Pilonidal Sinus – Limberg Flap Dr. Brij B. Agarwal MBBS, MS (Gold Medalist) FIMSA Dip Yoga (Gold Medalist) FCLS Vice Chairman, Professor & Senior Consultant, Department of Laparoscopic & General Surgery, GRIPMER  & Sir Ganga Ram Hospital, India. International Advisor, SLS America Secretary, Association of Surgeons of India, Delhi State Associate Editor, Indian Journal of Surgery Vice President, International Society of Colo-Proctology Chairman, Delhi State, International Medical Sciences Academy (IMSA) Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Presenter Disclosure Slide No financial conflict of interest Brij B. Agarwal No financial conflict of interest Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

What are the treatment options? Excision-Open Wound-Healing by Secondary Intention Excision- Wound-Healing by Primary Intention Other techniques Radiofrequency sinus excision Fibrin glue Phenolisation Vacuum –assisted closure therapy Endoscopic Excision Meinero P, Mori L, Gasloli G. Tech Coloproctol. 2013 May 17. Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

What are the end points? Primary End Point -Recurrence prevention Secondary End Point (Desirable) -Expediting the convalescence desirable Saylam B, Balli DN, Düzgün AP, Ozer MV, Coşkun F. Langenbecks Arch Surg. 2011 Jun;396(5):651-8. Thompson MR, Senapati A, Kitchen P. Br J Surg. 2011 Feb;98(2):198-209. Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

What are the principles? Optimization by incision & drainage if an abscess Complete excision of all tracts Obliteration of the inter-gluteal cleft Attempt to achieve primary closure and Placement of surgical scar away from the midline Post-operative Hair Care Saylam B, Balli DN, Düzgün AP, Ozer MV, Coşkun F. Langenbecks Arch Surg. 2011 Jun;396(5):651-8. Thompson MR, Senapati A, Kitchen P. Br J Surg. 2011 Feb;98(2):198-209. Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

What is the pre-requisite? Optimization by Incision & Drainage Incision and drainage preceding definite surgery achieves lower 20-year long-term recurrence rate Doll D, Matevossian E, Hoenemann C, Hoffmann S. J Dtsch Dermatol Ges. 2013;11(1):60-4. Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

What is the evidence? Recurrence higher in primary closure versus open healing Convalescence faster after closure versus open healing Surgical site infection (SSI)- same across the closure techniques Convalescence fastest with “Off midline” closure Recurrence and SSIs are highest after midline closure The Message- If opting to close, opt for ‘off midline’ closure McCallum IJ et al (2008) BMJ 336 (7649):868-71 Al-Khamis A et al (2010) Cochrane Database Syst Rev. 1 CD006213 Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Flap Closure They flatten the gluteal cleft with a , well vascularized pedicle sutured without tension. Most common complication is a seroma or wound separation. Suitable for cases where simpler operations have failed. Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Limberg Flap Basic Steps Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Pre-Operative Prone Position, Buttocks strapped apart Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Position & Anaesthesia Prone Buttocks strapped apart Local awake anaesthesia Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Marking the Incision before LA Equilateral Rhomboid, Angle>60 degrees Caudal Tip of Flap Placed lateral to midline Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Limberg Flap-Geometry Gibson T, editor. Modern Trends in Plastic Surgery. London: Butterworths; 1964 Chasmar LR. The Canadian Journal of Plastic Surgery. Summer 2007; 15(2)67 Azab ASG, Kamal MS, Saad RA et al. Br J Surg 1984;71:-154-5. Hull TL, Wu J. Surg Clin North Am. 2002 Dec;82(6):1169-85.Pilonidal disease. Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Skin Incision Placed After 5 min. of LA (30-50ml Skin Incision Placed After 5 min. of LA (30-50ml.1% Xylocaine + Adrenalin) Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Incision Deepened up to Sacral/ GlutealMuscle Fascia Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Methylene Blue Instillation Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Flap Rotation Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Flap Rotation Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Reverse Flap-Rtation

Flap Corners being Secured Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Rotated Flap Fascial Sutures Placed Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Margin Necrosis Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Conclusion Rotation Flap Surgery for Recurrent Pilonidal Disease can be done safely under LA as a day care procedure. Our RR 4% is comparable to published Literature Agarwal BB, ACRSIOCON Sep 2012, Dubai Cochrane Database Syst Rev. 2010 Jan 20; (1):CD006213 Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

Thanks for your kind attention and patient listening Thank You Pooja Pant, Ramneek Kaur & Krishna Adit Agarwal Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015