Techniques in Coloproctology

, Volume 18, Issue 10, pp 863–872 | Cite as

Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus

  • J. M. Enriquez-NavascuesEmail author
  • J. I. Emparanza
  • M. Alkorta
  • C. Placer



There are different open healing and primary closure approaches for chronic pilonidal sinus (CPD) that differ in principles and extension.


To compare the results of different closure surgical techniques, we performed a meta-analysis of randomized controlled trials (RCT) comparing: (1) open wide excision versus open limited excision (sinusectomy) or unroofing (sinotomy); (2) midline closure (conventional and tension-free) versus off-midline; (3) advancing versus rotation flaps; and (4) sinusectomy/sinotomy versus primary closure.


Data extraction and risk of bias assessment were conducted independently by the authors using the Cochrane Collaboration’s tool. Data were pooled using fixed and random-effects models. Primary outcomes were rate of healing, recurrence, wound infection and dehiscence. Twenty-five trials (2,949 patients) were included.


Four trials compared limited versus radical open healing. Although recurrence rate did not differ, all other outcomes favored the limited approach. Ten studies compared midline versus off-midline primary closure; wound infection and dehiscence were significantly higher after midline closure. Six RCT compared Karydakis/Bascom versus Limberg. No difference was found in recurrence or wound complications rate. Six RCT compared sinusectomy/sinotomy versus primary closure. Recurrence rate was significantly lower after sinusectomy/sinotomy; no significant differences were found in other outcomes.


Our meta-analysis suggest that some of the questions of which is the best surgical technique for CPD have now been answered: open radical excision and primary midline closure should be abandoned. Sinusotomy/sinectomy or en bloc resection with off midline primary closure are the preferred approaches.


