Pilonidal sinus disease with especial reference to Limberg flap

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Information about Pilonidal sinus disease with especial reference to Limberg flap

Published on September 30, 2015

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1. Pilonidal sinus disease with especial reference to Limberg flap

2. Review Article Pilonidal sinus disease with especial reference to Limberg flap Ajay K. Khanna a, *, Satyendra K. Tiwary b a Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh 221005, India b Assistant Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India 1. Background First historical description of pilonidal disease dates back to 1833 by Herbert Mayo as a hair containing sinus1 but the term 'Pilonidal' was coined by Hodge in 1880.2 The disease is a very common problem affecting middle-aged working population, and it most often arises in the hair follicles of the natal cleft of the sacrococcygeal area. Incidence of pilonidal sinus is about 26 cases per 100,000, affecting males thrice as much as females. Men are thought to be at higher risk because of their hirsute nature. Pilonidal sinus is also associated with obesity (37%), sedentary occupation (44%), and local irritation or trauma (34%).3 It may manifest as pilonidal cyst, sinus, or abscess, and inflammation may lead to rapid progression of the disease. During the Second World War, pilonidal disease very commonly appeared in jeep drivers, so called as ‘‘jeep disease’’.4 a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x a r t i c l e i n f o Article history: Received 30 June 2015 Accepted 28 July 2015 Available online xxx Keywords: Pilonidal sinus Jeep disease Limberg flap Epidemiology Bacterial contamination a b s t r a c t This article lays an emphasis on ‘‘Pilonidal Sinus disease’’ along with the historical back- ground, materials, and methods used. The term 'Pilonidal' was coined by Hodge in 1880. The disease commonly affects middle-aged working population and most often arises in the hair follicles of the natal cleft of the sacrococcygeal area. This disease affects males thrice as much as females because of their hirsute nature. Pilonidal sinus is associated with obesity, sedentary occupation, and local irritation or trauma. The management of pilonidal disease is complex and a big burden on hospital and community resource because of the recurrent nature of the disease. Various surgical methods have been practiced to treat sacrococcygeal pilonidal sinus disease. Each method is associated with different postoperative complica- tions, morbidity, and recurrence rates for each of the procedures. The most simple approach for pilonidal disease is simple incision. It is effective for simple, superficial, small, and mostly midline tracts. Excision is a simple technique used for chronic and recurrent pilonidal sinuses. Rhomboid Limberg flap reconstruction plastic surgery procedure was done after proper preoperative assessment and preparation in all cases. # 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd. * Corresponding author. Tel.: +91 9415201954. E-mail address: akhannabhu@gmail.com (A.K. Khanna). APME-309; No. of Pages 7 Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.013 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme http://dx.doi.org/10.1016/j.apme.2015.07.013 0976-0016/# 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.

