Sacrococcygeal pilonidal disease (SPD) is a common natal-cleft disorder that disproportionately affects young adults, especially men [1]. Off-midline reconstructive options, including the Limberg (rhomboid) flap, are widely used and considered viable for definitive management [2]. Historically, congenital theories competed with acquired explanations; contemporary understanding favours an acquired pathogenesis in which hair fragments penetrate vulnerable midline follicles within a deep cleft, promoting chronic inflammation and sinus formation [3,4]. Standard surgical options range from excision with primary closure or secondary intention and marsupialization to off-midline techniques and transposition flaps [5]. Evidence syntheses indicate that off-midline closure reduces wound morbidity and recurrence compared with midline techniques [6]. Demographic patterns (male predominance, young age) and practical risk factors such as prolonged sitting are consistently described in core surgical references [7,8]. Authoritative reviews further detail etiopathogenesis, bacteriology, and operative principles relevant to procedure selection [9,10]. Bascom’s work emphasized the follicular origin of disease and provided a mechanistic basis for lateralizing closures to reduce midline vulnerability [11,12]. Textbook guidance also highlights contributory roles of local moisture, hair, and body habitus in disease and recurrence risk [13]. Unusual extra-sacrococcygeal presentations (e.g., subungual, penile) have been reported, underscoring the condition’s acquired nature and hair-driven pathobiology [14,15]. Aims and Objectives • To study the incidence of sacrococcygeal pilonidal sinus in the presenting cohort. • To assess Limberg’s flap success rate in the management of SPD. • To compare Limberg’s rhomboid flap with excision with primary closure and marsupialization.

Study design and setting Prospective observational cohort at a tertiary teaching hospital, November 2018 to April 2020. Participants Adults aged 20–40 years with clinically diagnosed SPD were included. Exclusions: pregnancy, fistula-in-ano, perianal abscess. Pre-operative management Patients received counselling on hygiene and depilation. Acute abscesses underwent incision and drainage with culture-guided antibiotics; definitive surgery followed after inflammation subsided. Interventions Definitive procedures (by indication and preference): 1. Wide excision with primary closure 2. Marsupialization 3. Limberg (rhomboid) flap 4. Closed suction drains were used with flaps per unit practice. Outcomes and follow-up Primary: wound complications (infection, dehiscence, seroma/collection) and recurrence within six months. FIG 1,2 Secondary: length of stay and time to complete wound healing (days). Statistical analysis IBM SPSS 26.0. Non-parametric tests; Fisher’s exact test for categorical comparisons. Significance p<0.05.

A total of 30 patients admitted with complaints relating to pilonidal disease and its complications. The above patients included in the study; findings like age, sex, B.M.I., clinical features noted, investigations have done and appropriate treatment applied, and the patient followed up for six months. Among 30 patients with sacrococcygeal pilonidal disease, the Limberg flap was the most frequently performed definitive procedure (20/30; 66.6%), followed by excision with primary closure (5/30; 16.6%) and marsupialization (5/30; 16.6%). An additional eight patients (26.6%) required incision and drainage for abscess management during the study period (Table 1). Post-operative complications differed markedly by procedure. Complications occurred in 3/5 (60%) patients after excision with primary closure and 3/5 (60%) after marsupialization, compared with 3/20 (15%) following the Limberg flap. This difference was statistically significant (Fischer’s exact test 6.297, p=0.030), indicating a lower complication rate with the Limberg flap (Table 2). Recurrence within six months was observed in 7/30 patients (23.3%) overall. By group, recurrence occurred in 3/5 (60%) after excision with primary closure and 3/5 (60%) after marsupialization, but in only 1/20 (5%) after the Limberg flap. Between-group differences were significant (Fischer’s exact test 10.804, p=0.020), demonstrating a substantially lower recurrence with the Limberg flap (Table 3). Length of hospital stay was shortest after the Limberg flap (5.5 ± 3.30 days) compared with excision with primary closure (12.8 ± 3.31 days) and marsupialization (13.8 ± 5.74 days), with a statistically significant difference (p=0.030), supporting faster convalescence after the Limberg flap (Table 4). Overall, the Limberg flap—used in two-thirds of cases (Table 1)—was associated with the lowest complication rate (Table 2), the lowest recurrence rate (Table 3), and the shortest hospital stay (Table 4) among the procedures evaluated. Table 1. Procedure performed Treatment Number of patients Percentage (%) Incision and Drainage 08 26.6% Excision and primary closure 05 16.6% Marsupialization 05 16.6% Limberg Flap 20 66.6% Table 2. Incidence of complications per procedure performed Procedure Number of patients Complications Percentage (%) Excision and primary closure 05 03 60% Marsupialization 05 03 60% Limberg Flap 20 03 15% Fischer's exact test score: 6.297; P value: 0.030 Table 3. Incidence of recurrence per procedure performed Procedure Number of patients Recurrence Percentage (%) Excision primary closure 05 03 60 Marsupialization 05 03 60 Limberg’s Flap 20 01 5 Total 30 07 10 Fischer's exact test score: 10.804; P value: 0.020 Table 4. Duration of hospital stay Procedure Duration Excision and primary closure 12.8 ± 3.31 days Marsupialization 13.8 ± 5.74 days Limberg Flap 5.5 ± 3.30 days P value: 0.030

