The word pilonidal has been derived from the Latin words pilus meaning “hair” and nidus meaning “nest”. The disorder was first described by Herbert Mayo in 1833 [1]. Sacro-coccygeal pilonidal sinus disease (SPSD) is a chronic, recurrent inflammatory condition that typically affects the natal cleft underlying the sacrum and coccyx. It appears with a wide spectrum of clinical signs ranging from a solitary asymptomatic sinus opening to painful abscesses and complicated sinus tracts with several secondary openings draining sero-purulent or blood-stained fluid with hair and debris [2,3]. Systemic symptoms are rare but may be present if an acute abscess develops. The disease has a major influence on the quality of life of the patient due to constant pain, difficulty sitting or sleeping in the supine position, limited mobility and problems with cleanliness due to its anatomic placement [3,4].

Historically, pilonidal illness was thought to be a congenital disease, but it is now commonly regarded as an acquired pathology [3]. It primarily affects young individuals aged between 15 and 30 years with a pronounced male predominance , reported in a ratio of around 3:1 [3,5]. The estimated prevalence of SPSD in the general community is around 26 cases per 100,000 individuals per year [6]. One noteworthy epidemiological point is the fall in occurrence after the age of 40 years further supporting its relation to characteristics found in younger populations such as active lifestyle, hormonal impacts and hair dispersion patterns [3].

The pathophysiology of sacrococcygeal pilonidal sinus disease is multifaceted including mechanical, anatomical and biological aspects. The most recognized explanation is that loose or shed hairs are forced into the skin of the natal cleft by friction, shearing forces and suction effects caused by movement of the buttocks [3]. These hairs can enter the epidermis and cause a foreign body reaction followed by infection of the hair follicles. The procedure leads in the creation of a subcutaneous sinus tract typically 5–8 cm above the anal margin. With time this primary sinus may generate many secondary passages spreading laterally, further aggravating the condition [3,7].

Several risk factors have been reported to be connected with the development of SPSD, such as obesity, sedentary lifestyle, deep natal cleft, excessive body hair, poor personal hygiene and family history [3]. Moreover, occupations with extended sitting, such as drivers, office workers and military people, have been identified as important risk factors for illness occurrence [3]. Hormonal effects and genetic predisposition may also play a role in susceptibility to disease. Together, these factors lead to the illness becoming chronic and recurring, making it more difficult to control.

SPSD is generally characterized by a chronic history with numerous recurrences despite initial good treatment. There is still no consensus on how to treat this illness, because there are many different ways to treat it and no one standard way that everyone agrees on [6,10]. Conservative methods such as hygiene, hair removal and antibiotics may be helpful in selected patients, especially in early or mild illness [2]. However, most patients, especially those with recurrent or complex illness, ultimately require surgical intervention for definitive therapy [2].

Various surgical approaches for the treatment of SPSD have been described over the years, each with their own advantages and limitations [7–9]. Traditional surgical techniques include simple excision followed by secondary healing, excision with main midline closure, and flap treatments like the Limberg flap and the Karydakis procedure. Simple excision has been related with extended wound healing time, increased postoperative discomfort and higher recurrence rates while being technically simple. Primary closure after excision results in faster healing but generally carries greater rates of wound complications and recurrence [10,11].

The flap based procedures have gained more and more popularity because of their good results in terms of lessening recurrence rates and speedier recovery [10]. Among these, the Limberg flap operation has been examined extensively and is seen as a viable surgical treatment for SPSD. It is characterized by removal of the sinus with surrounding tissue and restoration with a rhomboid-shaped flap that flattens the natal cleft and reduces hair buildup and friction in the area. This approach helps in wound healing and also reduces the chances of the disease recurring by correcting the anatomical aspects that lead to the disease [11–13].

Despite the availability of numerous surgical treatments, there is still no consensus on the best treatment modality for SPSD [6,10]. The ideal operation should have numerous characteristics such as shorter hospital stay, early return to daily activities, minimum postoperative pain, low complication rates, acceptable cosmetic outcomes and most crucially a low recurrence rate [10,11]. However, it is still difficult to achieve all these goals with one technique and the choice of the surgery is often dependent on the surgeon’s inclination, the patient’s characteristics and the severity of the condition.The research shows diversity in the results of different surgical procedures, notably in terms of recurrence rates and postoperative complications [6,10–15]. Además, hay una falta de datos locales consistentes para evaluar la efectividad de estos procedimientos en poblaciones específicas. This underscores the need for additional research that compare different surgical methods and the best way to manage SPSD.