Pilonidal disease Sacrococcygeal sinus Outcomes research Surgical techniques 


Conflict of interest



  1. 1.
    Karydakis GE (1992) Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z J Surg 62:385–389PubMedCrossRefGoogle Scholar
  2. 2.
    Bascom J (1983) Pilonidal disease: long term results of follicle removal. Dis Colon Rectum 26:800–807PubMedCrossRefGoogle Scholar
  3. 3.
    Lee PJ, Raniga S, Biyani DK, Watson AJM, Faragher IG, Frizelle FA (2008) Sacrococcygeal pilonidal disease. Colorectal Dis 10:639–652PubMedCrossRefGoogle Scholar
  4. 4.
    Al-Khamis A, McCallum I, King PM, Bruce J (2010) Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Update in Cochrane Database Syst Rev 20:CD006213Google Scholar
  5. 5.
    McCallum IJ, King PM, Bruce J (2008) Healing by primary closure versus open healing after surgery for pilonial sinus: systematic review and meta-analysis. BMJ 336:868–871PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Soll C, Dindo D, Steinemann D, Hauffe T, Clavien PA, Hahnloser D (2011) Sinusectomy for primary pilonidal sinus: less is more. Surgery 150:996–1001PubMedCrossRefGoogle Scholar
  7. 7.
    Lord PH, Millar DM (1965) Pilonidal sinus: a simple treatment. Br J Surg 52:298–300PubMedCrossRefGoogle Scholar
  8. 8.
    Rabie ME, Al Refeidi AA, Al Hauzaee A, Hilal S, Al AH, Amri AA (2007) Sacroccoccygeal pilonidal disease: sinotomy vs excisional surgery, a rewtrospective study. ANZ J Surg 77:177–180PubMedCrossRefGoogle Scholar
  9. 9.
    Goligher J (1999) Surgery of anus, rectum and colon, 5th edn. UK Bailliere Tindall, London, pp 221–236Google Scholar
  10. 10.
    Obeid SAF (1988) A new technique for treatment of pilonidal sinus. Dis Colon Rectum 31:879–885PubMedCrossRefGoogle Scholar
  11. 11.
    Cheetham M (2012) Lateral incision surgery for pilonidal sinus: death of a dogma. World J Surg 36:436PubMedCrossRefGoogle Scholar
  12. 12.
    Moher D, Liberati A, Tetzaff T, Altman DG (2009) PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Int Med 151:264–269PubMedCrossRefGoogle Scholar
  13. 13.
    Higgins JP, Altman DG, Gotzsche PC et al (2011) Cochrane Bias Methods Group: Cochrane Statistical Methods Group. The Cochrane Collaboration’s tool for assessing risk of bias in randomized trials. BMJ 343:d5928PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Ortiz HH, Marti J, Sitges A (1977) Pilonidal sinus. A claim for simple track incision. Dis Colon Rectum 20:325–328PubMedCrossRefGoogle Scholar
  15. 15.
    Gupta PJ (2004) A randomized study between excision and marsupialization and radiofrequency sinus excision in sacrococcygeal pilonidal disease. Curr Surg 61:307–312PubMedCrossRefGoogle Scholar
  16. 16.
    Mohamed HA, Kadry I, Adly S (2005) Comparison between three therapeutic modalities for non-complicated pilonidal sinus disease. Surgeon 3:73–77PubMedCrossRefGoogle Scholar
  17. 17.
    Oncel N, Kurt M, Kement M, Colak E, Eser M, Uzun H (2002) Excision and marsupialization versus sinus excision for the treatment or limited chronic pilonidal disease: a prospective, randomized trial. Tech Coloproctol 6:165–169PubMedCrossRefGoogle Scholar
  18. 18.
    Tavassoli A, Noorshaflee S, Nazarzadeh R (2011) Comparison of excision with primary repair versus Limberg flap. Int J Surg 9:343–346PubMedCrossRefGoogle Scholar
  19. 19.
    Muzi MG, Milito G, Cadeddu F et al (2010) Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease. Am J Surg 200:9–14PubMedCrossRefGoogle Scholar
  20. 20.
    Okus A, Sevinç B, Karahan O et al (2012) Comparison of Limberg flap and tensión free primary closure during pilonidal sinus surgery. Worl J Surg 36:431–435CrossRefGoogle Scholar
  21. 21.
    Nursal TZ, Ezer A, Caliskan K et al (2010) Prospective randomized controlled trial comparing V-Y advancement flap with primary suture methods in pilonidal disease. Am J Surg 199:170–177PubMedCrossRefGoogle Scholar
  22. 22.
    Sakr M, Habib M, Shaheed AA (2006) Assessment of Karydakis technique as compared with midline closure for the management of chronic pilonidal sinus. J Pelvic Med Surg 12:201–206CrossRefGoogle Scholar
  23. 23.
    Elshazly W, Said K (2012) Clinical trial comparing excision and primary closure with modified limberg flap in the treatment of uncomplicated sacrococcygeal pilonidal disease. Alex J Med 48:13–18CrossRefGoogle Scholar
  24. 24.
    Polat N, Albayrak D, Ibis AC, Altan A (2008) Comparison between Karydakis repair and primary closure for surgical treatment of sacrococcygeal pilonidal sinus. Trakya Univ Tip Derg 25:87–94Google Scholar
  25. 25.
