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Comparison of short-term results of modified Karydakis flap and modified Limberg flap for pilonidal sinus surgery
ORIGINAL RESEARCH International Journal of Surgery 10 (2012) 601e606
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Original research
Comparison of short-term results of modified Karydakis flap and modified Limberg flap for pilonidal sinus surgery lar Bilgin a, Saadet Özer a, Suna Yoldas¸ c, Turgut Karaca a, Ömer Yoldas¸ b, *, Bülent Çag Nihal Gördesel Karaca d a
Ankara Occupational Disease Hospital, General Surgery, Ankara, Turkey Medical Park Hospital Group, General Surgery, Ordu, Turkey Anesthesiology and Reanimation, Medical Park Hospital Group, Ordu, Turkey d Department of Anaesthesiology, Ankara University Medical School, Ankara, Turkey b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 September 2012 Received in revised form 9 October 2012 Accepted 10 October 2012 Available online 22 October 2012
The aim of this study was to compare and analyze the short term results of modified Karydakis flap reconstruction (MKF) and modified Limberg flap reconstruction (MLF). This is a retrospective analysis of 81 patients operated for pilonidal sinus disease. There were 46 patients in MLF group and 35 patients in MKF group. We compared patients age, BMI, operation time, removal time of suction drain, time of feeling completely healed, type of presentation, complications, postoperative 1., 3., 5. Days VAS scores, time to stop analgesic drugs and time to sit on chair or throne without pain. Complication rate, analgesic drug stopping time, postoperative 5. days VAS score were lower in MLF group and there were significant difference between groups. MLF group patients feel better (P: 0.010), they recommended this operation to other pilonidal sinus patients (P: 0.010) and 36 of them rated their satisfaction excellent and 10 of them good (P: 0.010). MLF procedure was more comfortable for patients. Lesser pain, lower complication and recurrence rates and higher patient satisfaction were detected in MLF group. Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Pilonidal sinus disease Modified Limberg flap Modified Karydakis flap Pilonidal sinus treatment
1. Introduction Pilonidal sinüs disease is a common chronic disease occuring in the natal cleft of the sacrococygeal region and it is more common among young adults.1,2 It is characterized by inflammation, abscess and sinus formation. It is widely accepted that pilonidal sinus results from the penetration of shed hair shafts through the skin.3 Despite recent technological and technical developments there still is no consensus about treatment of pilonidal sinus disease. Shaving,4 phenol application,5 treatment with crystallised phenol,6 incision and curetage,7 unroofing and curetage,8 excision with primary closure,9 excision with marsupialization,10 vey flap reconstruction,11 Bascom procedure,12 Limberg flap reconstruction,13 modified Limberg flap reconstruction,14 Karydakis flap reconstruction,15 modified Karydakis flap reconstruction16 and musculocutan flap reconstruction17 are some of the treatment modalities for pilonidal disease. Karydakis procedure is one of the asymetric flap techniques described by Karydakis in 1973.15 He has reported largest patient number and lowest recurrence rate (<1%). And than technique was
modified by Bessa. Modified Karydakis flap (MKF) procedure was performed according to the technique described by Bessa.16 Modified Limberg transposition flap (MLF) procedure for pilonidal disease was described by Mentes in 2004. His recurrence rate was % 0 and healing time was 2 weeks.14 In the present study; the short term results of modified Karydakis flap reconstruction and modified Limberg flap reconstruction were analysed and compared. 2. Patients and methods This is a retrospective analysis of 81 patients operated for pilonidal sinus diseases. Between June 2009 and October 2011, 104 patients with pilonidal sinus disease were treated surgically. There were 46 patients, 44 men and 2 women in MLF group and 35 patients, 20 men and 15 women in MKF group. Twelve patients declined to join this study and we did not contact with 11 patients, a total of 81 patients were included in this study. We prepared question forms (Table 1) and 81 patients had been completed during the postoperative period and via data collection by telephone interview for long-term postoperative follow up. Patients presenting with an acute abscess in the sacrococcygeal region initially treated with a small incision under local anesthesia. Postopertaively they were given third generation cephalosporine and metronidazole for 10 days. Postoperative 14 days patients scheduled for MLF or Karydakis flap treatment. 2.1. Surgical procedure
* Corresponding author. E-mail address: [email protected] (Ö. Yoldas¸).
All operations were performed under spinal anesthesia. Patients were placed in jack-knife position. Shaving performed before 2 days of operation. The operation
1743-9191/$ e see front matter Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijsu.2012.10.001
ORIGINAL RESEARCH 602
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Table 1 The question form prepared for the patients. When did you stop analgesic drug? How severe is your pain today? - Postoperative 1st day? - Postoperative 3rd day? - Postoperative 5th day? When did you sit to chair without pain? When did you sit to throne without pain? When did you feel you were completely healed? If did you have to see/know a postoperative pilonidal sinus patient please compare your operation with them. Please rate your satisfaction with the results of operation Would you recommend this surgical technique to other pilonidal sinus patients?
VAS postoperative 1st day VAS postoperative 3rd day VAS postoperative 5th day
Worse: 1; similar: 2; better: 3 Dissatisfied: 1; somewhat satisfied: 2; good: 3; excellent: 4 Yes: 1; no: 2
side was cleaned with %10 povidone-iodine. One milliliter of methylene blue was injected without pressure through the external opening of all pilonidal sinus. Third generation cephalosporine and metronidazole was given intravenously before 30 min of the operation and after 6 h of operation. Patients were used oral form of third generation cephalosporine and metronidazole for 5 days postoperatively. The wound dressing performed every other day and after the drain removed we did not performed any wound dressing. Patients were discharged on the postoperative first day. The suction drain was removed when the effluent was less than 20 ml per 24 h. Sutures also removed on postoperative 12e14 days. 2.2. Group 1: modified Karydakis flap (MKF) reconstruction group The modified Karydakis procedure (Figs. 1e5) is one of the asymmetric flap techniques used in the treatment of sacrococygeal pilonidal sinus disease. Modified Karydakis flap technique was performed to lateralize the natal cleft. An elliptical excision was made to the natal cleft than mobilization of the flap from the median side of wound, and suturing of its edge to the lateral one was made up. The upper and lower ends of the ellipses were placed 2 cm lateral of the midline. For choosing the correct side for Karydakis flap we considered secondary opening and palpation after methylene blue injection. Excision was based on the side of secondary opening or fluctuation of sinus after methylene blue injection. In the present modification, the flap was sutured from its gluteal fascia directly to the lateral edge of the wound without fixation to the sacral fascia by using interrupted Vicryl 0/0 sutures, for the subcutaneous tissue interrupted Vicyril 2/0 and 3/0 was used. Before placing the subcutaneous sutures, a suction silicone drain was placed in the resultant dead space and brought out well laterally. Skin was closed with skin staples.