Hence, the aim of this study was to discuss our experience with different clinical presentations and surgical therapeutic techniques for sacrococcygeal pilonidal sinus illness in a tertiary care hospital. Special attention has been paid to the evaluation of the results obtained by flap procedures, and especially the Limberg technique. The aim of this study is to compare the efficacy of the various surgical techniques in terms of duration of the surgery, duration of hospital stay, wound healing, post-operative complications like infection and recurrence rates, with the ultimate aim of finding a better and reliable treatment option for this challenging disease.

A descriptive prospective study was done at POF Hospital Wah, a tertiary care teaching hospital, for a period of 12 years from January 2013 to December 2024. The study comprised 160 individuals of both genders with various clinical symptoms of sacrococcygeal pilonidal sinus disease (SPSD) . Patients between 16-35 years of age were included while patients above 40 years of age, pregnant women, patients with psychiatric illness and significant co-morbid conditions like diabetes mellitus, ischemic heart disease, chronic obstructive pulmonary disease, asthma, chronic renal disease or local skin disorders like psoriasis were excluded from the study. Complete clinical evaluation of all patients included complete history and physical examination, with special emphasis on local examination of the natal cleft to determine the number, location, size, and severity of sinus tracts and associated lesions. Most of the time, the anatomy of the sinus tracts and cavities was further investigated by ultrasound. In chosen individuals, MR imaging (MRI) was used in the later years of the research as the facility became accessible. All patients had regular laboratory and imaging examinations to assess suitability for anesthesia. Senior consultants made the decision about the type of surgical technique after assessing the clinical presentation and extent of disease and taking into account patient preference. Four basic surgical procedures were used: simple excision, excision with primary midline closure, Karydakis procedure and flap based treatment (Limberg flap). Simple excision was performed in primary disease patients without any concern for recurrence. Limberg flap surgery was favored in recurring disease patients or those with concerns for recurrence. Patients with cosmetic issues had excision with primary closure. Patients presenting with pilonidal abscess were initially handled by drainage of the abscess and a 7 day course of antibiotics (oral cefuroxime 250mg three times daily), followed by ultimate surgical management after three weeks. All surgeries were performed under regional anesthesia with the patient in the prone jack-knife posture. Prophylactic antibiotics (cefuroxime 1.5 g intravenous) were given 30 minutes before to incision. Standard surgical techniques were used in all cases and the procedures were performed by the same surgical team. In patients who underwent flap surgeries a redivac drain was put in. Histopathological examination of excised tissues was performed. Postoperatively, patients were provided appropriate analgesia and intravenous antibiotics for three doses, followed by oral antibiotics (cefuroxime 250 mg three times daily for five days). Patients were often discharged within 24–48 hours after mobilization and removal of drains. Wound assessment was done everyday during the hospital stay and upon release. The patients were followed up on postoperative days 7, 14 and 28, and subsequently monthly up to three months. Patients were examined at follow-up visits for wound healing, discomfort, and complications (infection, seroma development, wound dehiscence, and recurrence). Sutures were usually taken out on the 14th day after operation. On a standardized proforma all relevant data from admission to follow-up were entered. Statistical analysis was carried out using SPSS version 20. Quantitative data (age, operation time and hospital stay) were expressed as mean ± standard deviation while qualitative variables (gender, infection rate and recurrence) were expressed as frequencies and percentages. Means were compared using independent sample t-test and one-way ANOVA, and relationship between categorical variables was found using chi-square test. The statistical significance was p < 0.05.

The study comprised 160 patients with sacrococcygeal pilonidal sinus disease (SPSD). Among them, 146 (91.25%) were males and 14 (8.75%) were females, indicating a strong male majority . Patients ranged in age from 16 to 35 years. Four different surgical procedures were used to treat the patients; Limberg flap (n=83), excision only (n=60), excision with primary closure (n=12) and Karydakis operation (n=5).

Table 1: Gender Distribution of Patients

Table 2: Age Distribution According to Procedure

Table 3: Disease Presentation

Table 4: Operative Time (Minutes)

Table 5: Wound Healing Time (Days)

Table 6: Hospital Stay (Days)

Table 7: Postoperative Infection Rate

Table 8: Recurrence Rate

Table 9: Distribution of Procedures by Gender

The most prevalent approach was the Limberg flap operation (51.87%) with the best overall results including the shortest hospital stay (mean 3.17 days), faster wound healing and the lowest recurrence rate (6.02%). The excision only and excision with primary closure showed prolonged healing times with greater recurrence rate (38.33% and 66.67% correspondingly). The Karydakis technique had greater infection and recurrence rates, relatively, but conducted on fewer patients.

