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Year : 2015  |  Volume : 5  |  Issue : 2  |  Page : 74-77

Rhomboid excision with modified Limberg flap in the treatment of sacrococcygeal pilonidal disease

1 Department of General Surgery, Owaisi Hospital and Research Centre, Princess Esra Hospital, Deccan College of Medical Sciences, Hyderabad, Telangana, India
2 Department of General Surgery, Princess Esra Hospital, Deccan College of Medical Sciences, Hyderabad, Telangana, India
3 Department of Orthopaedics, Princess Esra Hospital, Deccan College of Medical Sciences, Hyderabad, Telangana, India

Date of Web Publication16-Jun-2015

Correspondence Address:
Dr. S M Hussain
Department of General Surgery, Owaisi Hospital and Research Centre, Deccan College of Medical Sciences, Hyderabad - 500 058, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-9596.158818

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Background: Optimal treatment for sacrococcygeal pilonidal disease has not been determined because of high complications and recurrence rate. We conducted this study to evaluate the effectiveness of rhomboid excision with modified Limberg flap in the treatment of sacrococcygeal pilonidal disease.
Patients and Methods: Twenty one patients with pilonidal sinus of both primary and recurrent presentations were operated from July 2011-July 2012. Following rhomboid excision of the pilonidal sinus a modified Limberg flap was performed and used to cover the defect under spinal anesthesia. Cases were followed up for median of 4 months post operatively.
Results: Of the 21 cases, 16 (76%) had no post operative complications, either during their stay in the hospital (3-9 days) or during the follow up period (4 months). Five cases presented with different complications. One patient had recurrence, two had complications of both wound infection and wound dehiscence and underwent second operation under local anaesthesia.
Conclusion: Rhomboid excision with modified Limberg flap is a promising surgical technique proved to be safe and effective in the treatment of both primary and recurrent pilonidal sinuses with less post-operative complications, short hospital stay and low recurrence rate.

Keywords: Limberg flap, recurrence, rhomboid excision, sacrococcyegeal pilonidal disease

How to cite this article:
Hussain S M, Farees S N, Abbas S J, Vakati Raghavendra S K. Rhomboid excision with modified Limberg flap in the treatment of sacrococcygeal pilonidal disease. Arch Int Surg 2015;5:74-7

How to cite this URL:
Hussain S M, Farees S N, Abbas S J, Vakati Raghavendra S K. Rhomboid excision with modified Limberg flap in the treatment of sacrococcygeal pilonidal disease. Arch Int Surg [serial online] 2015 [cited 2023 Sep 27];5:74-7. Available from:

  Introduction Top

Sacrococcygeal pilonidal disease, a chronic inflammation and infection of the sacrococcygeal or intergluteal region, is commonly seen in young adults after puberty and generally presents as an abscess or a painful sinus tract on the intergluteal natal cleft with chronic seropurulent discharge. [1] Initially, it was thought to be congenital in origin. But, now it is considered as an acquired condition that does not change by means of traditional surgical or nonsurgical techniques. In this regard, modifying natal cleft and lateralizing the scar from the midline are the most important factors to eliminate the essential causative factors of pilonidal sinus disease. [2]

Although many surgical and nonsurgical treatment methods have been described for the treatment of pilonidal disease, an optimal treatment has not been determined because of the high complications and recurrence rates. [3]

Numerous lateralizing surgical flap techniques based on this principle such as, Karydakis flap, Limberg flap, modified Limberg flap, Z-plasty, and Y-V advancement flap have been described for treating sacrococcygeal pilonidal disease. [1],[2],[3],[4]

In 1946, Limberg first described a technique for closing a 60° rhombus shape defect with transposition flap. [5] We chose modified Limberg flap technique to treat sacrococcygeal pilonidal disease. It offers advantages such as very easy to plan and perform; flattens the natal cleft with wide well-vascularized pedicle that can be sutured without tension, low recurrence rate, and less hospital stay. We conducted this study to evaluate the effectiveness of modified Limberg flap in our patients with sacrococcygeal pilonidal disease.

  Patients and Methods Top

This was a prospective study conducted from July 2011-July 2012 at Princess Esra Hospital, Deccan College of Medical Sciences, Hyderabad, India. All cases were chosen randomly from the outpatient department.