Fig. 1. Modified Karydakis procedure asymmetric incision marked with line and flap marked with arrows.
Fig. 2. Modified Karydakis procedure an asymmetric eliptical excision.
2.3. Group 2: modified Limberg flap reconstruction (MLF) group MLF (Figs. 6e11) operation was performed according to the technique described by Mentes et al.14 Before incision of operation we marked the incision by using pen for well tailored. We performed a wide rhomboid excision including the postsacral fascia, taking care to remove all sinus tracts en bloc. Inferior apex of the rhomboid excisions were 1e2 cm lateral to midline on the opposite to the donor area. A right or left sided fasciocutaneous transposition flap, incorporating the gluteal fascia, fully mobilized on its inferior edge and transposed medially to fulfill the rhomboid defect without tension. A suction silicone drain was placed in the postsacral fascia and the Limberg flap was secured with deep, interrupted 0/0, 2/0 vicyril sutures and subcutaneous layer was sutured with interrupted 3/0 Vicyril. The skin was closed with skin staples. The follow-up duration ranged from 2 to 28 months. 2.4. Statistical methods Data analysis was performed using the SPSS (SPSS Inc. Chicago, IL) 15.0 package program. A Student’s t test was used to compare age, BMI, operation time, removal time of suction drain, time to feel completely healed as a parametric test to determine differences in two groups. Pearson’s _2 analysis was used to compare type of presentation (recurrence and primer disease), complications (seroma, dehiscence, hematoma, wound infection). A ManneWhitney U statistic analysis was used as a non-parametric test to determine differences for intergroup comprasions of patients’ VAS 1, VAS 3 and VAS 5 scores, follow up time, time to stop analgesic drugs, and time to sit on chair or throne without pain. A P value <0.05 was considered significant.
Fig. 3. Modified Karydakis procedure. Fasciocutan flap and musculus gluteus maximus.
ORIGINAL RESEARCH T. Karaca et al. / International Journal of Surgery 10 (2012) 601e606
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Fig. 6. The rhomboid flap reconstruction was modified by tailoring the rhomboid excision asymmetrically to place the lower pole of the flap 1e2 cm lateral to the inferior midline (marked with line). Orginal rhomboid flap reconstruction, lower pole of the flap on the inferior midlne (marked with dotted line).
A modified Karydakis flap reconstruction was carried out in 35 (43.2%) of 81 patients and Modified Limberg flap reconstruction was carried out 46 (56.8%) of 81 patients with pilonidal sinus disease (Table 2). Eighty-one patients of 104 included in this study. The results of question form are in Table 3. Twelve of the MLF group and four of the MKF had recurrence disease. There were not significant difference in both groups for this type of presentation. There were significant difference between group 1 and group 2 according to BMI (mean value: 26.7 2.7 kg/m2 and 25.1 3.5 kg/ m2/P: 0.020), operation time (mean value: 45.3 11.3 min and 33.5 15.7 min/P < 0.001) and complication rate (4.2% and 22.9%/ P: 0.010). In MLF group 2 patients(4.2%) had complication but in MKF group 8 patients (22.9%) had complication. The difference between the groups for complication was statistically significant (P: 0.010). Two patients had seroma in MLF group and 6 patients in
MKF group (4.2% and 17.1%/P: 0.048) and the difference was statistically significant. In MLF group there were notany wound infection but in MKF group wound infection occurred in 2 patients (5.7%). In MLF group dehiscence did not occurred but in MKF group dehiscence occurred in four patients (11.4%). The difference was statistically significant (P: 0.016).The suction drain was removed on 6 3.3 days in MLF group and 6 1.9 days in MKF group. In MKF group there were 15 (42.8%) women patients and in MLF there were 2(4.34%) women patients. In MLF group recurrence did not occurred in any patient but in MKF group recurrence occurred in 2 patients (5.7%). MLF group stopped analgesic drug on 4.5 2 days and MKF group on 7.9 6.8 days. The difference was statistically significant (P: 0.002). VAS score were evaluated on postoperative 1, 3 and 5 days. On postoperative first day VAS score was 3.4 1.6 in MLF group and 3.7 1.7 in MKF group, on third day VAS score was 1.8 1.1 in MLF group and 2.3 1.4 in MKF group, but the difference was not statistically significant. On postoperative fifth day VAS score was 0.5 0.6 in MLF group and 1.0 0.8 in MKF group and the difference was statistically significant (P: 0.007). MLF group sit on chair and throne before MKF group. MLF group sit on chair on 9.8 7.4 days and MKF group sit on chair on 16.5 9.9 days (P: 0.001), MLF group sit throne on 5.4 4.3 days and MKF group sit throne on 11.7 8 days. MLF group felt completely healed on postoperative 19 16.7 days and MKF group felt completely healed
Fig. 5. Modified Karydakis procedure. After healed.
Fig. 7. MLF transposition. Rhomboid excision of the diseased tissue followed by preparation of the flap on the right gluteal area.
Fig. 4. Reconstruction using Modified Karydakis flap with an eventual closure line 2 cm lateral to the midline, especially at the lower end.
3. Results
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Fig. 8. MLF transposition. Fasciocutan flap transposed medially to fulfill the rhomboid defect. Fig. 10. MLF after skin was closed with skin staples.
on postoperative 23.5 8.5 days. But the difference was not statistically significant.
4. Discussion There is still no consensus about treatment of pilonidal sinus disease. Ideally, therapy should be associated with short hospital stay, less painful postoperative time, rapidly healing and return to work, less painful dressing of wound, short term wound care and a low recurrence rate. No techniques fulfills all of these criteria. Since the source of the disease is thought to be natal cleft and deep intergluteal sulcus,14 the aims of the flap techniques are natal cleft
Fig. 11. MLF after healing.
Table 2 Demographic and clinical characteristics of the patients.
Fig. 9. MLF transposition after drain replaced.