The sacrococcygeal pilonidal sinus disease (SPSD) is still a frequent surgical problem. There are several treatment possibilities but there is no generally accepted standard approach. The present study was undertaken to assess the different surgical approaches with special emphasis on flap-based procedures. The outcome of the procedures was compared in terms of operative time, wound healing, hospital stay, infection, and recurrence. The results of this study are congruent with the available literature, emphasizing the better results obtained with flap-based procedures, specifically the Limberg flap, in the treatment of SPSD.

This study demonstrated a male predominance with 91.25% of patients being male. This finding is consistent with earlier studies that reported a higher incidence of SPSD in males, possibly due to more body hair, hormonal impacts and occupational variables including extended sitting [3,5]. The age distribution in this study (16–35 years) is also consistent with the often affected age group reported in the literature, supporting the notion that SPSD typically affects young and active individuals [3,6].

The clinical manifestations noted in this series, including primary disease, recurrent sinus and abscess formation, are in keeping with previously described patterns of SPSD [2,3]. The chronic and recurrent character of the disease, in addition to its effect on quality of life, emphasizes the necessity of choosing an optimal surgical strategy that reduces recurrence and facilitates speedier recovery [4,7].

The comparison of several surgical techniques in this study proved that Limberg flap operation gave better outcomes as compared to other treatments. It was related with shorter hospital stay, faster wound healing and a much reduced recurrence rate (6.02%) compared to excision alone (38.33%), excision with primary closure (66.67%) and Karydakis operation (60%). These data are in keeping with earlier findings showing lower rates of recurrence and improved outcomes for patients undergoing flap-based procedures [10–13]. The capacity of the Limberg flap to flatten the natal cleft and limit buildup of hair and friction are crucial factors in preventing recurrence.

Excision solely is straightforward and commonly used however this study found it to be associated with longer wound healing and greater recurrence rates. These findings agree with previous research showing delayed healing and higher discomfort in patients due to open wound treatment [10,18]. Similarly, excision with primary closure was associated with faster initial healing, but increased rates of infection and recurrence, which is similarly in keeping with earlier observations [11,14]. These problems are believed to be related to excessive stress along the midline closure and poor vascularity of this location.The Karydakis method, which was supposed to decrease recurrence by lateralizing the site, had greater rates of infection and recurrence in this trial. However, the small number of patients in this cohort may limit the generalizability of these findings. Previous studies have associated the Karydakis approach with good results which could be due to differences in surgical technique, patient selection and postoperative care [11].Postoperative complications, especially wound infection and recurrence, are still the most critical issues in the management of SPSD. In this study, the infection rates were lowest in the Limberg flap group compared with the other procedures. This finding is in agreement with previously published literature which postulates that flap-based procedures promote better vascularization and less tension at the wound site, thereby decreasing the risk of infection [10,11].

Length of hospital stay and wound healing time are crucial measures of patient recovery and health-care burden. The Limberg flap technique was associated with significantly shorter hospital stay (mean 3.17 days) and faster healing compared to the excision only, which required prolonged hospitalization and delayed healing. These findings are in line with previous studies that highlighted the advantages of flap surgeries in minimizing the hospital stay and enabling an early return to normal activities [12,13].

A consensus on the appropriate therapy of SPSD is still lacking, despite several surgical possibilities [6,10]. The choice of procedure is typically based on surgeon expertise, patient preference and illness severity. But, based on the data of this study and the literature supporting it, flap-based procedures, notably Limberg flap, seem to offer the best results for recurrence, healing and patient satisfaction.In conclusion, the results of this study contribute to the increasing data in support of flap-based approaches for the management of sacrococcygeal pilonidal sinus illness. The Limberg flap operation was one of the best and can be recommended as a reliable and effective surgical procedure.

There are several surgical treatment options for sacrococcygeal pilonidal sinus disease, each of which has different results. In comparison to other procedures like excision only, excision with primary closure, and Karydakis procedure, the results of this study show that flap-based techniques, especially the Limberg flap, offer superior results in terms of shorter hospital stays, faster wound healing, and significantly lower recurrence rates.

Simple excision is still commonly used, although it is less favorable because it is linked to longer healing times and a higher rate of recurrence. Higher rates of complications and recurrence were also observed in excision with primary closure and Karydakis surgery. These findings suggest that the Limberg flap operation is a more dependable and successful surgical approach for treating sacrococcygeal pilonidal sinus illness. As a result, it is advised as the best method for improving clinical results and lowering the risk of disease recurrence.