3. Pilonidal disease can appear as an acute abscess along with sinus tract formation. There have been a lot of debate on whether pilonidal disease is congenital or acquired, but now it is beyond doubt that it is an acquired condition.5,6 A more complex manifestation usually after episode of inflammation can be characterized by chronic or recurrent abscesses with extensive branching sinus tracts. The commonest presenta- tion for which a patient seeks medical advice is in the form of an acute abscess characterized by the existence of a midline pit in the natal cleft typically identified 4–8 cm from the anus. A deep natal cleft serves favorable atmosphere for bacterial colonization due to anaerobic environment, sweating, hair in growth, close proximity to bacteria leading to contamination. This primary tract leads into a subcutaneous cavity, which contains granulation tissue and usually a nest of hairs that are present in two thirds of cases in men and in one third of those in women and may be seen projecting from the skin opening. Many patients have secondary lateral openings 2–5 cm above the midline pit. The skin opening and the superficial portion of the tract are lined with squamous cell epithelium, but the deep cavity and its extensions are not. Maximum number of cases of pilonidal sinus are present in postsacral area, but it may be seen in other regions such as interdigital, axillary, umbilical, peri-anal, para-anal, intra-anal, and cervical region.7,8 The management of pilonidal disease is complex and a big burden on hospital and community resource because of the recurrent nature of the disease.9,10 Treatment and prevention are successful, if causative factors such as deep natal cleft and presence of hair are taken care or minimized to prevent sweating, maceration, bacterial contamination, and penetra- tion of hairs.11,12 Proper decision making is based on the type of presentation and treatment modality that range from antibiotics, shaving, simple incision and drainage, phenol application, cryosurgery, excision with primary closure, excision with open packing, and excision with marsupializa- tion to a wide excision with reconstructive surgical proce- dures.13–16 There is no clinical consensus on the optimal management of the pilonidal sinus but low recurrence, low morbidity, acceptable cosmesis, insignificant tissue loss, and minimal economic loss should be the goal in management. Our experiences are mostly with reconstructive procedure of Limberg flap in 180 patients of pilonidal disease from year 2004 to 2014. 2. Materials and methods Retrospective data analysis of 180 patients during 2004–2014 was done. Detailed demographics, epidemiology, and clinical presentations were analyzed. Only cases with surgical inter- ventions were considered for study. Conservative manage- ment by antibiotics and drainage of pus was carried out in abscess, and these patients were later subjected to rhomboid excision Limberg flap reconstruction. Age, sex, duration, co-morbidity, presentation, number of openings, number of surgical interventions in past, treatment, duration of hospital stay, complications, and follow-up were recorded and analyzed (Table 1). 3. Results In 180 patients, males were 126 (70%), and females were 54 (30%). Mean age of presentation was 24.2 years (15–65 years) with mean BMI of 22.3 kg/m2 (17.1–30.5). Co-morbidity was present in 42 patients (23.3%) in the form diabetes, renal failure, and immunocompromised patient. Recurrent disease with history of past surgical intervention was noticed in 36 patients (20%). Most significant finding was history of previous infection or abscess in 171 patients (95%). Single tract was in 153 patients (85%) and multiple tract in 27 (15%). All patients underwent surgical intervention by Limberg flap reconstruction. Mean hospital stay was 3.2 days (1–9 days) and mean follow-up of 38.4 months (6–60 months). Recur- rence was noticed in only 6 cases (3.3%). Outcome and follow- up in pilonidal disease treated by Limberg Flap is shown in Table 2. Surgical excision and rhomboid Limberg flap reconstruc- tion plastic surgery procedure (Figs. 1–4) were done after proper preoperative assessment and preparation in all cases. First and foremost measure was control of inflammation and infection in all cases with antibiotics and drainage with incision and debridement. Anatomical mapping with fistulo- gram preoperatively in all cases was done to plan reconstruc- tive procedures. Fistulogram delineated the number of tract, depth of cavity and lateral extension leading to proper planning of extent of rhomboid flap excision for curative intent. Hairs over the region were shaved preoperatively in all cases. Spinal anesthesia was used in 171 cases (95%) and local anesthesia in 9 cases (5%). Position was jackknife prone in all Table 1 – Demographics of pilonidal disease (n = 180). Total, n, % 180 (100%) Male, n, % 126 (70%) Female, n, % 54 (54%) Age, years Mean 24.2 (15–65) BMI Mean 22.3 (17.1–30.5) Comorbidity (Diabetes, Immuno compromised, Renal failure), n, % 42 (23.3%) Recurrent disease, n, % 36 (20%) Previous infection or abscess, n, % 171 (95%) Single tract, n, % 153 (85%) Multiple tracts, n, % 27 (15%) Hospital stay Mean, 3.2 days (1–9 days) Follow-up Mean 38.4 months (6 months to 60 months) Recurrence, n, % 6 (3.3%) Table 2 – Outcome and follow up in pilonidal disease (n = 180). Seroma 2 (1.1%) Hematoma 6 (3.3%) Wound dehiscence 8 (4.4%) Flap necrosis 1 (0.5%) Wound infection 4 (2.2%) Residual pain and heaviness 9 (5%) Recurrence 6 (3.3%) Hypoasthesia 8 (4.4%) a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2 APME-309; No. of Pages 7 Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.013

