, Volume 41, Issue 2, pp 101–105 | Cite as

Out of the midline—cleft lift, advancement and rotation procedures

  • A. SenapatiEmail author


Surgery is usually necessary to treat symptomatic pilonidal disease. However, some operations have the propensity to make the patient worse. Uncomplicated disease should therefore be treated by operations that excise the pits rather than excisional surgery. More complex disease, however, cannot be treated by these techniques. It has been shown in many publications that off- or out-of-midline closures have better outcomes than midline closures and wounds. Descriptions and results of these procedures are described. Midline wounds should be abandoned in favour of off-midline closures.


Surgical procedures, operative Recurrence Wound healing Surgical flaps Pilonidal sinus 

Raus aus der Mittellinie – mit „cleft lift“, Verschiebe- oder Rotationslappen


Nur mit einem chirurgischen Eingriff kann ein Pilonidalsinus heilen. Einige Eingriffe können den Zustand des Patienten verschlechtern, deshalb sollten einfache Pilonidalsinus mit einfachen Methoden wie „pit picking“ statt chirurgischer Exzision behandelt werden. Kompliziertere Sinus werden hingegen mit einfachen Verfahren nicht ausreichend versorgt. Mittlerweile ist es Allgemeinwissen, dass Verfahren außerhalb der Mittellinie bessere Ergebnisse zeigen als Mittellinienverschlüsse. Gängige Off-Midline-Verfahren werden hier dargestellt. Mittellinienverschlüsse sollten nicht mehr angewandt und stattdessen Off-Midline-Verfahren eingesetzt werden.


Chirurgische Verfahren, operativ Rezidiv Wundheilung Chirurgische Lappen Pilonidalsinus 


