Limberg Flap Reconstruction for the Treatment of Pilonidal Sinus Disease

7/25/2019 Limberg Flap Reconstruction for the Treatment of Pilonidal Sinus Disease

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Chapitre / Chapter ....

LIMBERG FLAP

RECONSTRUCTION FOR THE

TREATMENT OF PILONIDAL

SINUS DISEASE

E.P. Misiakos, T. Troupis, S.

Hatzikokolis, A. Macheras, T.

Liakakos, P. Patapis, G. Karatzas

(Chirurgia, 11 (!"# !1$%!1&"

Introduction

Pilo'ial si'us isease is a co))o'

chro'ic isorer characterize *+

i'a))atio', a*scesses, a' si'us

-or)atio' i' the sacrococc+geal

regio'. t has a' i'cie'ce o- .& /

i' the ge'eral populatio' a' it

a0ects )ai'l+ +ou'g )ale ith a

peak i'cie'ce at the age o- 12%3!

+ears (1, 3". There are se4eral

theories regari'g its etiolog+ a'

pathoge'esis, a' it is co'siereas a' ac5uire lesio'. Mai'

preisposi'g -actors are poor

h+gie'e, e6cessi4e hairi'ess, a'

local trau)a i' the sacrococc+geal

area, as ell as the prese'ce o- a

eep 'atal cle-t. This isease is

ac5uire i' the 'atal cle-t a' eep

i'tergluteal sulcus as a result o-she hair sha-ts pushe i'to ski'

a*rasio's *+ the rotatio'al

)o4e)e'ts o- the *uttocks uri'g

alki'g ($, 7". Hair i'sertio' leas to

-oreig' *o+ reactio' a' the

e4elop)e't o- a' acute or

chro'icall+ i'-ecte site (!". This

process is )ore pro'ou'ce i'o*ese patie'ts, i' ho) the ski'

o4erl+i'g the i'tergluteal sulcus is

usuall+ et a' -ragile (7".

The ieal treat)e't strateg+ oul

i'clue ie e6cisio' o- the isease

regio' -olloe *+ atte'i'g o- the'atal cle-t to reuce the risk o-

recurre'ce (2".

8arious surgical tech'i5ues ha4e

*ee' escri*e, i'clui'g e6cisio'

ith pri)ar+ closure (&", e6cisio'

ith ope' packi'g (9", e6cisio' ith

)arsupializatio' (:", e6cisio' ith

ski' gra-ti'g (1", a' ap

reco'structio' (11, 13". The )ai'

pro*le)s associate ith the

co'4e'tio'al tech'i5ues are the

high i'-ectio' a' recurre'ce rate.

;' the other ha' proceures that

atte' the i'tergluteal sulcus a'

*ri'g the suture li'e asie the

)ili'e see) to *e superior i' ter)s

o- postoperati4e )or*iit+ a'

recurre'ce rate (1$".

The ai) o- the prese't stu+ as to

a'al+ze retrospecti4el+ the results o-

the surgical )a'age)e't o- a group

o- patie'ts ith co)plicate or

recurre't pilo'ial si'us

isease usi'g the Li)*erg

tra'spositio' ap a-ter rho)*oi

e6cisio' o- the isease area.

Material and Method


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Livres

*etee' Septe)*er 3$ a'

=ece)*er 37. All patie'ts ere

)ale a' ere age *etee' 1:%7&

+ears ()ea' age 32.7>1.2 +ears".

Te't+%three patie'ts (&1.: /" ha)ultiple ?stula tracks a' chro'ic

ischarge (stages $ a' 7"

accori'g to Cha4oi' classi?catio'

(17"@ a' : patie'ts (39.1 /" ha

recurre't isease. i4e o- the

patie'ts ith recurre'ce ha

u'ergo'e e6cisio' ith ope'

packi'g, $ )arsupializatio' a' o'e

e6cisio' ith pri)ar+ closure. Bo'e

o- the patie'ts ha *ee' operate

o' i' our cli'ic.

Surgica procedure!

Te't+%eight patie'ts u'ere't

surger+ u'er local a'esthesia. The

rest 7 patie'ts ere operate u'er

ge'eral a'esthesia. All patie'ts

recei4e proph+la6is agai'st

i'-ectio' ith 1 g o- ce-o6iti'. At

surger+ the+ ere place i' the

ack%k'i-e positio'. The

sacrococc+geal area as sha4e

a' clea'e ith po4io'e%ioi'e

solutio'. The e6te'sio' o- si'us as

eter)i'e usi'g a pro*e i'to the

si'us tracts. The area to *e e6cise

as )appe o' the ski' i' a

rho)*oi -or). Co'se5ue'tl+,

co)plete e6cisio' o- the pilo'ial

si'us tracks as carrie out *+

rho)*oi i'cisio'. The upper a'

loer tips o- the i'cisio' ere

place i' the )ili'e i' 37 cases(ig. 1A". Hoe4er, i' 9 )ost rece't

cases its i'-erior tip as tra'spose

laterall+ to i'corporate all ?stulous

tracts ()oi?e Li)*erg ap" (ig.