4. cases. After prepping and draping, lesion was marked and included in rhomboid area to be excised. Limberg flap was raised as per the dimensions to cover the defect. The flap was raised along with the fascia over the gluteus maximus. Two- layered closure was done with vicryl 2-0 for adipofacial approximation and prolene 3-0 for skin closure. Minivac suction drain was placed after hemostasis in 160 cases (88.1%). The patient was nursed in prone position or lateral position for initial 24 h. The dressing was changed after 48 h and the drain was removed if contents were less than 10–15 ml. Fig. 1 – Planning of Rhomboid or Limberg Flap Fig. 2 – Marking, incision and excision a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3 APME-309; No. of Pages 7 Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.013

5. 4. Discussion Various surgical methods have been practiced to treat sacrococcygeal pilonidal sinus disease; each is associated with different postoperative complications, morbidity, and recurrence rates for each of the procedures. Excision of the infected tissue and sinuses is not considered a major technical problem but healing is cumbersome and expensive for both the patient and physician due to its long duration and the Fig. 3 – Incision and mobilization of Limberg Flap Fig. 4 – Closure in Limberg Flap a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x4 APME-309; No. of Pages 7 Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.013

6. requirement for daily wound dressings using the open- packing technique.17 Although the primary closure method results in rapid recovery and quick resumption of daily activities, high complication and recurrence rates have been reported.18,19 Pilonidal disease affects men20,21 between 16 and 25 years of age. Usually it is associated with obesity22,23 and hirsute individuals, who experience profuse sweating and have a sedentary lifestyle.24,25 High morbidity and chronicity of the disease leads to significant economic burden. In acute phases of inflammation, an antibiotic and conservative approach is the choice. There is almost always history of inflammation or abscess formation. Definitive and curative approach always includes some type of surgical intervention. The treatment of pilonidal disease is mostly surgical. The most commonly used procedures today are simple incision, excision, marsupializa- tion, fistulotomy, and various plastic surgery techniques. Most simple approach for pilonidal disease is simple incision. It is basically a limited intervention in acute inflammatory stage and is most important for relieving pain and rapid recovery for subsequent definitive excision and flap reconstruction surgery. A midline incision through the mouths of the pits carried out and is effective in those cases of so-called raphe cannulization where infection spreads from pit to pit.26,27 It is effective for simple, superficial, small, and mostly midline tracts. After unroofing the tract, it is debrided, cleaned, and drained.28,29 Recurrence is frequent, and defini- tive plastic reconstructive procedure is planned for final cure. Excision is a simple technique used for chronic and recurrent pilonidal sinuses. Excision of all involved skin and subcutaneous tissue is must for definitive treatment. Wounds may be left open with healing by secondary intention, allowing the wound to granulate, or is closed by primary intention with immediate suturing.30,31 Various types of silastic dressing and negative pressure therapy are used to fasten the healing of wound. Laying the sinus open permits adequate drainage of secretions, pus, or debris. The healing by secondary intention requires more time, but has lower recurrence rate.32 In healing by primary intention, the pilonidal sinus is excised and the wound sutured by using deep tension sutures tied over a gauze dressing. The advantages are quicker healing, less hospital stay, and an early return to work, albeit with higher recurrence when compared to the open technique.33,34 Plastic surgery techniques that include these procedures do not only cover the wound but also, in theory, flatten the natal cleft, as well as reduce hair accumulation, mechanical irritation and risk of recurrence.20,35 Various kinds of flaps have been used: 1–2 skin flaps, fasciocutaneous flaps like the V-Y flap (for