Variable
MLF groups (N: 61)
MKF groups (43)
Age Men/women BMI (kg/m2) Primer/Nüx disease Operation time (minutes) Drain removed day Complication rate - Seroma - Hematoma - Dehiscence - Wound infection Recurrence
28.5 9 44/2 26.7 2.7 34/12 45.3 11.3 6 3.3 2 (4.2%) 2 (4.2%) 0 (0%) 0 0 (0%) 0 (0%)
26.9 6 20/15 25.1 3.5 31/4 33.5 15.7 6 1.9 8 (22.9) 6 (17.1) 0 (0%) 4 (11.4) 2 (5.7%) 2 (5.7%)
P values
0.1 <0.001 1.000 0.010 0.048 0.016 0.096 0.096
ORIGINAL RESEARCH T. Karaca et al. / International Journal of Surgery 10 (2012) 601e606
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Table 3 The results of the question form.
When did you stop analgesic drug? (days) How severe is your pain today? - Postoperative 1 st day? - Postoperative 3 rd day? - Postoperative 5 th day? When did you sit to chair without pain? (days) When did you sit to throne without pain? (days) When did you feel you were completely healed? (days) If did you have to see/know a postoperative pilonidal sinus patient please compare your operation with them. Please rate your satisfaction with the results of operation Would you recommend this surgical technique to other pilonidal sinus patients?
MLF group
MKF group
P value
4.5 2
7.9 6.8
0.002
3.4 1.6 1.8 1.1 0.5 0.6 9.8 7.4 5.4 4.3 19 16.7 Worse: 0; similar: 0; better: 46
3.7 1.7 2.3 1.4 1.0 0.8 16.5 9.9 11.7 8 23.5 8.5 Worse: 6; similar: 0; better: 29
0.495 0.058 0.007 0.001 <0.001 0.148 0.010
Dissatisfied: 0; somewhat satisfied: 0; good: 10; excellent: 36 Yes: 46; no: 0
Dissatisfied: 2; somewhat satisfied: 4; good: 10; excellent: 19 Yes: 27; no: 8
0.019
flatting, lateralization and fulfilling the defect without tension. Primary closure technique’s operation time is short but have significant postoperative morbidity and recurrence rate. In this technique wound infection rate is 12e32.7%, dehiscence rate is 10e 50% and recurrence rate is 5e12%.18e20 With this technique, natal cleft flatting and lateralization, fulfilling the defect without tension is impossible. Incision and curetage,7 unroofing curetage procedure8 and excision with marsupialization procedures9 are common used surgical techniques. But these procedures had painful postoperative time, delate healing and return to work, painful dressing of wound and long term wound care. But they have a low recurrence rate.10 When the midline lateralized or flattened, recurrences are less likely to occur than after primary closure or other methods that fail to reconstruct the intergluteal sulcus.14 Other studies reported a mean length of hospital stay 2e4 days.10,14e21 In the present study the length of hospital stay was 1 day for MKF group and 1 0.1 days for MLF group. The incidence of wound infection was ranged from 0% to 12%10,16e22 in MKF group and 0.8% to 12% in MLF group in the other studies.10,14e21 Despite BMI lesser in MKF group in the present study wound complication developed in 8 patients in MKF group. Wound infection occurred in 2 of 35 patients, seroma occurred in 6 of 35 patients. Seroma and than dehiscence both occurred in 2 of 35 patients and wound infection and than dehiscence both occurred in 2 of 35 patients. In MLF group we did not detect any infection, but seroma occurred in 2 of 46 patients (4.3%) and dehiscence did not occurred. Acute infected pilonidal sinus disease should be treated by incision drenage or incision curetage. In the present study the patients presenting with an acute abscess in the sacrococcygeal region initially treated with a small incision under local anesthesia and than postoperatively they were treated by third generation cephalosporine and metronidazole for 10 days. Patients were scheduled for MLF or MKF procedure after 14 days. All wound infections in the present study were managed under local anesthesia by removing the sutures, opening and cleaning the wound cavity and using appropriate antibiotics. Seroma was managed by fluid aspiration and antibiotics were added to prevent infection. Generally suction drains were left only 1e3 days in other studies.14e16 In the present study suction drains left when the effluent was less than 20 ml per 24 h. We left drains 6 1.9 days in MKF and 6 3.3 days in MLF group. Gurer et al. prospectively randomized 50 patients into two equal groups: drained and nondrained. Fluid collections were encountered in two patients (8%) of the drained group compared with eight patients (32%) in the nondrained group with the difference being statistically significant.21 In our opinion sources of low rate wound infection are antibiotic treatment by using third
0.010
generation cephalosporine and metronidazole, choosing noninfected pilonidal disease for surgery and delayed suction drainage. MLF procedure fulfills the defect with a lesser tension than in MKF procedure, so that we detected lower rates of wound related complications in MLF group. Lower rates of infection, seroma and dehiscence were detected in MLF group. The recurrence rate of MKF and MLF were 0e7%10,18e20,26,27 and 0e5.4%16e 20,24 respectively in other studies. In our study 2 of 35 patients had recurrence in MKF group but we had no recurrence in MLF group. Follow up time is 2e28 months. The other studies were similar according to the follow up time. Longer follow up time will be more significant to evaluate recurrence rate. In classic Limberg flap technique recurrence rate is 1.26e5.3%.10,14e28 In this technique inferior midline of operation was frequently macerated, healed slowly and might even be source of recurrence.18 In MLF technique inferior apex of the rhomboid excision were 1e2 cm lateral to midline on the opposite side of the donor area and depending on this recurrence rates are lower than classic Limberg flap. MLF group patients stopped analgesic drug on postopertative 4.5 2 days and MKF group patients stopped on 7.9 6.8 days. There was significant difference (P: 0.002) between two groups. Also postoperative 1st, 3rd and 5th days VAS score were lower in MLF group. But only the difference on postoperative 5thday was statistically significant (P: 0.007). MLF group patients started to sit on chair without pain on postoperative 9.8 7.4 days and sit to throne without pain on postoperative 5.4 4.3 days. There were significant difference between groups for sitting chair (P: 0.001) and sitting throne (P < 0.001). In our opinion in MKF group there were considerable discomfort and pain. It may result from the tension in the wound. MLF group patients felt completely healed on postoperative 19 16.7 days and MKF group patients felt completely healed on postoperative 23.5 8.5 days. Difference was not significant. Most patient felt completely healed after removal of the sutures. Patient satisfaction were depended on the development of complication, so the patients in MLF group were more satisfied about their operation because of the lower complication rates. Advantages of modified Karydakis procedure are; shorter operation time, shorter wound healing in dehiscence and easier learning curve. Advantages of modified limberg procedure are; beternatal cleft flatting and lateralization better, lesser tension in fulfilling the defect. Disadvantage of MLF is larger operation scar. In conclusion; although MLF procedures’ operation time was longer than MKF group, MLF procedure was more comfortable for patients. Lesser pain, lower complication and recurrence rates and high degree of patient satisfaction were detected in MLF group.