Compliance with ethical guidelines

Conflict of interest

A. Senapati declares that she has no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Mölle, Ommer, Lange, Girona (2018) (eds) Chirurgische Proktologie, 3rd edn.Google Scholar
  2. 2.
    Guner A, Cekic AB, Boz A, Turkyilmaz S, Kucuktulu U (2016) A proposed staging system for chronic symptomatic pilonidal sinus disease and results in patients treated with stage-based approach. BMC Surg 16(1):18. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Irkörücü O (2016) Management for pilonidal disease: before you compare, use a classification system. Asian J Surg 39(4):260–261. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Wysocki AP, Andersson RE, Gips M, Girgin M, Guner A, Immerman S, Kanat BH, Kayaalp C, Milone M, Petersen S, Senapati A, Tezel E, Doll D (2018) Towards a classification for sacrococcygeal pilonidal disease—Berlin 2017. Pilonidal Sinus J 4(1):5–12Google Scholar
  5. 5.
    Gips M, Melki Y, Salem L, Weil R, Sulkes J (2008) Minimal surgery for pilonidal disease using trephines: description of a new technique and long-term outcomes in 1,358 patients. Dis Colon Rectum 51(11):1656–1662. (discussion 1662–3)CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Senapati A, Cripps NPJ, Thompson MR (2000) Bascom’s operation in the day-surgical management of symptomatic pilonidal sinus. Br J Surg. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Meinero P, Stazi A, Carbone A, Fasolini F, Regusci L, La Torre M (2016) Endoscopic pilonidal sinus treatment: a prospective multicentre trial. Colorectal Dis 18(5):O164–O170. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Allen-Mersh TG (1990) Pilonidal sinus: finding the right track for treatment. Br J Surg 77(2):123–132 ( Accessed December 11, 2015)CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Petersen S, Koch R, Stelzner S, Wendlandt T‑P, Ludwig K (2002) Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Dis Colon Rectum 45(11):1458–1467. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    McCallum I, King PM, Bruce J (2007) Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev. CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    McCallum IJD, King PM, Bruce J (2008) Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis. BMJ 336(7649):868–871. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Al-Khamis A, McCallum I, King PM, Bruce J (2010) Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev. CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Enriquez-Navascues JM, Emparanza JI, Alkorta M, Placer C (2014) Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus. Tech Coloproctol 18(10):863–872. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Karydakis GE (1973) New approach to the problem of pilonidal sinus. Lancet 2(7843):1414–1415 ( Accessed December 5, 2015)CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Karydakis GE (1992) Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z J Surg 62(5):385–389 ( Accessed December 2, 2015)CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Keshava A, Young CJ, Rickard MJFX, Sinclair G (2007) Karydakis flap repair for sacrococcygeal pilonidal sinus disease: how important is technique? ANZ J Surg 77(3):181–183. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Bessa SS (2007) Results of the lateral advancing flap operation (modified Karydakis procedure) for the management of pilonidal sinus disease. Dis Colon Rectum 50(11):1935–1940. CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Kitchen PR (1996) Pilonidal sinus: experience with the Karydakis flap. Br J Surg 83(10):1452–1455 ( Accessed December 2, 2015)CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Moran DC, Kavanagh DO, Adhmed I, Regan MC (2011) Excision and primary closure using the Karydakis flap for the treatment of pilonidal disease: outcomes from a single institution. World J Surg 35(8):1803–1808. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Patel L, Bloom A‑M (1999) Prolonged delay in healing after surgical treatment of pilonidal sinus is avoidable. Colorectal Dis 1(2):107–110. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Keshvari A, Keramati MR, Fazeli MS, Kazemeini A, Meysamie A, Nouritaromlou MK (2015) Karydakis flap versus excision-only technique in pilonidal disease. J Surg Res 198(1):260–266. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Sewefy AM, Hassanen A, Atyia AM, Saleh SK (2017) Karydakis flap with compressing tie-over interrupted sutures without drain versus standard Karydakis for treatment of sacrococcygeal pilonidal sinus disease. Dis Colon Rectum 60(5):514–520. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Abo-Ryia MH, Abd-Allah HS, Al-Shareef MM, Abdulrazek MM (2018) Fascio-adipo-cutaneous lateral advancement flap for treatment of pilonidal sinus: a modification of the Karydakis operation—cohort study. World J Surg 42(6):1721–1726. CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Anderson JH, Yip CO, Nagabhushan JS, Connelly SJ (2008) Day-case Karydakis flap for pilonidal sinus. Dis Colon Rectum 51(1):134–138. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Stauffer VK, Luedi MM, Kauf P et al (2018) Common surgical procedures in pilonidal sinus disease: a meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep 8(1):3058. CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Senapati A (2013) Managing recurrent pilonidal disease. In: Zbar A, Madoff R, Wexner S (eds) Reconstructive surgery of the rectum, anus and perineum. Springer, LondonGoogle Scholar