1D". A right%sie -asciocuta'eous

rho)*oi tra'spositio' api'corporati'g the gluteal -ascia as

tailore to ?t the size o- the

rho)*oi area. The ap as the'

tra'spose )eiall+ to ?ll the

rho)*oi e-ect ithout te'sio'

(ig. 1C". A-ter )eticulous

he)ostasis the surgical ou' as

close ithout rai' i' all cases.

Appro6i)atio' o- the -ascial la+er

a' su*cuta'eous tissues as

per-or)e ith pol+gl+colic aci

sutures, to pre4e't ea space. The

ski' as close ith i'terrupte

pol+prop+le'e sutures (ig. 3".

Fi!ure "# A. Preoperati4e esig' o- the

rho)*oi e6cisio' a' ap i' the classical

Li)*erg ap reco'structio' tech'i5ue. B.

Preoperati4e esig' o- the )oi?e

Li)*erg ap tech'i5ue. The rho)*oi

e6cisio' as tailore as+))etricall+ to

place the loer pole o- the ap 1 3 c)

lateral to the i'-erior )ili'e. C.

Postoperati4e sche)atic prese'tatio' o- the

tra'spose ap suture i' the rho)*oi

e-ect.

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Fi!ure $#Postoperati4e appeara'ce o- a

)oi?e Li)*erg ap.

"oo#-up

All patie'ts ere release -or

)o*ilizatio' a-ter the ?rst 2 hours

postoperati4el+, *ut ere a4ise

-or li)ite e6te'sio' o- the sacral

regio' u'til the+ -elt co)pletel+ -ree

o- te'sio' a' pai'. =ischarge

-olloe soo' a-ter accori'g tose'ior surgeo's esti)atio'. The

patie'ts ere a4ise to keep the

sacrococc+geal area clea' a'

sha4e. Co)plicatio' rates,

hospitalizatio', ti)e re5uire to

resu)e ail+ acti4ities, patie't

co)plai'ts, a' recurre'ce rate

ere all recore. ollo%upe6a)i'atio's ere o'e at the e'

o- the ?rst, si6th, a' tel-th )o'th

a-ter surger+. De+o' the ?rst +ear

the patie'ts ere e6a)i'e ith

pho'e calls at e4er+ 2 )o'ths. The

-ollo%up perio ra'ge *etee' 17

a' 39 )o'ths ()ea' -ollo%up 12

)o'ths".

Reult

All patie'ts sta+e i' the outpatie't

ar -or a -e hours a' the' the+

ere ischarge as soo' as the+

coul *e )o*ilize. our patie'tsho chose to u'ergo ge'eral

a'esthesia sta+e i' hospital -or 37

to $3 hours. Thus the )ea' uratio'

o- hospital sta+ as 13 hours (ra'ge

2 hours to $3 hours". There as

)i'i)al pai' or te'sio' i' the

sacrococc+geal area a-ter surger+.

Hair sha-ts ere prese't i' the

ca4ities o- all patie'ts. Postoperati4e

short%ter) co)plicatio's ere# a

)i'i)al super?cial i'-ectio' i' o'e

case ($.13 /", a' sero)a i' $

cases (:.7 /". These cases ere

treate co'ser4ati4el+. Purule't

ou' i'-ectio', he)ato)a or ap

'ecrosis i 'ot e4elop i' a'+

patie't. ' all cases e ha goo

)ai'te'a'ce o- the ap.

The co'4alesce'ce perio as short

i' all patie'ts. The+ retur'e to ork

ithi' 7 to 13 a+s ()ea' ti)e to

retur' to ork as : a+s". Bo

recurre'ce or a'+ other

co)plicatio' as etecte uri'g

the -ollo%up perio. ;ur patie'ts

ere satis?e ith the cos)etic

appeara'ce a-ter surger+, si'ce

)ost o- the) ha alrea+ e6te'si4e

isease ith ?stulous tracks a'For

scars.

