Primary closure or rhomboid excision and Limberg flap for the management of primary sacrococcygeal pilonidal disease? A meta-analysis of randomized controlled trials

Aim Sacrococcygeal pilonidal disease is a common condition afflicting the young male working and student population, resulting in considerable pain, embarrassment and loss of work days. Controversy surrounds the most appropriate surgical approach to achieve low recurrence rates whilst minimizing morbidity and permitting an early return to work. This study aims to review the published literature comparing excision followed by either primary suture or rhomboid flap repair. Methods PubMed, EMBASE, MEDLINE and The Cochrane Library were systematically reviewed, by two independent investigators, for relevant randomized controlled trials. Keywords and MeSH terms included 'pilonidal disease', 'primary suture/repair', 'rhomboid flap' and 'limberg/modified Limberg flap'. 'Related study' function and manuscript bibliographies were searched for further relevant studies. Study quality was assessed using the Jadad score. Meta-analysis was performed on pooled data, utilizing a random effects model when heterogeneity was high and a fixed effects model when heterogeneity was low. The primary end-point assessed was disease recurrence. Secondary end-points included wound dehiscence, pain scores, hospital stay and return to work. Results Six studies were eventually included for pooled analysis following exclusion of randomized controlled trials with poor methodology. Two studies compared 'off-midline' (Karydakis) primary suture with the Limberg flap repair. Six hundred and forty-one patients were included (331 flap repairs). Rhomboid flap excision demonstrated a trend towards less disease recurrence (P = 0.07), lower wound infection (P = 0.001) and dehiscence (P = 0.01). However, no significant difference was found for pain scores, hospital stay or return to work. Conclusion The current published literature supports the use of the rhomboid flap excision and the Limberg flap-repair procedures over primary midline suture techniques for the elective management of primary pilonidal disease. Further high-quality studies are necessary to compare flap with off-midline repairs.