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Ethical approval None. Sources of funding None. Authors’ contribution Omer Yoldas: writing, data collection. Mesut Tez: data analysis and statistical analysis. Turgut Karaca: study design, idea for the study. Conflicts of interest None. References 1. Hardawey RM. Pilonidal cyst; neither pilonidal nor cyst. Archives of Surgery 1958;76:143e7. 2. Bertelsen CA. Cleft-lift operation for pilonidal sinuses under tumescent local anesthesia: a prospective cohort study of peri- and postoperative pain. Diseases of the Colon & Rectum 2011 Jul;54(7):895e900. 3. Pilonidal disease. Surgical Clinics of North America 1994;74:1309e15. 4. Armstrong JH, Barcia PJ. Pilonidal sinus disease: the conservative approach. Archives of Surgery 1994;129:914e9. 5. Schneider IHF, Thaler K, Kockerling TF. Treatment of pilonidal sinuses by phenol injections. International Journal of Colorectal Disease 1994;9:200e2. 6. Dogru O, Camci C, Aygen E, Girgin M, Topuz O. Pilonidal sinus treated with crystallized phenol: an eight-year experience. Diseases of the Colon & Rectum 2004 Nov;47(11):1934e8. 7. Bisset IP, Isbister WH. The management of patients with pilonidal diseaseda comparative study. Australian and New Zealand Journal of Surgery 1987;57: 939e42. 8. Kepenekci I, Demirkan A, Celasin H, Gecim IE. Unroofing and curettage for the treatment of acute and chronic pilonidal disease. World Journal of Surgery 2010 Jan;34(1):153e7. 9. Fuzun M, Bakır H, Soylu M, Tansug T, Kaymak E, Harmancıoglu O. Which technique for treatment of pilonidal sinusdopen or closed? Diseases of the Colon & Rectum 1994;37:1148e50. 10. Silva JH. Pilonidal cyst: cause and treatment. Diseases of the Colon & Rectum 2000;43:1146e56. 11. Berkem H, Topaloglus S, Ozel H, Avsar FM, Yildiz Y, Yuksel BC, et-al. V-Y advancement flap closures for complicated pilonidal sinus disease. International Journal of Colorectal Diseases 2005;20:343e8. 12. Bascom JU. Repeat pilonidal operations. American Journal of Surgery 1987;154: 118e22.
13. Arumugam PJ, Chandrasekaran TV, Morgan AR, Beynon J, Carr ND. The rhomboid flap for pilonidal disease. Colorectal Diseases 2003;5:218e21. 14. Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, Oguz M. Modified Limberg transposition flap for sacrococcygeal pilonidal sinus. Surgery Today 2004;34(5):419e23. 15. Karydakis GE. New approach to the problem of pilonidal sinus. Lancet 1973 Dec 22;2(7843):1414e5. 16. Bessa SS. Results of the lateral advancing flap operation (modified Karydakis procedure) for the management of pilonidal sinus disease. Diseases of the Colon & Rectum 2007 Nov;50(11):1935e40. Epub 2007 Sep 8. 17. Stroosma OC. Gluteal fascioplasty as a method of primary closure in the treatment of pilonidal sinus. Archivum Chirurgicum Neerlandicum 1978;30: 61e4. 18. Cihan A, Mentes BB, Tatlicioglu E, Ozmen S, Leventoglu S, Ucan BH. Modified Limberg flap reconstruction compares favourably with primary repair for pilonidal sinus surgery. ANZ Journal of Surgery 2004 Apr;74(4): 238e42. 19. Can MF, Sevinc MM, Yilmaz M. Comparison of Karydakis flap reconstruction versus primary midline closure in sacrococcygeal pilonidal disease: results of 200 military service members. Surgical Today 2009;39(7):580e6. Epub 2009 Jun 28. 20. Brieler HS. Infected pilonidal sinus. Langenbecks Archiv für Chirurgie Supplement Kongressband 1997;114:497e500. 21. 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. American Journal of Surgery 2010 Sep;200(3):318e27. Epub 2010 Feb 1. 22. Petersen S, Aumann G, Kramer A, Doll D, Sailer M, Hellmich G. Short-term results of Karydakis flap for pilonidal sinus disease. Techniques in Coloproctology 2007 Sep;11(3):235e40. Epub 2007 Aug 3. 23. Gurer A, Gomceli I, Ozdogan M, Ozlem N, Sozen S, Aydin R. Is routine cavity drainage necessary in Karydakis flap operation? A prospective, randomized trial. Diseases of the Colon & Rectum 2005;48:1797e9. 24. Moran DC, Kavangh DO, Adhmed I, Regan MC. Excision and primary closure using the Karydakis flap for the treatment of pilonidal disease: outcomes from a single institution. World Journal of Surgery 2011 Aug;35(8):1803e8. 25. Keshava A, Young CJ, Rickard MJ, Sinclair G. Karydakis flap repair for sacrococcygeal pilonidal sinus disease: how important is technique? ANZ Journal of Surgery 2007 Mar;77(3):181e3. 26. Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir M. Limberg flap procedure for pilonidal sinus disease: results of 353 patients. Langenbecks Archives of Surgery 2008 Mar;393(2):185e9. Epub 2007 Sep 22. 27. Urhan MK, Küçükel F, Topgül K, Ozer I, Sarı S. Rhomboid excision and Limberg flap for managing pilonidal sinus: results of 102 cases. Diseases of the Colon & Rectum 2002;45:656e9. 28. Müller K, Marti L, Tarantino I, Jayne DG, Wolff K, Hetzer FH. Prospective analysis of cosmesis, morbidity, and patient satisfaction following Limberg flap for the treatment of sacrococcygeal pilonidal sinus. Diseases of the Colon & Rectum 2011 Apr;54(4):487e94.