Dicuion

Pilo'ial si'us isease is co'siere

Hoang duc Nam MD - 2013$


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Livres

as a chro'ic, i'ter)itte't,

i'a))ator+ process rarel+

occurri'g i' co'ge'ital cases as

e6te'sio's o- si'us a' ura to

'eural ca'al (1!, 12". Latel+ thetheor+ -or co'ge'ital etiolog+ has

*ee' supersee *+ a theor+

i'4ol4i'g hair i'sertio' to the 'atal

cle-t (:, 1&". A eep 'atal cle-t is a'

e'4iro')e't -a4ori'g seati'g, hair

pe'etratio', a' *acterial

co'ta)i'atio'. =uri'g alki'g, the

*uttock )o4e)e'ts help hairs to

pe'etrate the ski' a' cause a

-oreig' *o+ reactio' a' i'-ectio'.

This grauall+ leas to pilo'ial

a*scess a'For si'us -or)atio' (19,

1:".

Pilo'ial si'us isease occurs )ore

o-te' i' aolesce't or +ou'g )ales.

' our stu+ e selecte o'l+ )ale

patie'ts their )ea' age as 32.7

+ears. 'ee i' )ost reports there

is a )ale prepo'era'ce, hich is a

-urther i'icatio' supporti'g the

theor+ -or ac5uire etiolog+, a' the

)ea' age is close to ours (!, 1!".

There is also a' i'crease i'cie'ce

i' Caucasia's a' ecrease i'

A-rica' a' Asia' races, epe'i'g

)ai'l+ o' hair istri*utio' a'

groth (!". t is e'cou'tere )ore

-re5ue'tl+ i' o*ese patie'ts ue to

i'crease perspiratio' a' gluteal

-rictio' a' i' patie'ts ith poor

h+gie'e a' local hirsutis) (3".

There is co'siera*le co'tro4ers+

regari'g the opti)al treat)e't o-this co))o' isease. Surgical

i'ter4e'tio's are ge'erall+ pre-erre

agai'st co'ser4ati4e treat)e't.

Hoe4er, a lo'g list o- surgical

tech'i5ues reects the i'a*ilit+ to

?' a' ecie't )oe o- treat)e'tappro4e *+ all surgeo's. E6cisio'

o- the isease tissue o' to the

presacral -ascia is ge'erall+

accepte, *ut the )a'age)e't o-

the re)ai'i'g space is still a )atter

o- e*ate. Pri)ar+ suturi'g a-ter

resectio' leas to a resulta't ea

space, hich is actuall+ a co'ti'ui'g

'atal cle-t. This preisposes to

i'-ectious co)plicatio's a' a high

recurre'ce rate approachi'g 3 /

(1!, 3, 31, 33". ;ther co'4e'tio'al

)ethos, such as the Ila+ ope'I

tech'i5ue ith co'ti'uous clea'si'g

o- the ou' a' packi'g u'til

gra'ulatio' occurs, a' the Ise)i%

ope'I tech'i5ues, i.e., closi'g the

ou' ith partial sutures a'

)arsupializatio', are all associate

ith lo'g%ter) ou' care a' high

rate o- recurre'ce (1$, 33". Hogso'

a' Gree'stei' reporte that cases

treate *+ i'cisio' a' rai'age or

e6cisio' ith )arsupializatio' ha a

recurre'ce rate o- 7 / ($". ;thers

reporte that )arsupializatio' is

associate ith a loer recurre'ce

rate o- 1.3 /%9 /, *ut a lo'g heali'g

perio o- $%! eeks (:, 3$". '

aitio', patie'ts co)plai' o-

i'crease pai' a' isco)-ort i' the

ou' area, especiall+ i- the closure

o- the e-ect has *ee' o'e u'erte'sio'. Also, the large areas o- scar

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tissue i' the ope' or se)i%ope'

tech'i5ues )a+ cause te'sio',

especiall+ o' sitti'g, e4e' +ears

a-ter surger+ (37".

Si'ce )ost recurre'ces occur i' thei'tergluteal sulcus, )ethos that

atte' the i'tergluteal sulcus oul

eraicate the etiolog+ a' eli)i'ate

the risk o- recurre'ce (!, 3, 3!".

Co)plete closure o- the e-ect

ithout te'sio' is o'l+ pro4ie *+

reco'structio's such as the J%plast+,

the


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Livres

atte'tio' i' the rece't +ear as a

)ea's to )a'age co)plicate or

recurre't pilo'ial si'us isease.

Accori'g to this tech'i5ue a

rho)*oi shape e6cisio' i'clui'gall si'uses a' tracks is carrie out.