recurrent and complicated sinus disease) and rhomboid excision and the Limberg flap.6 The Karydakis flap36 achieves asymmetric closure of the pilonidal wounds by avoiding to place the wound in the midline at the depth of the natal cleft and also flattens the cleft, reducing hair accumula- tion and mechanical irritation36,37 resulting in decreased recurrence. A tendency toward using flap reconstruction techniques to treat pilonidal sinus has been established, as they provide the desired results, such as flattening of the natal cleft, providing tissue healing without tension, short duration of healing and return to work, acceptable cosmetic results, and low recurrence rates.38 The problem, related to a continuing deep natal cleft after surgery, leads surgeons to find techniques in order to minimize or flatten natal cleft. Infection starts in hair follicles due to open orifices leading to sinus as hypothesized by Bascom and excision of midline pits with lateral open drainage of any associated abscess essential for cure. Natal cleft effect, wound tension, and complete excision are three key factors that prompted various plastic reconstructive procedures such as Z plasty, W plasty, V-Y plasty, and various flap techniques. Various techniques have been described that attempt to eliminate factors that cause negative primary closure results such as a midline incision scar and tissue tension resulting in lower recurrence rates.12,20,39–42 One of the most commonly used techniques is Limberg flap reconstruction. The flap necrosis after Limberg flap is rare, and it varies from 0 to 3.3% of cases in literature.43 In our study, only one patient out of 180 had partial flap necrosis, which is acceptable and comparable to various studies in past. The rate of development of seroma after Limberg flap is 0–14.5% of cases in various studies. Mentes et al. reported a seroma rate of 2.2% without placing a drain and a mean duration of hospitalization of 4.51 Æ 2.85 days in their series of 353 patients.44 Kirkil et al. reported the rates of seroma development in groups with and without drains to be 10.7 and 18.5%, respectively (total, 14.5%), in their series of 55 patients who were randomized for drain placement with a mean 3.2 days of hospitalization.45 They reported that all such patients were treated by repeated aspiration of seroma. Okuş et al. reported a mean duration of hospitalization of 1.85 days and that no seroma developed in any patient treated with Limberg flap in their prospective study of 49 patients in an Limberg flap group in which drains were placed in all patients.46 Therefore, these studies suggest no relationship between development of a seroma and duration of hospitalization. We discharged our patients 24–48 h after surgery with a mean of 3.2 days (1–9 days). The rates of hematoma and wound dehiscence after Limberg flap are 0–4% and 0–10.4%, respectively, and in our patients, such were 3.3 and 4.4%. Although hematomas have been treated with repeated aspiration in some studies, but good hemostasis is the key to prevent hematoma.45 The rate of wound infection after the Limberg flap procedure varies from 0–8% of cases.43 Different rates of infection in studies with similar numbers of patients and duration of hospitalization have been reported, suggesting that there is no direct relationship between the duration of hospitalization and the development of infection. The rate of infection was 2.2% (4 patients) in our series of 180 patients. The most commonly reported result in long-term studies is the recurrence rate. The reported rates of recurrence following Limberg flap vary between 0 and 9%.43 Two other long-term problems with Limberg flap are hypoesthesia at the operative site and cosmetic dissatisfaction. Mentes et al. reported a recurrence rate of 2.2%.44 The rates of recurrence and hypoesthesia in our study agree with those in the literature (3.3 and 4.4%, respectively). Short- and long-term postoperative results are in agree- ment with the literature data in patients treated with the Limberg flap procedure in our study. The duration of hospitalization varies from 1.7 to 5.9 days43,44 in studies in which Limberg flap was performed. a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 5 APME-309; No. of Pages 7 Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.013

