Pilonidal Sinus Disease & Limberg Flap

Pilonidal Sinus Disease
All surgery for this condition is usually done under general anaesthetic. If patients present as an emergency with an abscess, then this is opened up, the pus evacuated and the abscess cavity cleaned. It will often be packed by a special type of dressing which will need to be replaced on a regular basis, initially daily, but less often as the wound continues to heal. This may take some weeks.  People having this procedure have about a two thirds chance of the condition healing for good without the need for further surgery. About one third will be left with recurrent symptoms from the original sinus tract.  In the elective setting, scheduled surgery can be planned. 

The biggest problem with any treatment for this disease is the risk of recurrence. Various operations have been tried in the past in an attempt to minimise the risk of recurrence, but even the most advanced procedures still have the risk of recurrence of approximately 2%. Basingstoke Colorectal generally favours a procedure called ‘Cleft Closure’; the recurrence rate is about 4%. This is usually done as a day case procedure, but sometimes people stay for one night afterwards. The Consultant will discuss things in more detail but essentially, once put to sleep by general anaesthetic, all of the area of disease is cut out and the wound checked to make sure it is all healthy. The edges of the skin and both sides of the buttock are then freed up a little bit and the wound is then closed with multi-layered stitches. The scar is usually reasonably long, but the way the surgery is performed means that it lays to one side of the mid line, just to one side of either buttock cheek. This is the key in trying to minimise a risk of recurrence. It is usual practice to leave a small surgical drain in the wound which comes out of the side and this is usually left in place for three days.  Patients are allowed home with this drain and asked to return to the Hospital to have it removed and the wound checked on day three after the procedure. The drain is left to allow any residual fluid to drain away to try and prevent any infection in the first few days after the operation. The stitches used are usually dissolvable sutures which do not require any removal, but your surgeon will let you know if this is not the case.

After the procedure, you will be able to eat and drink normally and go to the toilet in the normal fashion.  Slight care should be taken when wiping yourself. You may find it somewhat sore afterwards; you will be given painkillers to go home with. Normally, sitting is the most painful position, as this not only stretches the wound from top to toe, but also from side to side.  Standing and reclining/lying are often more comfortable in the immediate aftermath of surgery. This will gradually improve over a couple of weeks.  

Limberg Flap
This is a much more extensive procedure for people who either have extensive pilonidal disease or who have disease affecting both sides of the buttocks. A diamond (rhomboid) shaped piece of skin and underlying fat is removed and a plastic surgical type of procedure is used to mobilise a similarly shaped piece of skin from the adjacent buttock. One side of the diamond is left attached to maintain blood supply. The diamond is then swung to the site of the old excision and multiple layers of stitches are used to close and attach the new diamond shape of skin into the wound. This is the operation with the lowest chance of recurrence for Pilonidal Sinus Disease (about 2%). However, it is a much more invasive procedure and patients are usually in hospital for at least a couple of days afterwards. One or two drains are left in place for between three to five days. This is because there is a much larger area underneath the excision site so there is a greater chance of fluid build up. The scar is also quite noticeable and patients are left with a four sided shape that looks a little like a question mark. This will be discussed with you in a lot more detail with your surgeon should this become relevant. This is a bigger operation for this disease, with a longer post operative recovery time and longer hospital stay. It is therefore, reserved for people with the most difficult to treat, or extensive disease.

Risks of these operations:
In line with most operations, there is always a risk of bleeding/bruising after the procedure, although electrocautery is used to seal the blood vessels to try and minimise this. The tissue is infected, so antibiotics are given as a matter of routine at the time of surgery to try to minimise the risk of post operative infection. The drains also help to this regard.  It will be sore afterwards, especially in a sitting position.  As mentioned before, recurrence is the biggest problem with this operation for this disease.  The risk of recurrence with Cleft Closure is approximately 4% and with Limberg Flap 2%. All surgical procedures inevitably leave a degree of scarring, and the scars from these two procedures can be reasonably large. Your Consultant will explain this in a bit more detail to you prior to surgery. Due to the nature of the surgery, people may need to schedule up to four weeks off work, and it is not uncommon with people having a Limberg flap to be off work for a couple of weeks beyond this.

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