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Original research
Comparison of short-term results of modified Karydakis flap and modified Limberg flap for pilonidal sinus surgery lar Bilgin a, Saadet Özer a, Suna Yoldas¸ c, Turgut Karaca a, Ömer Yoldas¸ b, *, Bülent Çag Nihal Gördesel Karaca d a
Ankara Occupational Disease Hospital, General Surgery, Ankara, Turkey Medical Park Hospital Group, General Surgery, Ordu, Turkey Anesthesiology and Reanimation, Medical Park Hospital Group, Ordu, Turkey d Department of Anaesthesiology, Ankara University Medical School, Ankara, Turkey b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 September 2012 Received in revised form 9 October 2012 Accepted 10 October 2012 Available online 22 October 2012
The aim of this study was to compare and analyze the short term results of modified Karydakis flap reconstruction (MKF) and modified Limberg flap reconstruction (MLF). This is a retrospective analysis of 81 patients operated for pilonidal sinus disease. There were 46 patients in MLF group and 35 patients in MKF group. We compared patients age, BMI, operation time, removal time of suction drain, time of feeling completely healed, type of presentation, complications, postoperative 1., 3., 5. Days VAS scores, time to stop analgesic drugs and time to sit on chair or throne without pain. Complication rate, analgesic drug stopping time, postoperative 5. days VAS score were lower in MLF group and there were significant difference between groups. MLF group patients feel better (P: 0.010), they recommended this operation to other pilonidal sinus patients (P: 0.010) and 36 of them rated their satisfaction excellent and 10 of them good (P: 0.010). MLF procedure was more comfortable for patients. Lesser pain, lower complication and recurrence rates and higher patient satisfaction were detected in MLF group. Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Pilonidal sinus disease Modified Limberg flap Modified Karydakis flap Pilonidal sinus treatment
1. Introduction Pilonidal sinüs disease is a common chronic disease occuring in the natal cleft of the sacrococygeal region and it is more common among young adults.1,2 It is characterized by inflammation, abscess and sinus formation. It is widely accepted that pilonidal sinus results from the penetration of shed hair shafts through the skin.3 Despite recent technological and technical developments there still is no consensus about treatment of pilonidal sinus disease. Shaving,4 phenol application,5 treatment with crystallised phenol,6 incision and curetage,7 unroofing and curetage,8 excision with primary closure,9 excision with marsupialization,10 vey flap reconstruction,11 Bascom procedure,12 Limberg flap reconstruction,13 modified Limberg flap reconstruction,14 Karydakis flap reconstruction,15 modified Karydakis flap reconstruction16 and musculocutan flap reconstruction17 are some of the treatment modalities for pilonidal disease. Karydakis procedure is one of the asymetric flap techniques described by Karydakis in 1973.15 He has reported largest patient number and lowest recurrence rate (<1%). And than technique was
modified by Bessa. Modified Karydakis flap (MKF) procedure was performed according to the technique described by Bessa.16 Modified Limberg transposition flap (MLF) procedure for pilonidal disease was described by Mentes in 2004. His recurrence rate was % 0 and healing time was 2 weeks.14 In the present study; the short term results of modified Karydakis flap reconstruction and modified Limberg flap reconstruction were analysed and compared. 2. Patients and methods This is a retrospective analysis of 81 patients operated for pilonidal sinus diseases. Between June 2009 and October 2011, 104 patients with pilonidal sinus disease were treated surgically. There were 46 patients, 44 men and 2 women in MLF group and 35 patients, 20 men and 15 women in MKF group. Twelve patients declined to join this study and we did not contact with 11 patients, a total of 81 patients were included in this study. We prepared question forms (Table 1) and 81 patients had been completed during the postoperative period and via data collection by telephone interview for long-term postoperative follow up. Patients presenting with an acute abscess in the sacrococcygeal region initially treated with a small incision under local anesthesia. Postopertaively they were given third generation cephalosporine and metronidazole for 10 days. Postoperative 14 days patients scheduled for MLF or Karydakis flap treatment. 2.1. Surgical procedure
* Corresponding author. E-mail address: [email protected] (Ö. Yoldas¸).
All operations were performed under spinal anesthesia. Patients were placed in jack-knife position. Shaving performed before 2 days of operation. The operation
1743-9191/$ e see front matter Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijsu.2012.10.001
ORIGINAL RESEARCH 602
T. Karaca et al. / International Journal of Surgery 10 (2012) 601e606
Table 1 The question form prepared for the patients. When did you stop analgesic drug? How severe is your pain today? - Postoperative 1st day? - Postoperative 3rd day? - Postoperative 5th day? When did you sit to chair without pain? When did you sit to throne without pain? When did you feel you were completely healed? If did you have to see/know a postoperative pilonidal sinus patient please compare your operation with them. Please rate your satisfaction with the results of operation Would you recommend this surgical technique to other pilonidal sinus patients?
VAS postoperative 1st day VAS postoperative 3rd day VAS postoperative 5th day
Worse: 1; similar: 2; better: 3 Dissatisfied: 1; somewhat satisfied: 2; good: 3; excellent: 4 Yes: 1; no: 2
side was cleaned with %10 povidone-iodine. One milliliter of methylene blue was injected without pressure through the external opening of all pilonidal sinus. Third generation cephalosporine and metronidazole was given intravenously before 30 min of the operation and after 6 h of operation. Patients were used oral form of third generation cephalosporine and metronidazole for 5 days postoperatively. The wound dressing performed every other day and after the drain removed we did not performed any wound dressing. Patients were discharged on the postoperative first day. The suction drain was removed when the effluent was less than 20 ml per 24 h. Sutures also removed on postoperative 12e14 days. 2.2. Group 1: modified Karydakis flap (MKF) reconstruction group The modified Karydakis procedure (Figs. 1e5) is one of the asymmetric flap techniques used in the treatment of sacrococygeal pilonidal sinus disease. Modified Karydakis flap technique was performed to lateralize the natal cleft. An elliptical excision was made to the natal cleft than mobilization of the flap from the median side of wound, and suturing of its edge to the lateral one was made up. The upper and lower ends of the ellipses were placed 2 cm lateral of the midline. For choosing the correct side for Karydakis flap we considered secondary opening and palpation after methylene blue injection. Excision was based on the side of secondary opening or fluctuation of sinus after methylene blue injection. In the present modification, the flap was sutured from its gluteal fascia directly to the lateral edge of the wound without fixation to the sacral fascia by using interrupted Vicryl 0/0 sutures, for the subcutaneous tissue interrupted Vicyril 2/0 and 3/0 was used. Before placing the subcutaneous sutures, a suction silicone drain was placed in the resultant dead space and brought out well laterally. Skin was closed with skin staples.