7. 5. Conclusion Pilonidal sinus is a benign disorder but two serious issues are associated with it; those are significant economic loss and significant morbidity. It affects the working middle-aged population and individuals receiving their education or those in early phases of their job. The time spent in the hospital continues to result in significant economic issues. The Limberg flap procedure has minimal postoperative complications and very low recurrence in long-term follow-up with minimal time to be spent in hospital. Though it requires a good geometric calculation for raising the flap, the flap never fails with an advantage of flattening natal cleft so to have the low recurrence of the disease. Conflicts of interest The authors have none to declare. r e f e r e n c e s 1. Mayo OH. Observations on Injuries and Disease of Rectum. London: Burgess and Hill; 1833:45–46. 2. Hodge RM. Pilonidal sinus. Boston Med Surg J. 1880;103:485– 486. 3. Sondeno K, Andersen E, Nesvik I, Spreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis. 1995;10:39–42. 4. Mentes O, Bagci M, Bilgin T, Coskun I, Ozgul O, Ozdemir M. Management of pilonidal sinus disease with oblique excision and primary closure results of 493 patients. Dis Colon Rectum. 2006;49:104–108. 5. Basom J. Pilonidal disease: long-term results of follicle removal. Dis Colon Rectum. 1983;26:800–807. 6. Chintapatla S, Safarowi N, Kumar S, Haboubi N. Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol. 2003;7:3–8. 7. Weston SD, Schlachter IS. Pilonidal cyst of the anal canal: case report. Dis Colon Rectum. 1963;6:139–141. 8. Eryilmaz R, Sahin M, Okan I, Alimoglu O, Somay A. Umbilical pilonidal sinus disease: predisposing factors and treatment. World J Surg. 2005;29:1158–1168. 9. Goodall P. The etiology and treatment of pilonidal sinus: a review of 163 patients. Br J Surg. 1961;49:212–218. 10. Clothiers PR, Haywood IR. The natural history of the post anal (pilonidal) sinus. Ann R Coll Surg Engl. 1984;66: 201–203. 11. Schoelller T, Wechselberger G, Otto A, et al. Definite surgical treatment of complicated recurrent pilonidal disease with modified fasciocutaneous V-Y advancement flap. Surgery. 1997;121:258–263. 12. Bascom J. Pilonidal disease: origin from follicles of hairs and results of follicle removal at treatment. Surgery. 1980;87:567–572. 13. Quinodoz PD, Chilcott M, Grolleau JL, et al. Surgical treatment of sacrococcygeal pilonidal sinus disease by excision and skin flaps: the Toulouse experience. Eur J Surg. 1999;165:1061–1065. 14. Cubukcu A, Gonullu NN, Pakosy M, et al. The role of obesity on recurrence of pilonidal sinus disease in patients who were treated by excision and Limberg flap transposition. Int J Colorectal Dis. 2000;15:173–175. 15. Arumugam PJ, Chandrasekaran TV, Morgan AR, et al. The rhomboid flap for pilonidal disease. Colorectal Dis. 2003;5:218–221. 16. Yilmaz S, Kirimlioglu V, Katz D. Role of simple V-Y advancement flap in the treatment of complicated pilonidal sinus. Eur J Surg. 2000;166:269–272. 17. al-Hassan HK, Francis IM, Neglen P. Primary closure or secondary granulation after excision of pilonidal sinus? Acta Chir Scand. 1990;156:695–699. 18. Urhan M, Kucukel F, Topgul K, Ozer I, Sari S. Rhomboid excision and Limberg flap for managing pilonidal sinus; result of 102 cases. Dis Colon Rectum. 2002;45:656–659. 19. Holm J, Hulten L. Simple primary closure for pionidal disease. Acta Chir Scand. 1970;136:537–540. 20. Karydakis GE. New approach to the problem of pilonidal sinus. Lancet. 1973;2:1414–1415. 21. Clothier RR, Haywood IR. The natural history of the post anal (pilonidal) sinus. Ann R Coll Surg Engl. 1984;66:201–203. 22. Bascom J. Surgical treatment of pilonidal disease. BMJ. 2008;336:842–843. 23. Menzel T, Dorner A, Cramer J. Excision and open wound treatment of pilonidal sinus. Rate of recurrence and duration of work incapacity. Deusch med Wochenschr. 1997;122:1447–1451. 24. Bule LA. Classic articles in colonic and rectal surgery 1890- 1975; jeep disease (Pilonidal disease of mechanized warfare). Dis Colon Rectum. 1982;25:384–390. 25. Kronborg O, Christensen K, Zimmermann-Nielsen C. Chronic pilonidal disease: a randomized trial with a complete 3 year follow up. Br J Surg. 1985;72:303–304. 26. Bascom J, Bascom T. Failed Pilonidal surgery: new paradigm and new operation leading to cures. Arch Surg. 2002;137:1146–1151. 27. Flannery BP, Kidd HA. A review of pilonidal sinus lesions and a method of treatment. Postgrad Med J. 1967;43:353–358. 28. Bascom J, Bascom T. Utility of cleft lift procedure in refractory pilonidal disease. Am J Surg. 2007;193:606–609. 29. Rickets JA. Ambulatory surgical management of pilonidal sinus. Am Surg. 1974;40:237–240. 30. Armstrong JH, Barcia PJ. Pilonidal sinus disease. The conservative approach. Arch Surg. 1994;129:914–919. 31. Lord PH, Miller DM. Pilonidal sinus: a simple treatment. Br J Surg. 1965;52:298–300. 32. Miocinovic M, Horzic M, Bunoza D. The treatment of pilonidal disease of sacrococcygeal region by the method of limited excision and open wound healing. Acta Med Croatia. 2000;54:27–31. 33. Jones DJ. ABC of colorectal diseases. Pilonidal sinus. BMJ. 1992;305:410–412. 34. Serour F, Somekh E, Krutman B, Gorenstein A. Excision with primary closure and suction drainage for pilonidal sinus in adolescent patients. Paediatric Surg Int. 2002;18:159–161. 35. Sondenna A, Anderson E, Neswik I, Soreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis. 1995;10:39–42. 36. Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z Surg. 1992;62:385–389. 37. Morden P, Drongowski RA, Geiger JD, Hirschi RB, Teitelbaum DH. Comparison of Karydakis versus midline excision for treatment of pilonidal sinus disease. Pediatr Surg Int. 2005;21:793–796. 38. Khadrawy O, Hashish M, Ismail K, Shalaby H. Outcome of the rhomboid flap for recurrent pilonidal disease. World J Surg. 2009;33:1064–1068. 39. Khanna A, Rombeau JL. Pilonidal disease. Clin Colon Rectal Surg. 2011;24:46–53. a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x6 APME-309; No. of Pages 7 Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.013

