|Ahead of print publication
New surgical technique: Mohan's flap for pilonidal sinus defect closure
Amitabh Mohan1, Munish Malhotra2, R Nagamahendran3
1 Classified Specialist Surgery & Reconstructive Surgeon, INHS Asvini, Mumbai, Maharashtra, India
2 Classified Specialist Surgery & Onco Surgeon, INHS Asvini, Mumbai, Maharashtra, India
3 Resident, General Surgery, Department of General Surgery, INHS Asvini, Mumbai, Maharashtra, India
|Date of Submission||08-Feb-2020|
|Date of Decision||10-Mar-2020|
|Date of Acceptance||12-Jul-2020|
|Date of Web Publication||19-Oct-2020|
Resident, Department of General Surgery, INHS Asvini, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Pilonidal sinus is a common disease frequently encountered in the outpatient department. We are presenting our clinical outcomes with excision of the sinus followed by a local flap procedure, Mohan's rotation and advancement flap for its reconstruction. Materials and Methods: In this technique, patients underwent wide local excision and rotation and advancement flap. Over 3 years, seventy patients underwent pilonidal sinus defect closure with this technique. The size of the defect ranged between 4 cm to 10 cm in its greatest dimension. Results: Tension-free and durable closure of the defect was achieved with good obliteration of the depth in the natal cleft. Surgical wounds healed satisfactorily, except for 11% of the patients who developed seroma. Defects closed with similar neighboring skin provided good skin match, with superior cosmetic results. No recurrence was observed during the study period necessitating secondary surgery. Conclusions: The rotation and advancement flap was found to be a useful technique for the treatment of pilonidal sinus with nil recurrence rate and early return to work.
Keywords: Pilonidal sinus, Rotation and advancement flap, Mohan's flap
| Introduction|| |
Pilonidal disease is a very common disease, frequently encountered in the outpatient department. The patient is usually an adolescent presenting as a sinus in the intergluteal region with intermittent discharge. It was first described in 1833 by Dr. Mayo, and the term pilonidal sinus was coined by Dr. Hodge in 1880. The acceptable pathophysiology of the disease was first described by Dr. Patey and Scarf. Incidence was calculated to be 26 cases/100.000 of the Indian population. The disease has a male preponderance, often attributed to hirsute nature. Pilonidal sinus is also associated with obesity (37%), sedentary occupation (44%), and local irritation or trauma (34%). This disease was very commonly observed in jeep drivers during the Second World War, and hence, it was named as “jeep disease.”
The treatment aims at complete tract excision and defect closure with well-vascularized tissue without tension. Obliteration of the intergluteal sulcus is of paramount importance in reducing recurrence. A close relationship exists between success of wound closure and postoperative morbidity and recurrence in the surgical treatment of pilonidal sinus (PS). Although various surgical methods have been described for reconstruction of PS, including phenol application, unroofing and curettage, open treatment, repair with partial and primary suture, repair with a local flap,, and repair with a local or distant fasciocutaneous and musculocutaneous flap, recurrence rate remains a major problem.
| Materials and Methods|| |
Patients and study design
A descriptive observational study was performed in accordance with the ethical standards of the institutional research committee. Before enrollment, written informed consent was obtained from every patient.
All the patients who presented with pilonidal sinus including those who underwent previous surgery were included in the study. Patients with active infection and pilonidal abscess were excluded from the study. No imaging was done before surgery as the diagnosis is clinical.
A total of total of 75 patients were studied, of whom five (males) were excluded due to the presence of pilonidal abscess. [Flow Diagram 1]. Mohan's rotation and advancement flap technique was performed for sacrococcygeal defects in seventy cases (61 males and 09 females) during the study, and the patients' details such as age, gender, primary or secondary, previous intervention, and size of defect were recorded. All patients were treated with Per Operative (Confirmed – during operation) third-generation cephalosporin (cefotaxime 1 g) antibiotic and continued for 2 postoperative days for every 12 h.
Surgery is performed spinal anesthesia with a patient in prone position. The first dose of antibiotic (cefotaxime 1 g IV) was administered to patients before starting with the skin incision. The surgical area was exposed by lateral traction of the buttocks with adhesive tape. Parts were cleaned with 10% povidone-iodine, and sterile draping is done.