Fig. 1. Modified Karydakis procedure asymmetric incision marked with line and flap marked with arrows.
Fig. 2. Modified Karydakis procedure an asymmetric eliptical excision.
2.3. Group 2: modified Limberg flap reconstruction (MLF) group MLF (Figs. 6e11) operation was performed according to the technique described by Mentes et al.14 Before incision of operation we marked the incision by using pen for well tailored. We performed a wide rhomboid excision including the postsacral fascia, taking care to remove all sinus tracts en bloc. Inferior apex of the rhomboid excisions were 1e2 cm lateral to midline on the opposite to the donor area. A right or left sided fasciocutaneous transposition flap, incorporating the gluteal fascia, fully mobilized on its inferior edge and transposed medially to fulfill the rhomboid defect without tension. A suction silicone drain was placed in the postsacral fascia and the Limberg flap was secured with deep, interrupted 0/0, 2/0 vicyril sutures and subcutaneous layer was sutured with interrupted 3/0 Vicyril. The skin was closed with skin staples. The follow-up duration ranged from 2 to 28 months. 2.4. Statistical methods Data analysis was performed using the SPSS (SPSS Inc. Chicago, IL) 15.0 package program. A Student’s t test was used to compare age, BMI, operation time, removal time of suction drain, time to feel completely healed as a parametric test to determine differences in two groups. Pearson’s _2 analysis was used to compare type of presentation (recurrence and primer disease), complications (seroma, dehiscence, hematoma, wound infection). A ManneWhitney U statistic analysis was used as a non-parametric test to determine differences for intergroup comprasions of patients’ VAS 1, VAS 3 and VAS 5 scores, follow up time, time to stop analgesic drugs, and time to sit on chair or throne without pain. A P value <0.05 was considered significant.
Fig. 3. Modified Karydakis procedure. Fasciocutan flap and musculus gluteus maximus.
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Fig. 6. The rhomboid flap reconstruction was modified by tailoring the rhomboid excision asymmetrically to place the lower pole of the flap 1e2 cm lateral to the inferior midline (marked with line). Orginal rhomboid flap reconstruction, lower pole of the flap on the inferior midlne (marked with dotted line).
A modified Karydakis flap reconstruction was carried out in 35 (43.2%) of 81 patients and Modified Limberg flap reconstruction was carried out 46 (56.8%) of 81 patients with pilonidal sinus disease (Table 2). Eighty-one patients of 104 included in this study. The results of question form are in Table 3. Twelve of the MLF group and four of the MKF had recurrence disease. There were not significant difference in both groups for this type of presentation. There were significant difference between group 1 and group 2 according to BMI (mean value: 26.7 2.7 kg/m2 and 25.1 3.5 kg/ m2/P: 0.020), operation time (mean value: 45.3 11.3 min and 33.5 15.7 min/P < 0.001) and complication rate (4.2% and 22.9%/ P: 0.010). In MLF group 2 patients(4.2%) had complication but in MKF group 8 patients (22.9%) had complication. The difference between the groups for complication was statistically significant (P: 0.010). Two patients had seroma in MLF group and 6 patients in
MKF group (4.2% and 17.1%/P: 0.048) and the difference was statistically significant. In MLF group there were notany wound infection but in MKF group wound infection occurred in 2 patients (5.7%). In MLF group dehiscence did not occurred but in MKF group dehiscence occurred in four patients (11.4%). The difference was statistically significant (P: 0.016).The suction drain was removed on 6 3.3 days in MLF group and 6 1.9 days in MKF group. In MKF group there were 15 (42.8%) women patients and in MLF there were 2(4.34%) women patients. In MLF group recurrence did not occurred in any patient but in MKF group recurrence occurred in 2 patients (5.7%). MLF group stopped analgesic drug on 4.5 2 days and MKF group on 7.9 6.8 days. The difference was statistically significant (P: 0.002). VAS score were evaluated on postoperative 1, 3 and 5 days. On postoperative first day VAS score was 3.4 1.6 in MLF group and 3.7 1.7 in MKF group, on third day VAS score was 1.8 1.1 in MLF group and 2.3 1.4 in MKF group, but the difference was not statistically significant. On postoperative fifth day VAS score was 0.5 0.6 in MLF group and 1.0 0.8 in MKF group and the difference was statistically significant (P: 0.007). MLF group sit on chair and throne before MKF group. MLF group sit on chair on 9.8 7.4 days and MKF group sit on chair on 16.5 9.9 days (P: 0.001), MLF group sit throne on 5.4 4.3 days and MKF group sit throne on 11.7 8 days. MLF group felt completely healed on postoperative 19 16.7 days and MKF group felt completely healed
Fig. 5. Modified Karydakis procedure. After healed.
Fig. 7. MLF transposition. Rhomboid excision of the diseased tissue followed by preparation of the flap on the right gluteal area.
Fig. 4. Reconstruction using Modified Karydakis flap with an eventual closure line 2 cm lateral to the midline, especially at the lower end.
3. Results
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Fig. 8. MLF transposition. Fasciocutan flap transposed medially to fulfill the rhomboid defect. Fig. 10. MLF after skin was closed with skin staples.
on postoperative 23.5 8.5 days. But the difference was not statistically significant.
4. Discussion There is still no consensus about treatment of pilonidal sinus disease. Ideally, therapy should be associated with short hospital stay, less painful postoperative time, rapidly healing and return to work, less painful dressing of wound, short term wound care and a low recurrence rate. No techniques fulfills all of these criteria. Since the source of the disease is thought to be natal cleft and deep intergluteal sulcus,14 the aims of the flap techniques are natal cleft
Fig. 11. MLF after healing.
Table 2 Demographic and clinical characteristics of the patients.
Fig. 9. MLF transposition after drain replaced.