8. 40. Sharma PP. Multiple Z Plasty in pilonidal sinus – a new technique under local anesthesia. World J Surg. 2006;30:2261–2265. 41. Kim JK, Jeong JC, Lee JB, Jung KH, Bae BK. S-plasty for pilonidal disease: modified primary closure reducing tension. J Korean Surg Soc. 2012;82:63–69. 42. Nessar G, Kayaalp C, Seven C. Elliptical rotation flap for pilonidal sinus. Am J Surg. 2004;187:300–303. 43. Daphan C, Takelioglu MH, Sayilgan C. Limberg flap repair for pilonidal sinus disease. Dis Colon Rectum. 2004;47:233–237. 44. Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir M. Limberg flap procedure for pilonidal sinus disease: results of 353 patients. Langenbecks Arch Surg. 2008;393:185–189. 45. Kirkil C, Boyuk A, Bulbuller N, Aygen E, Karabulut K, Koskun S. The effects of drainage on the rates of early wound complications and recurrences after Limberg flap reconstruction in patients with pilonidal disease. Tech Coloproctol. 2011;15:425–429. 46. Okuş A, Sevinc B, Karahan O, Eryilmaz MA. Comparison of Limberg flap and tension-free primary closure during pilonidal sinus surgery. World J Surg. 2012;36:431–435. a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 7 APME-309; No. of Pages 7 Please cite this article in press as: Khanna AK, Tiwary SK. Pilonidal sinus disease with especial reference to Limberg flap, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.013

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