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Featured Commentary

Our online subscription format, SRGS Connect, features 10 commentaries on recently published articles in top medical journals with each new edition. The commentaries are by practicing surgeons and focus on the strengths and weaknesses of the research and its contribution to advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of SRGS Connect, What You Should Know.


Yildiz T, Ilce Z, Kucuk A. Modified Limberg flap technique in the treatment of pilonidal sinus disease in teenagers. J Pediatr Surg 2014; 49(11):1610-3.

Comment
David Kays, MD, FACS, University of Florida, Gainesville

Bottom line: The growing literature in adolescents is complemented by randomized, controlled trials in young adults that together clarify that pilonidal disease excision with midline closure or open wound care should be abandoned in favor of one of several superior flap closure techniques.

 

This report from Yildiz and colleagues looks at outcomes in eight consecutive teenage patients who underwent pilonidal sinus excision with primary midline closure and compares them to the subsequent 32 who underwent excision and closure via a modified Limberg flap technique. The authors adopted the Limberg flap after uniformly poor results with midline closure.

The Limberg flap is a wide diamond or rhomboid-shaped excision of involved pilonidal tissue with an additional rhomboid-shaped release of adjacent tissue that is then rotated into the defect. Wound complications, including infection and dehiscence, were less frequent (16% vs. 88%) and disease recurrence was less (0% vs. 38%) with the Limberg flap compared to excision and midline closure.

This series of 32 consecutive excisions of pilonidal disease without a recurrence is remarkable, but the subject deserves a wider review. The articles listed below aggressively compare contemporary surgical managements of pilonidal disease, including excision with wound packing, excision with primary midline closure, and three variations of excision with flap closure.

As demonstrated in the Yildiz report, excision of pilonidal disease with midline closure has a prohibitively high wound complication rate, as the healing suture line is exposed to exactly the same risk factors that caused the original disease. These include a deep natal cleft, hirsutism, and obesity among others. Flap closures owe their success to flattening the natal cleft and moving the healing suture line out of the dark, hairy, and wet environment that spawned the disease.

In experienced hands, the three major flaps (Bascom cleft lift, Karydakis flap, and Limberg flap) all represent major advances with superior results compared with open symmetrical excision with either midline closure or open wound packing. These latter two options should be abandoned in favor of flap closures, as wound complication rates average less than 20% with flap closures and recurrence rates are generally less than 5% (zero in several studies), demonstrably superior to non-flap closure options.

Both the Bascom lift and the Karydakis flap are asymmetric excisions of pilonidal disease with off-midline closure. As such, they are similar, with somewhat shorter operative times compared with the Limberg flap and its variations. Each flap has proponents, but it appears all flaps have low recurrence rates in experienced hands. Of note, the off-midline closures may be preferable to the Limberg flap for adolescents concerned about cosmetic outcomes.

Since pilonidal disease onset is often related to puberty, and the incidence seems to be increasing commensurate with increasing obesity, this and similar reports are timely and important for surgeons dealing with these ages. The growing literature in adolescents is complemented by randomized, controlled trials in young adults that together clarify that pilonidal disease excision with midline closure or open wound care should be abandoned in favor of one of several superior flap closure techniques.

Suggested reading

Afşarlar CE, Yılmaz E, Karaman A, et al. Treatment of adolescent pilonidal disease with a new modification to the Limberg flap: symmetrically rotated rhomboid excision and lateralization of the Limberg flap technique. J Pediatr Surg 2013 Aug; 48(8):1744-9.

Arslan K, Said Kokcam S, Koksal H, et al. Which flap method should be preferred for the treatment of pilonidal sinus? A prospective randomized study. Tech Coloproctol 2014 Jan; 18(1):29-37.

Enriquez-Navascues JM, Emparanza J I, Alkorta M, et al. Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus. Tech Coloproctol 2014 Oct; 18(10):863-7.

Gendy AS, Glick RD, Hong AR, et al. A comparison of the cleft lift procedure vs wide excision and packing for the treatment of pilonidal disease in adolescents. J Pediatr Surg 2011 Jun; 46(6):1256-9.

Guner A, Boz A, Ozkan OF, et al. Limberg flap versus Bascom cleft lift techniques for sacrococcygeal pilonidal sinus: prospective, randomized trial. World J Surg 2013 Sep; 37(9):2074-80.