The preoperative marking of the flaps is designed using a ruler and sterile skin marker, as shown in [Figure 1].
|Figure 1: Technique of approximation (point A to B) and intermittent suturing with nonabsorbable suture material|
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After markings, incision was given and deepened over the marking. Further dissections were done with cautery up to the presacral fascia. During dissection, extreme precautions were taken to avoid injury to gluteal perforators. Pilonidal sinus was left untouched, and a pseudotumor approach was done. Excision was done up to the presacral fascia. Once the flap was raised up to the presacral fascia, tension-free suturing was done, as shown in [Figure 2], [Figure 3], [Figure 4]. All patients were started on oral diet after 6 h. Patients were confined to bed in prone position till the first postoperative day.
|Figure 2: On table marking of sinus defects. Twice the width of the defects is taken as the length and arc is drawn which forms the line of incision|
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|Figure 3: Pilonidal sinus defect after excision. Presacral fascia is visible with which the flap survives|
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|Figure 4: Postoperative image showing suture line away from the midline and esthetic scar|
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| Results|| |
A total of 70 patients, including nine females, composed the study group. The age distribution of the patients ranged from 22 years to 36 years. Seven patients (10%) had recurrent disease following treatment by various other techniques by other centers. The defect size ranged from 4 to 10 cm, with a flap size ranging from 8 to 19 cm [Table 2]. In our study, in the postoperative period, eight patients (11.4%) developed seroma, drainage was done, and wound healed well. One patient developed wound gaping (1.4%) and treated with secondary suturing in early postoperative period.
In the initial few cases of our technique, seroma formation was a frequently encountered complication, as shown in [Table 1]. The complication was tackled by keeping drain just below the raised flap and was effective. All the patients were followed up for a period of 1 year.
| Discussion|| |
Pilonidal sinus has been reported on various regions of the body including the umbilical region, the interdigital region of the hands (hairdressers' disease), and also the axillary region, but the most common presentation is seen in the intergluteal region. Being more common in working-age bracket, patients usually seek medical attention for early recovery with least impact on activities on daily living. To prevent recurrence, obliteration of the deep natal cleft remains the critical factor. The treatment is surgical by rule which aims at tension-free repair and to avoid recurrences. Various techniques are followed, but recurrence rates remained high with marginal difference in other procedures.
Rotation and advancement flap has been implemented primarily in scalp defects with good results. Various studies also support similar reconstruction in patients with soft-tissue defects of the scalp. Scalp defect closure is challenging because of unforgiving soft-tissue elasticity. Rotational scalp flap is a well-known and time-tested procedure for reconstruction of medium-sized complex scalp defects. The identical technique has been employed in PS where a flap is raised above the presacral fascia with proper measurements, as shown in figures. After raising the flap, a drain is kept in the bed. Then, the flap is rotated to match the defect and sutured away from midline as shown in [Figure 1]. This method holds good with least complications and recurrence rates, as evident in our study.
Limberg flap claims to be effective for pilonidal disease with low complication rates, short hospitalization, and low recurrence rates. In several studies, Limberg procedure is related to significant flap necrosis and recurrence, as proven by Jethwani et al. In one other study, Hussain et al. reported five cases who presented with different complications. One patient had recurrence and two had complications of both wound infection and wound dehiscence and underwent second surgery. In our technique, no recurrence was observed.
Several other studies have compared a modified Limberg flap with other flap techniques. Mentes et al. and Ersoy et al. have compared a modified Limberg flap with Karydaki's flap. They observed that Limberg flap has low complications and recurrence rate compared to Karydaki's flap. In comparison with other flap techniques, Karydaki's technique is found to have a high recurrence rate which is nil with our described rotation and advancement flap. Berkem et al. reported high recurrence rates when the PS was reconstructed using the V-Y advancement flaps, and therefore, the vertical suture line remained in the midline. Although various named procedures are available as a surgeon's armamentarium, no standard technique has been described at this juncture without recurrences. Near similar technique was adopted by Mutaf et al., who described a triangular closure technique, which was first described in 2003 for closure of an oversized meningomyelocele PS.
