THE COMPARATIVE STUDY BETWEEN OPEN TECHNIQUES VERSUS LIMBERG FLAP TECHNIQUE IN MANAGEMENT OF SACROCOCCYGEAL PILONIDAL SINUS

Abstract Background: Comparative study of laparoscopic and open surgical method in management of peptic ulcer perforation Methods: The present study was conducted in patients presented with perforation peritonitis to the emergency department in G.G.S medical college and hospital, a tertiary care hospital in Faridkot, Punjab in which comparison of the clinical outcome between laparoscopic and open surgical methods for treatment of Gastro duodenal perforation was study. Results: Mean operative time of laparoscopic repair group was higher (158.2±0.64 min) in comparison to open repair group (70.8±0.42 min). In the present study post-operative pain score was assessed in each and every patient using Visual analogue scale. On post-operative day 1, mean VAS for OR Group was significantly higher in comparison to LR Group. Later on postoperative day 3, Majority of patients of in LR group had a highest score of 1-4 while in OR group was score 5-7.Nexton postoperative day 5, again mean VAS for LR patients was less in comparison to OR Group. Conclusion: As this is the first kind of study in our geographical area in which role of alcohol proved to be an important risk factor. Laparoscopic approach for repair of perforated peptic ulcer may offer significant advantage over open repair approach with lesser post-operative pain, lsser postoperative complications like wound infections, comparable reperforation rates and lesser duration of hospital stay.


Introduction
Pilonidal sinus is a chronic inflammatory process of the skin and subcutaneous tissue of the sacro-coccygeal region. It presents clinically as a depression or one or multiple holes in the midline in the intergluteal cleft. In the course of the disease, the inflammation may exacerbate or even an abscess may form. 1 Pilonidal cyst is usually diagnosed in young males (4 times more often than in females), usually of Caucasian descent, less frequently African or Asian, most commonly after puberty (mostly in 2nd and 3rd decade of life). In females, the disease develops at a younger age, which is probably due to earlier beginning of puberty. 2 Treatment of a pilonidal cyst is difficult due to low efficacy of therapeutic methods. Clinical assessment is necessary, and the choice of proper management depends on disease stage. In the case of a shallow (depth less than 2cm) lesion with protruding hair, a trial of conservative treatment may be attempted. However, the patient should accept the risk of developing an abscess on every stage of treatment. Conservative treatment is only possible for non-infected pilonidal cysts. 3 Every abscess requires surgical intervention. Conservative methods used in the past, such as phenol injection, cryosurgery, thermal destruction, local radiation, are no longer recommended due to high rate of complications and patient's discomfort. While applying conservative methods, it should be remembered to remove all hairs from the pilonidal sinus accessible through the skin opening. 4 One of conservative methods is application of fibrin glue for cyst closure. This method may only be used in patients with early lesions, with no history of abscesses, who have never underwent surgical treatment and have only one opening of the pilonidal sinus. 5 A fundamental principle of surgical treatment is total resection of the lesion, including its lateral channels, up to fascia of sacrum. Application of dye to the external opening makes it easier to identify lateral channels of the cyst. 6 The most commonly used method is simple excision of pilonidal cyst. Primary wound closure shortens healing time, however, it is associated with an increased complication rate, including infection and dehiscence, and recurrence of the disease as a result. Leaving the wound 'open' to heal requires longer convalescence time, but also with lower rate of recurrence. Relocation of flaps should be reserved for patients with extensive chronic lesions. In the case of less extensive pilonidal cysts, deep incisions with mobilization of subcutaneous tissue allows for faster healing and is more acceptable by patients than flap surgery. or without marsupialization, the excision of all tracks with or without primary closure and the excision of all tracks and then closure by some other means designed to avoid a midline wound (Limberg procedure, Z-plasty, Karydakis procedure) but it is usually surgeon preference, which influence the choice of method. 8 • Patient having spinal deformities.

Study Design
• Hospital based descriptive study.

Sample Size
• 60 consecutive patients included and using randomisation software were divided into two groups GROUP-A and GROUP-B.

Group-A
• Included patient's who underwent wide excision and primary closure using limberg flap method.

Group-B
• Included patients with wide excision and healing by secondary intention.
• Data collected and compared, and analysed for operative time, post-operative pain, duration of hospital stay, postoperative complication such as seroma formation, postoperative wound infection, flap necrosis, wound dehiscences, and time to complete healing.

Sampling Technique/ Method
• Non probability convenient sampling.

Results
The present study was conducted in the Department of General Surgery at Guru Gobind Singh Medical College and Hospital, Faridkot to compare Limberg flap vs Lay open technique in treatment of pilonidal sinus.
Sixty patients underwent for pilonidal sinus surgery were studied in a prospective manner. Patients were randomized into two groups comprising of 30 patients each.

Limberg flap group
Lay open group Patients underwent wide local excision followed by limberg flap primary closure.
Patients underwent wide local excision followed by healing by secondary intention.  In our study post-operative pain on day 1 compared found that mean grading of pain according to visual analog scale found to be 6.00±2.27 for limberg flap group and 5.86±2. 13 for lay open group, the difference found to be statistically insignificant.  In our study post-operative pain on day 5 compared found that mean grading of pain according to visual analog scale found to be 3.26±1.20 for limberg flap group and 4.30±2.00 for lay open group, the difference found to be statistically insignificant.    In present study, wound dehiscence seen only in limberg flap group in 2 patients. The difference statistically insignificant.

Discussion
In present study post operative pain evaluated on day 1, 3, 5 interval, data recorded on the basis of visual analog score. A mean of visual analog score 6.0 A seroma is a collection of fluid that builds up under the surface of skin. Cause of seroma formation is tissue disruption or tissue removal. To prevent seroma formation we placed vacuum suction tube drain all cases. A clear discharge from wound indicates seroma such differential tendencies for the two procedures are accounted by more tissue handling in the limberg flap procedure which leads to more seroma formation seroma was drained externally to prevent infection, abscess formation, delayed wound healing, wound dehiscence, flap necrosis that may lead to prolonged hospitalization.
All patient included in this study got similar antibiotic coverage. First 48 hours antibiotic was given then switched off to oral antibiotic coverage. Wound infection was indicated by presence any factor listed below • local rise of temperature, • purulent discharge from the wound, • presence of fever • tenderness Some patients had seroma collection that becomes infected while few got infection due to poor local hygiene. Most of the patient got wound infection on 4 th -5 th post operative day.
A thorough look at the immediate postoperative complication profile of the two procedures leads to the conclusion that wound collections (seroma) tend to occur with Limberg flaps whereas suppurative wound infections tend to occur more with lay open procedure. Such differential tendencies for the two procedures are accounted by the extensive dissection for the flap procedure and strained wound at the basin of natal cleft for the lay open. Flap necrosis can occur either due to ischemia/pressure necrosis or due to tension at suture line. All patient were advised to lie in prone position for 48 hours after surgery to prevent ischemia and pressure necrosis. Most of flap necrosis was epidermal so managed conservatively.
In present study wound dehiscence in 6.7% cases of Limberg flap group. No wound dehiscence recorded in lay open group.
Two factors were responsible for wound Dehiscence

• Suppurative wound infection
• Tension at suture line Tension at suture line was seen in limberg flap due to transposition of flap. Suppurative wound infection is also the major cause of wound dehiscence.
No recurrence seen in any patients in present study, may be due to short duration of follow up.
In present study mean duration of wound complete healing found to be short 30. 33±