to work

    were shorter in the BGMAF group (2.1 0.3 and

    12.6 2.6 days, respectively) compared to the LF group

    (2.5 0.6 and 14.0 2.1 days, respectively) (P \ 0.001and P = 0.003, respectively), and the cosmetic satisfaction

    score was higher in the BGMAF group than in the LF

    group (3.2 0.5 vs. 2.9 0.5, res