Variable
MLF groups (N: 61)
MKF groups (43)
Age Men/women BMI (kg/m2) Primer/Nüx disease Operation time (minutes) Drain removed day Complication rate - Seroma - Hematoma - Dehiscence - Wound infection Recurrence
28.5 9 44/2 26.7 2.7 34/12 45.3 11.3 6 3.3 2 (4.2%) 2 (4.2%) 0 (0%) 0 0 (0%) 0 (0%)
26.9 6 20/15 25.1 3.5 31/4 33.5 15.7 6 1.9 8 (22.9) 6 (17.1) 0 (0%) 4 (11.4) 2 (5.7%) 2 (5.7%)
P values
0.1 <0.001 1.000 0.010 0.048 0.016 0.096 0.096
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Table 3 The results of the question form.
When did you stop analgesic drug? (days) How severe is your pain today? - Postoperative 1 st day? - Postoperative 3 rd day? - Postoperative 5 th day? When did you sit to chair without pain? (days) When did you sit to throne without pain? (days) When did you feel you were completely healed? (days) If did you have to see/know a postoperative pilonidal sinus patient please compare your operation with them. Please rate your satisfaction with the results of operation Would you recommend this surgical technique to other pilonidal sinus patients?
MLF group
MKF group
P value
4.5 2
7.9 6.8
0.002
3.4 1.6 1.8 1.1 0.5 0.6 9.8 7.4 5.4 4.3 19 16.7 Worse: 0; similar: 0; better: 46
3.7 1.7 2.3 1.4 1.0 0.8 16.5 9.9 11.7 8 23.5 8.5 Worse: 6; similar: 0; better: 29
0.495 0.058 0.007 0.001 <0.001 0.148 0.010
Dissatisfied: 0; somewhat satisfied: 0; good: 10; excellent: 36 Yes: 46; no: 0
Dissatisfied: 2; somewhat satisfied: 4; good: 10; excellent: 19 Yes: 27; no: 8
0.019
flatting, lateralization and fulfilling the defect without tension. Primary closure technique’s operation time is short but have significant postoperative morbidity and recurrence rate. In this technique wound infection rate is 12e32.7%, dehiscence rate is 10e 50% and recurrence rate is 5e12%.18e20 With this technique, natal cleft flatting and lateralization, fulfilling the defect without tension is impossible. Incision and curetage,7 unroofing curetage procedure8 and excision with marsupialization procedures9 are common used surgical techniques. But these procedures had painful postoperative time, delate healing and return to work, painful dressing of wound and long term wound care. But they have a low recurrence rate.10 When the midline lateralized or flattened, recurrences are less likely to occur than after primary closure or other methods that fail to reconstruct the intergluteal sulcus.14 Other studies reported a mean length of hospital stay 2e4 days.10,14e21 In the present study the length of hospital stay was 1 day for MKF group and 1 0.1 days for MLF group. The incidence of wound infection was ranged from 0% to 12%10,16e22 in MKF group and 0.8% to 12% in MLF group in the other studies.10,14e21 Despite BMI lesser in MKF group in the present study wound complication developed in 8 patients in MKF group. Wound infection occurred in 2 of 35 patients, seroma occurred in 6 of 35 patients. Seroma and than dehiscence both occurred in 2 of 35 patients and wound infection and than dehiscence both occurred in 2 of 35 patients. In MLF group we did not detect any infection, but seroma occurred in 2 of 46 patients (4.3%) and dehiscence did not occurred. Acute infected pilonidal sinus disease should be treated by incision drenage or incision curetage. In the present study the patients presenting with an acute abscess in the sacrococcygeal region initially treated with a small incision under local anesthesia and than postoperatively they were treated by third generation cephalosporine and metronidazole for 10 days. Patients were scheduled for MLF or MKF procedure after 14 days. All wound infections in the present study were managed under local anesthesia by removing the sutures, opening and cleaning the wound cavity and using appropriate antibiotics. Seroma was managed by fluid aspiration and antibiotics were added to prevent infection. Generally suction drains were left only 1e3 days in other studies.14e16 In the present study suction drains left when the effluent was less than 20 ml per 24 h. We left drains 6 1.9 days in MKF and 6 3.3 days in MLF group. Gurer et al. prospectively randomized 50 patients into two equal groups: drained and nondrained. Fluid collections were encountered in two patients (8%) of the drained group compared with eight patients (32%) in the nondrained group with the difference being statistically significant.21 In our opinion sources of low rate wound infection are antibiotic treatment by using third
0.010
generation cephalosporine and metronidazole, choosing noninfected pilonidal disease for surgery and delayed suction drainage. MLF procedure fulfills the defect with a lesser tension than in MKF procedure, so that we detected lower rates of wound related complications in MLF group. Lower rates of infection, seroma and dehiscence were detected in MLF group. The recurrence rate of MKF and MLF were 0e7%10,18e20,26,27 and 0e5.4%16e 20,24 respectively in other studies. In our study 2 of 35 patients had recurrence in MKF group but we had no recurrence in MLF group. Follow up time is 2e28 months. The other studies were similar according to the follow up time. Longer follow up time will be more significant to evaluate recurrence rate. In classic Limberg flap technique recurrence rate is 1.26e5.3%.10,14e28 In this technique inferior midline of operation was frequently macerated, healed slowly and might even be source of recurrence.18 In MLF technique inferior apex of the rhomboid excision were 1e2 cm lateral to midline on the opposite side of the donor area and depending on this recurrence rates are lower than classic Limberg flap. MLF group patients stopped analgesic drug on postopertative 4.5 2 days and MKF group patients stopped on 7.9 6.8 days. There was significant difference (P: 0.002) between two groups. Also postoperative 1st, 3rd and 5th days VAS score were lower in MLF group. But only the difference on postoperative 5thday was statistically significant (P: 0.007). MLF group patients started to sit on chair without pain on postoperative 9.8 7.4 days and sit to throne without pain on postoperative 5.4 4.3 days. There were significant difference between groups for sitting chair (P: 0.001) and sitting throne (P < 0.001). In our opinion in MKF group there were considerable discomfort and pain. It may result from the tension in the wound. MLF group patients felt completely healed on postoperative 19 16.7 days and MKF group patients felt completely healed on postoperative 23.5 8.5 days. Difference was not significant. Most patient felt completely healed after removal of the sutures. Patient satisfaction were depended on the development of complication, so the patients in MLF group were more satisfied about their operation because of the lower complication rates. Advantages of modified Karydakis procedure are; shorter operation time, shorter wound healing in dehiscence and easier learning curve. Advantages of modified limberg procedure are; beternatal cleft flatting and lateralization better, lesser tension in fulfilling the defect. Disadvantage of MLF is larger operation scar. In conclusion; although MLF procedures’ operation time was longer than MKF group, MLF procedure was more comfortable for patients. Lesser pain, lower complication and recurrence rates and high degree of patient satisfaction were detected in MLF group.
