1. 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

2. 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

3. 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 May 17.
Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

4. 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 Jun;396(5):651-8.
Thompson MR, Senapati A, Kitchen P. Br J Surg Feb;98(2):
Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

5. 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 Jun;396(5):651-8.
Thompson MR, Senapati A, Kitchen P. Br J Surg Feb;98(2):
Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

6. 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

7. 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

8. 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

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

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

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

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

13. 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

14. 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:
Hull TL, Wu J. Surg Clin North Am Dec;82(6): Pilonidal disease.
Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

15. 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

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

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

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

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

20. Reverse Flap-Rtation

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

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

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

24. 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 Jan 20; (1):CD006213
Brij B. Agarwal, Surgeon Society Of Jaipur, ASI Rajasthan Chapter, 16 Aug 2015

25. 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