    Abu Galala KH, Salam IM, Khali R, El Ashaal YI, Chandran VP, Sim MSAJW (1999) Treatment of pilonidal sinus by primary closure with a transposed rhomboid flap compared with deep suturing: a prospective randomized clinical trial. Eur J Surg 165:468–472PubMedCrossRefGoogle Scholar
  26. 26.
    Ertan T, Koc M, Gocmen E, Aslar K, Keskek M, Kilic M (2005) Does technique alter quality of life after pilonidal sinus surgery? Am J Surg 190:388–392PubMedCrossRefGoogle Scholar
  27. 27.
    Akca T, Colak T, Urtunsoy B, Kanik A, Aydin S (2005) Randomized clinical trial comparing primary closure with the Limberg flap in the treatment of primary sacrococcygeal pilonidal disease. Br J Surg 92:1081–1084PubMedCrossRefGoogle Scholar
  28. 28.
    Ates M, Dirican A, Sarac M, Aslam A, Colak C (2011) Short and long-term results of the Karydakis flap versus the Limberg flap for treating pilonidal sinus disease: a prospective randomized study. Am J Surg 202:568–573PubMedCrossRefGoogle Scholar
  29. 29.
    Bessa SS (2013) Comparison of short-term results between the modified Karydakis flap and the modified Limberg flap in the management of pilonidal sinus disease: a randomized controlled study. Dis Colon Rectum 56:491–498PubMedCrossRefGoogle Scholar
  30. 30.
    Ersoy E, Devay AO, Aktimur R, Doganay B, Ördogan M, Gündogdu RH (2009) Comparison of the short term results after Limberg and Karydakis procedures for pilonidal disease: randomized prospective analysis of 100 patients. Colorectal Dis 11:705–710PubMedCrossRefGoogle Scholar
  31. 31.
    Can MF, Sevinc MH, Hancerliogullari O, Yilmaz M, Yagci G (2010) Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease. Am J Surg 200:318–327PubMedCrossRefGoogle Scholar
  32. 32.
    Arslan K, Kokcam S, Koksal H et al (2014) Which flap method should be preferred for the treatment of pilonidal sinus? A prospective randomized study. Tech Coloproctol 18:29–37PubMedCrossRefGoogle Scholar
  33. 33.
    Guner A, Aydin B, Ozkan OF, Ileli O, Kece C, Reis E (2013) Limberg flap versus Bascom cleft techniques for sacrococcygeal pilonidal sinus: prospective randomized trial. World J Surg 37:2074–2080PubMedCrossRefGoogle Scholar
  34. 34.
    Gencosmanoglu R, Inceoglu R (2005) Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus: a prospective, randomized clinical trial with a complete two-year follow-up. Int J Colorectal Dis 20:415–422PubMedCrossRefGoogle Scholar
  35. 35.
    Amorin J, Villani D, Ruiz R, Salinas A (1989) Resection and primary closure vs simple curettage in the treatment of pilonidal sinus: a prospective and randomized study. Rev Venez Cir 42:138–141Google Scholar
  36. 36.
    Karakayali F, Karagulle E, Karabulut Z, Oksuz E, Moray G, Haberal M (2009) Unroofing and marsupialization vs rhomboid excision and Limberg flap in pilonidal disease: a prospective, randomized clinical trial. Dis Colon Rectum 52:496–502PubMedCrossRefGoogle Scholar
  37. 37.
    Nordon IM, Senepati A, Cripps NPJ (2009) A prospective randomized controlled trial of simple Bascom’s technique versus Bascom’s cleft closure for the treatment of chronic pilonidal disease. Am J Surg 197:189–192PubMedCrossRefGoogle Scholar
  38. 38.
    Lorant T, Ribbe I, Mahteme H, Gustafsson UM, Graf W (2011) Sinus excision and primary closure versus laying open in pilonidal sinus: a prospective randomized trial. Dis Colon Rectum 54:300–305PubMedCrossRefGoogle Scholar
  39. 39.
    de Paredes V, Bouchrd D, Janier M, Berger A (2013) Pilonidal sinus disease. J Visc Surg 150:237–247CrossRefGoogle Scholar
  40. 40.
    Abbas MA (2006) Unroofing and marsupialization should be the first choice for most pilonidal sinus. Dis Colon Rectum 49:1242PubMedCrossRefGoogle Scholar
  41. 41.
    Milone M, Di Minno MND, Musella M et al (2013) The role of drainage after excision and primary closure of pilonidal sinus; a meta-analysis. Tech Coloproctol 17:625–630PubMedCrossRefGoogle Scholar
  42. 42.
    Al-Khayat H, Al-Khayat H, Sadeq A et al (2007) Risk factors for wound complication in pilonidal sinus. J Am Coll Surg 205:439–444PubMedCrossRefGoogle Scholar
  43. 43.
    Tezel E (2007) A new classification according to navicular area concept for sacrococcygeal pilonidal disease. Colorectal Dis 9:572–576CrossRefGoogle Scholar
  44. 44.
    Doll D (2007) Sinotomy versus excisional surgery for pilonidal sinus. ANZ J Surg 77:599–600PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2014

Authors and Affiliations

  • J. M. Enriquez-Navascues
    • 1
    Email author
  • J. I. Emparanza
    • 1
  • M. Alkorta
    • 1
  • C. Placer
    • 1
  1. 1.Servicio de Cirugía General y Digestiva, Hospital Universitario DonostiaUniversidad del Pais Vasco-Euskal Herria UnibersitateaDonostia-San SebastianSpain

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