A lateral (right or le-t"

-asciocuta'eous tra'spositio' ap,

i'corporati'g the gluteal -ascia, is

-ull+ )o*ilize o' its i'-erior part

a' tra'spose )eiall+ to ?ll the

rho)*oi e-ect. ' case o-

e6te'si4e isease ith si'us tracks

close to the i'-erior )ili'e e )a+

place the i'-erior ape6 o- the

rho)*oi e6cisio' 1%3 c) lateral to

the )ili'e o' the sie opposite to

the o'or area (1$". The e-ect is

close ith i'terrupte sutures

ithout te'sio' to per)it -ull *loo

suppl+ to the ap (ig. 1". Si'ce all

-ree space i' the gluteal regio' is

co4ere, there is 'o 'ee -or a

rai'age tu*e ($&".

The Li)*erg ap repair has se4eral

a4a'tages# it is a 4er+ ecie't

)etho to atte' the 'atal cle-t a'

ith si)ple )oi?catio's it )a+

isplace the i'cisio' scar -ro) the

)ili'e (3, 1:". Thus ski'

)aceratio' a' e*ris accu)ulatio'

is i)i'ishe a' seati'g resulti'g

-ro) -rictio'al )o4e)e'ts o- the

*uttocks is ecrease. - all si'us

tracks are re)o4e, the' all

preisposi'g -actors are eli)i'ate

a' the recurre'ce rate is 4er+ lo

(%& /" (3, !, 13, 1:, $9". Si'ce)ost o- these recurre'ces occur i'

the )ili'e, a )oi?catio' o- the

Li)*erg ap tech'i5ue has *ee'

use *+ se4eral authors ($:, 7".

Accori'g to the latter tech'i5ue,

the ou' a' all suture holes aretake' aa+ -ro) the )ili'e, a'

the loer pole o- the i'cisio' is

place o' the co'tralateral sie o-

the ele4ate ap. This a+ there is

'o i'cisio' i' the loer i'tergluteal

sulcus.

' our series the i))eiate

postoperati4e outco)e a-ter the

proceure as outsta'i'g. The

)aorit+ o- our patie'ts ere

)a'age i' a' outpatie't *asis.

The+ i 'ot ha4e a'+ pai' or

co'siera*le te'sio' i' the

sacrococc+geal area a' ere a*le

-or )o*ilizatio' as soo' as 7 to 2

hours a-ter surger+. A -e patie'ts

ho electe to u'ergo ge'eral

a'esthesia sta+e i' hospital -or less

tha' $3 hours. The co'4alesce'ce

perio as also short# patie'ts ere

a*le to retur' to regular ail+

acti4ities ithi' 7 to 13 a+s, ith a

)ea' ti)e : a+s, a )uch shorter

perio tha' the o'e reporte

elsehere (71". ;'l+ )i'or

co)plicatio's ere e'cou'tere i' a

-e patie'ts ()or*iit+ rate 13.! /".

Bo ap ische)ia or 'ecrosis as

'ote. The a*o4e results are

e5ui4ale't or e4e' *etter tha' the

o'es reporte elsehere (3, !, 1$".

Bo recurre'ces ere etecte i' a

-ollo%up perio ra'gi'g *etee' 17a' 39 )o'ths. A zero recurre'ce

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rate -or the )oi?e Li)*erg ap

proceure is also reporte *+

Me'tes, Ciha' a' Teki' (3, 1$, $:,

7". Although e i 'ot ha4e a'+

recurre'ces or other pro*le)s iththe classical Li)*erg ap proceure

so -ar, e rece'tl+ i'trouce the

)oi?e Li)*erg ap tech'i5ue,

si'ce it is 'o co'siere as the

)ost relia*le tech'i5ue.

As regars the cos)etic appeara'ce

a-ter surger+ it is ell k'o' that

plast+ tech'i5ues lea4e a

co'siera*le surgical scar, a' 'ot

all patie'ts are satis?e -ro) this

poi't o- 4ie (1:". or that reaso'

e ere relucta't to select -e)ale

patie'ts -or this t+pe o- surger+.

Hoe4er, o' the lo'g%ter) 'o'e o-

our patie'ts ha a serious co)plai't

a*out the cos)etic appeara'ce o-

the scar, *ecause the+ all ha

e6te'si4e i'4ol4e)e't i' thesacrococc+geal area, or ha alrea+

scars -ro) pre4ious surger+.

' co'clusio', the Li)*erg

proceure has *ee' pro4e' to *e a

sa-e a' a4a'tageous tech'i5ue i'

the treat)e't o- co)plicateF

recurre't pilo'ial si'us isease,

o0eri'g )i'i)al postoperati4e pai',

a lo co)plicatio' rate, a 5uick

heali'g ti)e, short hospitalizatio'

a' isa*ilit+ a' a 4er+ lo

recurre'ce rate.

Hoang duc Nam MD - 2013&

Documents

Limberg Flap Reconstruction for the Treatment of Pilonidal Sinus Disease