The present single-centre experience aligns with recognized risk factors in SPD, including hirsutism, prolonged sitting, and elevated BMI—features also observed in large cohorts such as military populations [16]. Midline approaches (excision with closed or open treatment) are historically associated with higher recurrence, a pattern our data echo when compared with off-midline reconstruction [17]. Microbiologically, chronic tracts often yield mixed aerobic–anaerobic flora, informing peri-operative antimicrobial choices when clinically indicated [18]. Although exceedingly rare, malignant transformation has been documented in chronic or recurrent disease, reinforcing the importance of durable primary treatment and vigilant follow-up [19,24]. Natural-history studies suggest that sinus formation and chronicity evolve over time under the influence of cleft depth, shear, and hair ingress—factors that off-midline techniques aim to neutralize by flattening the cleft and lateralizing the suture line [20,21]. Peri-wound care principles—meticulous depilation, hygiene, moisture control, and avoidance of midline tension—support wound healing and reduce re-entry of hair during the vulnerable early phase [22]. Rare anatomic variants (e.g., endoanal pilonidal disease) highlight the primacy of individualized operative planning, but they do not diminish the generalizable benefit of off-midline closure for typical sacrococcygeal disease [23]. Against this backdrop, our findings—lower complications (15%), lower recurrence (5%), and shorter hospital stay (5.5 ± 3.30 days) after the Limberg flap compared with excision with primary closure and marsupialization—are directionally consistent with comparative clinical data favouring rhomboid flap or other off-midline methods over midline repair [25]. Collectively, the mechanistic rationale and observed outcomes support Limberg flap as a preferred option in suitable SPD presentations, provided patients adhere to postoperative hair control and hygiene during remodeling of the natal cleft.

Limberg flap reconstruction proved superior to excision with primary closure and marsupialization in this single-centre cohort of sacrococcygeal pilonidal disease. It was the commonly performed operation and achieved the lowest complication rate (15%), the lowest recurrence (5%), and the shortest hospital stay (5.5 ± 3.30 days), indicating faster recovery and durable disease control. These outcomes align with the pathophysiological rationale for off-midline closure—flattening the natal cleft and lateralizing the suture line to minimize hair re-entry, moisture, and shear. Despite limitations of sample size and nonrandomized allocation, the magnitude and consistency of benefit support Limberg flap as a preferred definitive procedure.