  27. 27.
    Bali İ, Aziret M, Sözen S et al (2015) Effectiveness of Limberg and Karydakis flap in recurrent pilonidal sinus disease. Clinics (Sao Paulo) 70(5):350–355. CrossRefGoogle Scholar
  28. 28.
    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(4):491–498. CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Ates M, Dirican A, Sarac M, Aslan 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(5):568–573. CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Ersoy E, Devay AO, Aktimur R, Doganay B, Ozdoğan M, Gündoğdu 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(7):705–710. CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Arslan K, Said Kokcam S, Koksal H, Turan E, Atay A, Dogru O (2014) Which flap method should be preferred for the treatment of pilonidal sinus? A prospective randomized study. Tech Coloproctol 18(1):29–37. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Bascom J, Bascom T (2007) Utility of the cleft lift procedure in refractory pilonidal disease. Am J Surg 193(5):606–609. (discussion 609)CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Senapati A, Cripps NPJ, Flashman K, Thompson MR (2011) Cleft closure for the treatment of pilonidal sinus disease. Colorectal Dis 13(3):333–336. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Rushfeldt C, Bernstein A, Norderval S, Revhaug A (2008) Introducing an asymmetric cleft lift technique as a uniform procedure for pilonidal sinus surgery. Scand J Surg 97(1):77–81 ( Accessed December 14, 2015)CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Abdelrazeq AS, Rahman M, Botterill ID, Alexander DJ (2008) Short-term and long-term outcomes of the cleft lift procedure in the management of nonacute pilonidal disorders. Dis Colon Rectum 51(7):1100–1106. CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Tezel E, Bostanci H, Anadol AZ, Kurukahvecioglu O (2009) Cleft lift procedure for sacrococcygeal pilonidal disease. Dis Colon Rectum 52(1):135–139. CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Guner A, Ozkan OF, Kece C, Kesici S, Kucuktulu U (2013) Modification of the Bascom cleft lift procedure for chronic pilonidal sinus: results in 141 patients. Colorectal Dis 15(7):e402–e406. CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Ortega PM, Baixauli J, Arredondo J et al (2014) Is the cleft lift procedure for non-acute sacrococcygeal pilonidal disease a definitive treatment? Long-term outcomes in 74 patients. Surg Today 44(12):2318–2323. CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Favuzza J, Brand M, Francescatti A, Orkin B (2015) Cleft lift procedure for pilonidal disease: technique and perioperative management. Tech Coloproctol 19(8):477–482. CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Nordon IM, Senapati 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(2):189–192. CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Guner A, Boz A, Ozkan OF, Ileli O, Kece C, Reis E (2013) Limberg flap versus Bascom cleft lift techniques for sacrococcygeal pilonidal sinus: prospective, randomized trial. World J Surg 37(9):2074–2080. CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Dudink R, Veldkamp J, Nienhuijs S, Heemskerk J (2011) Secondary healing versus midline closure and modified Bascom natal cleft lift for pilonidal sinus disease. Scand J Surg 100(2):110–113 ( Accessed December 14, 2015)CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Keighley MRB (2019) Williams NS Keighley & Williams’ surgery of the anus, rectum and colon, 4th edn. (Two-volume set) CRC press, p 229Google Scholar
  44. 44.
    Boshnaq M, Phan YC, Martini I, Harilingam M, Akhtar M, Tsavellas G (2018) Limberg flap in management of pilonidal sinus disease: systematic review and a local experience. Acta Chir Belg 118(2):78–84. CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Omer Y, Hayrettin D, Murat C, Mustafa Y, Evren D (2015) Comparison of modified limberg flap and modified elliptical rotation flap for pilonidal sinus surgery: a retrospective cohort study. Int J Surg 16(Pt A):74–77. CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Akca T, Colak T, Ustunsoy 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(9):1081–1084. CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Horwood J, Hanratty D, Chandran P, Billings P (2012) Primary closure or rhomboid excision and Limberg flap for the management of primary sacrococcygeal pilonidal disease? A meta-analysis of randomized controlled trials. Colorectal Dis 14(2):143–151. CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Tokac M, Dumlu EG, Aydin MS, Yalcın A, Kilic M (2015) Comparison of modified limberg flap and karydakis flap operations in pilonidal sinus surgery: prospective randomized study. Int Surg 100(5):870–877. CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Prassas D, Rolfs T‑M, Schumacher F‑J, Krieg A (2018) Karydakis flap reconstruction versus Limberg flap transposition for pilonidal sinus disease: a meta-analysis of randomized controlled trials. Langenbecks Arch Surg 403(5):547–554. CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Sahebally SM, McMahon G, Walsh SR, Burke JP (2018) Classical Limberg versus classical Karydakis