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Ethical approval None. Sources of funding None. Authors’ contribution Omer Yoldas: writing, data collection. Mesut Tez: data analysis and statistical analysis. Turgut Karaca: study design, idea for the study. Conflicts of interest None. References 1. Hardawey RM. Pilonidal cyst; neither pilonidal nor cyst. Archives of Surgery 1958;76:143e7. 2. Bertelsen CA. Cleft-lift operation for pilonidal sinuses under tumescent local anesthesia: a prospective cohort study of peri- and postoperative pain. Diseases of the Colon & Rectum 2011 Jul;54(7):895e900. 3. Pilonidal disease. Surgical Clinics of North America 1994;74:1309e15. 4. Armstrong JH, Barcia PJ. Pilonidal sinus disease: the conservative approach. Archives of Surgery 1994;129:914e9. 5. Schneider IHF, Thaler K, Kockerling TF. Treatment of pilonidal sinuses by phenol injections. International Journal of Colorectal Disease 1994;9:200e2. 6. Dogru O, Camci C, Aygen E, Girgin M, Topuz O. Pilonidal sinus treated with crystallized phenol: an eight-year experience. Diseases of the Colon & Rectum 2004 Nov;47(11):1934e8. 7. Bisset IP, Isbister WH. The management of patients with pilonidal diseaseda comparative study. Australian and New Zealand Journal of Surgery 1987;57: 939e42. 8. Kepenekci I, Demirkan A, Celasin H, Gecim IE. Unroofing and curettage for the treatment of acute and chronic pilonidal disease. World Journal of Surgery 2010 Jan;34(1):153e7. 9. Fuzun M, Bakır H, Soylu M, Tansug T, Kaymak E, Harmancıoglu O. Which technique for treatment of pilonidal sinusdopen or closed? Diseases of the Colon & Rectum 1994;37:1148e50. 10. Silva JH. Pilonidal cyst: cause and treatment. Diseases of the Colon & Rectum 2000;43:1146e56. 11. Berkem H, Topaloglus S, Ozel H, Avsar FM, Yildiz Y, Yuksel BC, et-al. V-Y advancement flap closures for complicated pilonidal sinus disease. International Journal of Colorectal Diseases 2005;20:343e8. 12. Bascom JU. Repeat pilonidal operations. American Journal of Surgery 1987;154: 118e22.
13. Arumugam PJ, Chandrasekaran TV, Morgan AR, Beynon J, Carr ND. The rhomboid flap for pilonidal disease. Colorectal Diseases 2003;5:218e21. 14. Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, Oguz M. Modified Limberg transposition flap for sacrococcygeal pilonidal sinus. Surgery Today 2004;34(5):419e23. 15. Karydakis GE. New approach to the problem of pilonidal sinus. Lancet 1973 Dec 22;2(7843):1414e5. 16. Bessa SS. Results of the lateral advancing flap operation (modified Karydakis procedure) for the management of pilonidal sinus disease. Diseases of the Colon & Rectum 2007 Nov;50(11):1935e40. Epub 2007 Sep 8. 17. Stroosma OC. Gluteal fascioplasty as a method of primary closure in the treatment of pilonidal sinus. Archivum Chirurgicum Neerlandicum 1978;30: 61e4. 18. Cihan A, Mentes BB, Tatlicioglu E, Ozmen S, Leventoglu S, Ucan BH. Modified Limberg flap reconstruction compares favourably with primary repair for pilonidal sinus surgery. ANZ Journal of Surgery 2004 Apr;74(4): 238e42. 19. Can MF, Sevinc MM, Yilmaz M. Comparison of Karydakis flap reconstruction versus primary midline closure in sacrococcygeal pilonidal disease: results of 200 military service members. Surgical Today 2009;39(7):580e6. Epub 2009 Jun 28. 20. Brieler HS. Infected pilonidal sinus. Langenbecks Archiv für Chirurgie Supplement Kongressband 1997;114:497e500. 21. 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. American Journal of Surgery 2010 Sep;200(3):318e27. Epub 2010 Feb 1. 22. Petersen S, Aumann G, Kramer A, Doll D, Sailer M, Hellmich G. Short-term results of Karydakis flap for pilonidal sinus disease. Techniques in Coloproctology 2007 Sep;11(3):235e40. Epub 2007 Aug 3. 23. Gurer A, Gomceli I, Ozdogan M, Ozlem N, Sozen S, Aydin R. Is routine cavity drainage necessary in Karydakis flap operation? A prospective, randomized trial. Diseases of the Colon & Rectum 2005;48:1797e9. 24. Moran DC, Kavangh DO, Adhmed I, Regan MC. Excision and primary closure using the Karydakis flap for the treatment of pilonidal disease: outcomes from a single institution. World Journal of Surgery 2011 Aug;35(8):1803e8. 25. Keshava A, Young CJ, Rickard MJ, Sinclair G. Karydakis flap repair for sacrococcygeal pilonidal sinus disease: how important is technique? ANZ Journal of Surgery 2007 Mar;77(3):181e3. 26. Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir M. Limberg flap procedure for pilonidal sinus disease: results of 353 patients. Langenbecks Archives of Surgery 2008 Mar;393(2):185e9. Epub 2007 Sep 22. 27. Urhan MK, Küçükel F, Topgül K, Ozer I, Sarı S. Rhomboid excision and Limberg flap for managing pilonidal sinus: results of 102 cases. Diseases of the Colon & Rectum 2002;45:656e9. 28. Müller K, Marti L, Tarantino I, Jayne DG, Wolff K, Hetzer FH. Prospective analysis of cosmesis, morbidity, and patient satisfaction following Limberg flap for the treatment of sacrococcygeal pilonidal sinus. Diseases of the Colon & Rectum 2011 Apr;54(4):487e94.