Although our study incorporates a definite advantage over other studies, still it is not free from limitations. It includes: (i) the sample size is small and follow-up period is less and (ii) The study is not a randomized controlled study.
| Conclusions|| |
The rotation and advancement flap technique is found to be a useful surgical technique for pilonidal sinus. Its advantage in terms of esthetic closure with almost nil recurrent rate and least postoperative complication is far superior to other surgical procedures in practice. To conclude, pilonidal sinus is a common disease of the intergluteal region with a significant effect on the quality of life. Surgery remains the mainstay of treatment. Although various techniques are described, recurrence rate remains high. This study with new surgical technique could be a small, single-center study, however, a prospective study with a large study group will be more accurate in determining outcomes of the procedure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Søndenaa K, Andersen E, Nesvik I, Søreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis 1995;10:39-42.
Akıncı ÖF, Bozer M, Uzunköy A, Düzgün ŞA, Coşkun A. Incidence and aetiological factors in pilonidal sinus among Turkish soldiers. Eur J Surg 1999;165:339-42.
Buie LA. Classic articles in colonic and rectal surgery. 1890-1975: Jeep disease (pilonidal disease of mechanized warfare). Dis Colon Rectum. 1982;25:384-90.
Jethwani U, Singh G, Mohil RS, Kandwal V, Chouhan J, Saroha R, et al
. Limberg flap for pilonidal sinus disease: our experience. OA Case Reports 2013 Aug 08;2(7):69
Schneider IH, Thaler K, Köckerling F. Treatment of pilonidal sinuses by phenol injections. Int J Colorectal Dis 1994;9:200-2.
Kepenekci I, Demirkan A, Celasin H, Gecim IE. Unroofing and curettage for the treatment of acute and chronic pilonidal disease. World J Surg 2010;34:153-7.
da Silva JH. Pilonidal cyst: Cause and treatment. Dis Colon Rectum 2000;43:1146-56.
Berkem H, Topaloglu S, Ozel H, Avsar FM, Yildiz Y, Yuksel BC, et al
. V-Y advancement flap closures for complicated pilonidal sinus disease. Int J Colorectal Dis 2005;20:343-8.
Bascom JU. Repeat pilonidal operations. Am J Surg 1987;154:118-22.
Arumugam PJ, Chandrasekaran TV, Morgan AR, Beynon J, Carr ND. The rhomboid flap for pilonidal disease. Colorectal Disease 2003;5: 218-21.
Eryilmaz R, Sahin M, Okan I, Alimoglu O, Somay A. Umbilical pilonidal sinus disease: predisposing factors and treatment. World J Surg2005;29:1158-60.
Ballas K, Psarras K, Rafailidis S, Konstantinidis H, Sakadamis A. Interdigital pilonidal sinus in a hairdresser. J Hand Surg Br 2006;31:290-1.
Ohtsuka H, Arashiro K, Watanabe T. Pilonidal sinus of the axilla – Case report of 5 patients and review of the literature. Ann Plast Surg 1994;33:322-25.
Jethwani U, Singh G, Mohil RS, Kandwal V, Chouhan J, Saroha R, et al
. Limberg flap for pilonidal sinus disease: Our experience. OA Case Reports 2013;2:69.
Hussain ZI, Aghahoseini A, Alexander D. Converting emergency pilonidal abscess into an elective procedure. Dis Colon Rectum 2012;55:640-5.
Harlak A, Mentes O, Kilic S, Coskun K, Duman K, Yilmaz F. Sacrococcygeal pilonidal disease: Analysis of previously proposed risk factors. Clinics (Sao Paulo) 2010;65:125-31.
Ersoy OF, Karaca S, Kayaoglu HA, Ozkan N, Celik A, Ozum T. Comparison of different surgical options in the treatment of pilonidal disease: Retrospective analysis of 175 patients. Kaohsiung J Med Sci 2007;23:67-70.
Zorlu M, Şahiner İT, Zobacı E, Kocak C, Yastı AÇ, Dolapçı M. Early results with the Mutaf technique: A novel off-midline approach in pilonidal sinus surgery. Ann Surg Treat Res 2016;90:265-71.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]