Of 21 patients diagnosed with sacrococcygeal pilonidal disease, 12 (57.14%) were male and nine (42.86%) were females, with a mean (± SD) age of 25.48 ± 3.01 years. Duration of illness is shown in [Table 1]. None had any other coexisting illnesses.
Table 1: Duration of pilonidal sinus among study patients

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After assessing their clinical condition (including laboratory investigation which were within normal limits), we decided to operate once they were found eligible for surgery. After obtaining their written consent, patients were operated with rhomboid excision with modified Limberg flap technique.

Surgical site was prepared with 10% povidine iodine solution after shaving and thorough cleaning. Patients were operated in prone position under spinal anesthesia. Trunk was slightly jack-knifed at the hips and buttocks retracted with adhesive tape to allow wide exposure of the operative field. All sinus openings were injected with methylene blue to visualize the sinus tracts.

Modified limberg flap

A rhombus including the pilonidal sinus and the flap line was marked on skin as shown in [Figure 1]. Under the guidance of methylene blue, the rhombus was excised down to the presacral fascia and fasciocutaneous flap was transposed medially so that the defect would be closed without tension. The size of the prepared flap was equal to that of the rhomboid area and flap sutured asymmetrically placing lower pole of flap lateral to intergluteal sulcus as shown in [Figure 2].
Figure 1: Rhomboid excision of sinus with markings for modified Limberg flap

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Figure 2: Approximation of modified Limberg flap covering the rhomboid defect

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Patients received intravenous antibiotics (cephalosporin group) during operation.

A suction drain was placed beneath the flap through a separate stab incision, and subcutaneous tissue was approximated with polyglycolic acid sutures. Skin was closed separately using 3-0 polypropylene sutures as shown in [Figure 3], [Figure 4], [Figure 5]. Suction drain was removed on the 3 rd or 4 th postoperative day, depending upon the amount and duration of drainage. Sutures were removed between 10 th and 12 th postoperative day.
Figure 3: Closure of the rhomboid defect

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Figure 4: Closure of the rhomboid defect with corners first

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Figure 5: Completion of the procedure with drain in situ

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  Results Top

This procedure was successful in 16 (76.2%) patients. Post operative complications [Table 2] were seen in five patients, two patients had more than one complication [Table 2]. Two patients had both wound infection and wound dehiscence requiring second operation under local anesthesia. Mean length of hospital stay was 3.2 ± 6.8 days. Mean length of follow-up was 4 months.
Table 2: Postoperative complications

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We observed failure of this procedure in only three cases, of which two had postoperative complications (wound infection and wound dehiscence in one each). Both got operated after a course of antibiotics before getting discharged from the hospital. Recurrence of pilonidal sinus was seen in one patient after 2 months of follow-up.

  Discussion Top

Estimated incidence of sacrococcygeal pilonidal disease is 26 per 10,000 people. This disease is considerably more common in some Mediterranean and Persian Gulf region countries. [5] Driving, obesity, deep natal cleft, poor hygiene, male gender, and young age increases the risk of disease. [6],[7] We observed that of 1,700 patients who visited our outpatient department during the study period, 30 had pilonidal sinus.

Hypothesis for the occurrence of pilonidal sinus have been based on embryonic origin. The disease has largely been considered to be due to the accumulation of hair penetrating skin and an acquired condition. [8] The invader consisting of loose hair, a force that causes hair insertion and vulnerability of skin to hair insertion at depth of natal cleft are strong evidence supporting acquired theory. In our patients, poor hygiene and deep natal cleft were the common causes.

Many surgical procedures for sacrococcygeal pilonidal disease have been developed. But, an optimal treatment approach with low complication and recurrence rates has still not been recommended. [1],[3] Simple excision and primary closure or open wound healing does not flatten the natal cleft and cannot prevent penetration of hair to skin at depths of natal cleft and may lead to more patient discomfort, and a high midline recurrence rate. [9] Day surgery with simple curettage or phenol injection may remove hair and cure the sinus. But, the midline wound may take several weeks to heal and recurrence rate is more because of open portal for hair insertion.

It is widely accepted that concept of flap technique by flattening and lateralization of natal cleft prevents recurrence. Technique of Karydakis has difficulty in mobilization and closure for complex sacrococcygeal disease. Z-plasty and Y-V advancement flaps covers the wound defect by moving full thickness skin and subcutaneous tissue into midline defect. But, these have been thought to be over treatment for sacrococcygeal pilonidal disease because of large tissue displacements.