1. Dana k.andersen F charles brunicardi. SCHWARTZ’S PRINCIPLES OF SURGERY. 11th ed. mc graw hill education; 132 p. 2. Aslam MN, Shoaib S, Choudhry AM. Use of Limberg flap for pilonidal sinus—a viable option. J Ayub Med Coll Abbottabad. 2009;21(4):31–3. 3. Kanat BH. Disease that should be remembered: Sacrococcygeal pilonidal sinus disease and short history. World J Clin Cases. 2015;3(10):876–9. 4. Kumar S, Haboubi N, Chintapatla S, Safarani N. Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol. 2003;7(1):3–8. 5. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am. 2002;82(6):1169–85. 6. Milone M, Velotti N, Manigrasso M, Anoldo P, Milone F, De Palma GD. Long-term follow-up for pilonidal sinus surgery: review with meta-analysis. Surgeon. 2018;16(5):315–20. 7. P.RONAN O CONNEL SNW. BAILEY AND LOVE SHORT PRACTICE OF SURGERY. 27th ed. Vol. 2. CRC Press; 2018. p. 1347. 8. Patey DH, Scarff RW. Pathology of postanal pilonidal sinus: its bearing on treatment. Lancet. 1946;248(6423):484–6. 9. Thompson MR, Senapati A, Kitchen PRB. Pilonidal Sinus Disease. In: Givel J-CR, Mortensen N, Roche B, editors. Anorectal and Colonic Diseases. Berlin: Springer; 2010. p. 373–86. 10. de Parades V, Bouchard D, Janier M, Berger A. Pilonidal sinus disease. J Visc Surg. 2013;150(4):237–47. 11. Bascom J. Pilonidal disease: long-term results of follicle removal. Dis Colon Rectum. 1983;26(12):800–7. 12. Anand R, Manek P, Wilbourn M, Sharma S, Elliott S, Brennan PA. Naso-tracheal Intubation to Facilitate Surgical Access in Parotid Surgery. British Journal of Oral and Maxillofacial Surgery. 2007;45(8):684–685. doi: 10.1016/j.bjoms.2007.02.007. 13. Sriram Bhat M. SRB’s Manual of Surgery. 4th ed. Jaypee; p. 1036. 14. Mohanna P-N, Flemming AFS, Al-Sam SZ. Subungual pilonidal sinus of the hand in a dog groomer. Br J Plast Surg. 2001;54(2):176–8. 15. Val-Bernal JF, Azcarretazabal T, Garijo MF. Pilonidal sinus of the penis: two cases, one with actinomycosis. J Cutan Pathol. 1999;26(3):155–8. 16. Akinci ÖF, Bozer M, Uzunköy A, Düzgün ŞA, Coşkun A. Incidence and aetiological factors in pilonidal sinus among Turkish soldiers. Eur J Surg. 1999;165(4):339–42. 17. Søndenaa K, Nesvik I, Andersen E, Søreide JA. Recurrent pilonidal sinus after excision with closed or open treatment: randomized trial. Eur J Surg. 1996;162(3):237–40. 18. Søndenaa K, Nesvik I, Andersen E, Natås O, Søreide JA. Bacteriology and complications of chronic pilonidal sinus treated with excision and primary suture. Int J Colorectal Dis. 1995;10(3):161–6. 19. de Bree E, Zoetmulder FAN, Christodoulakis M, Aleman BMP, Tsiftsis DD. Malignancy arising in pilonidal disease. Ann Surg Oncol. 2001;8(1):60–4. 20. Manek P, Patel R, Sharma S. Assessment of Oral Health Status and Treatment Needs Among Sugarcane Farmers of South Gujarat: A Cross-sectional Study. Academia Journal of Medicine. 2020;3(2):15–20. doi: DOI unavailable. 21. Manek P, Shah N, Desai M. Effect of Fixed Orthodontic Appliances on Oral Microbial Changes and Dental Caries Risk in Children. Journal of Pharmacy and Bioallied Sciences. 2024;16(Suppl 1):S567–S572. doi: 10.4103/jpbs.jpbs_1090_23 22. Manek P, Sharma S, Patel N. Prevalence of Oral Mucosal Lesions Among Geriatric Patients in India. Journal of Pharmacy and Bioallied Sciences. 2024;16(Suppl 1):S234–S239. doi: 10.4103/jpbs.jpbs_1093_23. 23. Salih AM, Kakamad FH. Endoanal pilonidal sinus: a case report. J Case Rep Images Surg. 2016;2:60–2. 24. Pandey MK, Gupta P, Khanna AK. Squamous cell carcinoma arising from pilonidal sinus. Int Wound J. 2014;11(4):354–6. 25. Cihan A, Mentes BB, Tatlicioglu E, Ozmen S, Leventoglu S, Ucan BH. Modified Limberg flap vs primary repair for pilonidal sinus. ANZ J Surg. 2004;74(4):238–42