flaps for pilonidal disease- an updated systematic review and meta-analysis of randomized controlled trials. Surgeon. CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Okuş A, Sevinç B, Karahan O, Eryilmaz MA (2012) Comparison of Limberg flap and tension-free primary closure during pilonidal sinus surgery. World J Surg 36(2):431–435. CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Karapolat B, Büyükakıncak S, Kurnaz E, Küçüktülü Ü (2018) Comparison of limberg flap and oval flap techniques in sacrococcygeal pilonidal sinus disease surgery. Turk J Surg. CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Mackowski A, Levitt M (2017) Outcomes of the house advancement flap for pilonidal sinus. ANZ J Surg 87(9):692–694. CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Fazeli MS, Adel MG, Lebaschi AH (2006) Comparison of outcomes in Z‑plasty and delayed healing by secondary intention of the wound after excision of the sacral pilonidal sinus: results of a randomized, clinical trial. Dis Colon Rectum 49(12):1831–1836. CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Karakas BR (2013) Comparison of Z‑plasty, limberg flap, and asymmetric modified Limberg flap techniques for the pilonidal sinus treatment: review of literature. Acta Chir Iugosl 60(3):31–37 ( Accessed September 16, 2018)CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Kayal A, Hussain A, Choudhary A, Meghwal A (2014) A comparative study between Karydakis flap reconstruction and double Z‑Plasty in patients with sacrococcygeal pilonidal disease. Int Sch Res Notices 2014:523015. CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Rao J, Deora H, Mandia R (2015) A retrospective study of 40 cases of pilonidal sinus with excision of tract and Z‑plasty as treatment of choice for both primary and recurrent cases. Indian J Surg 77(Suppl 2):691–693. CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Dýlek ON, Bekereciodlu M (1998) Role of simple V‑Y advancement flap in the treatment of complicated pilonidal sinus. Eur J Surg 164(12):961–964. CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Sahasrabudhe P, Panse N, Waghmare C, Waykole P (2012) V‑Y advancement flap technique in resurfacing postexcisional defect in cases with pilonidal sinus disease-study of 25 cases. Indian J Surg 74(5):364–370. CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Koca YS, Yıldız I, Ugur M, Barut I (2018) The V‑Y flap technique in complicated and recurrent pilonidal sinus disease. Ann Ital Chir 89:66–69 ( Accessed September 16, 2018)PubMedPubMedCentralGoogle Scholar
  61. 61.
    Naveen N, Kumar MK, Babu KR, Dhanraj P (2014) Tandem rhomboid flap repair: a new technique in treatment of extensive pilonidal disease of the natal cleft. J Clin Diagn Res 8(9):ND3–ND4. CrossRefGoogle Scholar
  62. 62.
    Yabanoglu H, Karagulle E, Belli S, Turk E (2015) Results of modified Dufourmentel rhomboid flap in patients with extensive sacrococcygeal pilonidal disease. Acta Chir Belg 114(1):52–57 ( Accessed December 15)CrossRefGoogle Scholar
  63. 63.
    Tan AM, Ahmad Z, Loh CY, Gardiner S, Mathur B (2018) A useful alternative surgical technique to reconstructing large defects following excision of recurrent pilonidal sinus disease in the intergluteal region: an operative approach for the transverse lumbar artery perforator flap. Int Wound J 15(4):534–537. CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Doll D, Luedi MM, Evers T, Kauf P, Matevossian E (2015) Recurrence-free survival, but not surgical therapy per se, determines 583 patients’ long-term satisfaction following primary pilonidal sinus surgery. Int J Colorectal Dis 30(5):605–611. CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Di Castro A, Guerra F, Levi Sandri GB, Ettorre GM (2016) Minimally invasive surgery for the treatment of pilonidal disease. The Gips procedure on 2347 patients. Int J Surg 36(Pt A):201–205. CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Müller K, Marti L, Tarantino I, Jayne DG, Wolff K, Hetzer FH (2011) Prospective analysis of cosmesis, morbidity, and patient satisfaction following Limberg flap for the treatment of sacrococcygeal pilonidal sinus. Dis Colon Rectum 54(4):487–494. CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Yildiz MK, Ozkan E, Odabaşı HM et al (2013) Karydakis flap procedure in patients with sacrococcygeal pilonidal sinus disease: experience of a single centre in Istanbul. ScientificWorldJournal 2013:807027. CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Muzi MG, Maglio R, Milito G et al (2014) Long-term results of pilonidal sinus disease with modified primary closure: new technique on 450 patients. Am Surg 80(5):484–488 ( Accessed September 16, 2018)PubMedPubMedCentralGoogle Scholar
  69. 69.
    Thompson MR, Senapati A, Kitchen P (2011) Simple day-case surgery for pilonidal sinus disease. Br J Surg. CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Lund JN (2017) Less is more in the treatment of pilonidal sinus disease. Dis Colon Rectum 60(1):e1. CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Doll D (2017) Pilonidal disease surgery needs more off-midline closure education. World J Surg 41(4):1147–1148. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019

Authors and Affiliations

  1. 1.St. Mark’s HospitalHarrow, LondonUK
  2. 2.Queen Alexandra HospitalPortsmouth, HantsUK

Personalised recommendations