Among all flap techniques, modified Limberg flap procedure is considered to be a safe and reliable technique in treatment of sacrococcygeal pilonidal disease with less complications and recurrence rates, if performed according to appropriate surgical principle. [10] It is particularly a useful technique for complex sinuses with multiple pits and extended tracts when radical excision leaves a large defect. [4]

Several other studies have compared modified Limberg flap with other flap techniques. Mentes et al., [11] Ersoy et al., [12] and Can et al., [13] have compared modified Limberg flap with Karydakis flap. They observed that modified Limberg flap has low complications and recurrence rate compared to Karydakis flap. Walid et al., [14] showed that modified Limberg flap superior to open excision. With these factors favoring modified Llimberg flap, we opted for this procedure in our patients. We noted that this procedure resulted in less postoperative complications, shorter duration of stay (compared to 10-15 days with other procedures), and less recurrence.

  Conclusion Top

Rhomboid excision with Limberg flap is a promising surgical technique in treatment of both primary and recurrent pilonidal sinuses with less postoperative complications, short hospital stay, and low recurrence rate.

  Acknowledgement Top

Authors acknowledge the patients who permitted to publish the data. We acknowledge the staff of Esra Hospital, Hyderabad for being supportive throughout the study. We acknowledge the efforts of Dr. M S Latha in the preparation of this manuscript.

  References Top

Petersen S, Koch R, Stelzner S, Wendlandt TP, Ludwig K. Primary closure techniques in chronic pilonidal sinus: A survey of the result of different surgical approaches. Dis Colon Rectum 2002;45:1458-67.  Back to cited text no. 1
Nursal TZ, Ezer A, Caliskan K, Törer N, Belli S, Moray G. Prospective randomized controlled trial comparing V-Y advancement flap with primary suture methods in pilonidal disease. Am J Surg 2010;199:170-7.  Back to cited text no. 2
Al-Khamis A, McCallum I, King PM, Bruce J. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev 2010:CD006213.  Back to cited text no. 3
Urhan MK, Kücükel F, Topgul K, Ozer I, Sari S. Rhomboid excision and Limberg flap for managing pilonidal sinus: Results of 102 cases. Dis Colon Rectum 2002;45:656-9.  Back to cited text no. 4
Chiedozi LC, Al-Rayyes FA, Salem MM, Al-Haddi FH, Al-Bidewi AA. Management of pilonidal sinus. Saudi Med J 2002;23:786-8.  Back to cited text no. 5
Søndenaa K, Andersen E, Nesvik I, Søreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis 1995;10:39-42.  Back to cited text no. 6
Akinci OF, Coskun A, Uzunkoy A. Simple and effective surgical treatment of pilonidal sinus: Asymmetric excision and primary closure using suction drain and subcuticular skin closure. Dis Colon Rectum 2000;43:701-6.  Back to cited text no. 7
da Silva JH. Pilonidal cyst: Cause and treatment. Dis Colon Rectum 2000;43:1146-56.  Back to cited text no. 8
Aydede H, Erhan Y, Sakarya A, Kumkumoglu Y. Comparison of three methods in surgical treatment of pilonidal disease. ANZ J Surg 2001;71:362-4.  Back to cited text no. 9
Kapan M, Kapan S, Pekmezci S, Durgun V. Sacrococcygeal pilonidal sinus disease with Limberg flap repair. Tech Coloproctol 2002;6:27-32.  Back to cited text no. 10
Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, Oguz M. Modified Limberg transposition flap for sacrococcygeal pilonidal sinus. Surg Today 2004;34:419-23.  Back to cited text no. 11
Ersoy E, Devay AO, Aktimur R, Doganay B, Ozdoğan M, Gündoğdu RH. Comparison of the short-term results after Limberg and Karydakis procedures for pilonidal disease: Randomized prospective analysis of 100 patients. Colorectal Dis 2009;11:705-10.  Back to cited text no. 12
Can MF, Sevinc MM, Hancerliogullari O, Yilmaz M, Yagci G. Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease. Am J Surg 2010;200:318-27.  Back to cited text no. 13
Walid GE, Kaled S. Clinical trial comparing open excision and primary closure with modified limberg flap in treatment of uncomplicated SPD. AJM 2012;48:13-8.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


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