Simulation-Based Training in the Limberg Flap Technique for Pilonidal Sinus Disease

By Rubab Nafees¹, Rabia Aftab², Komal Faheem¹, Madeeha Shahid³, Aun Ali¹

Affiliations

1. Department of General Surgery, Fazaia Ruth Pfau Medical College, PAF Hospital Base Faisal, Karachi, Pakistan
2. Department of Educational Development and Anaesthesiology, Aga Khan University, Karachi, Pakistan
3. Department of General Surgery, Niazi Medical and Dental College, Sargodha, Pakistan

doi: 10.29271/jcpsp.2026.08.1090

ABSTRACT
Intergluteal pilonidal sinus is a common disease among adults, especially males and is related to high morbidity. The rhomboid flap reconstruction for pilonidal sinus is a transposition flap designed to close a 60° rhombus-shaped defect. This rhomboid flap is basically a chain of connecting equilateral triangles with 60° angles. The planning, outlining, and implementation of the rhombus-shaped flap are very challenging and require technical and cognitive skills to avoid any discrepancies and structural problems in flap raising and reconstruction. This can be achieved by introducing a realistic, simulation-based model of pilonidal sinus disease that allows trainees to practise and become familiar with flap measurements and marking, followed by flap elevation and mobilisation. For this research, a prospective design was adopted to evaluate the effect of simulation-based training on surgical performance in Limberg flap reconstruction for pilonidal sinus disease on real patients. The study aimed to determine the effectiveness of simulation-based training in the Limberg flap technique for pilonidal sinus disease using a task trainer.

Key Words: Limberg flap, Pilonidal sinus disease, Simulation, Reconstruction, Rhombus.

Intergluteal pilonidal sinus is a common disease among adults, especially males, related to high morbidity. The incidence of this disease is 26 per 100,000 people. Previously, it was thought to be a congenital condition caused by excess skin in the natal cleft; however, subsequent research has established that the condition is caused by the presence of hair in the natal cleft. The presence of hair acts as a foreign body, leading to chronic inflammation, the formation of single or multiple sinus tracts, pus discharge, and abscess formation.¹ There are multiple sur- gical options available for pilonidal sinus disease, including incision and drainage with lay open of the sinus tract, which heal by secondary intention, excision of the tract with primary closure, and excision of the tract and closure with a reconstructive flap. The pilonidal sinus disease management usually remains unsatisfactory when treated with conservative or conventional treatment methods due to recurrence of the disease, causing pain and discomfort, with on-and-off pus discharge or abscess formation. Nowadays, several advanced surgical techniques are available in addition to conventional methods; however, no single method is recognised as a recommended surgical treatment for pilonidal sinus disease.²

The rhomboid flap reconstruction for pilonidal sinus disease was first described in 1946 by Limberg. This rhomboid flap is a transposition flap to close a 60° rhombus-shaped defect. The rhomboid flap is easy to suture without tension as it flattens the natal cleft and has good vascularity.³ The planning, out-lining, marking, and implementation of the rhombus-shaped flap is very challenging, which requires technical and cognitive skills to avoid any discrepancies and structural problems in flap raise and reconstruction.⁴

Junior doctors and surgical trainees require greater exposure and continuous practice to achieve expertise and confidence in technical procedures such as the Limberg flap technique. This can be achieved by introducing a realistic, simulation- based model of pilonidal sinus disease that allows trainees to practise and become familiar with flap measurements and marking, followed by flap elevation and mobilisation.⁵ Simulation models are beneficial for trainees to gain confidence and refine their skills by continuous and repeated practice in a safe environment; thus, they can achieve the expertise of Limberg flap reconstruction. Multiple simulator models are recommended in the literature for flap reconstruction.⁶ The study aimed to determine the effectiveness of simulation-based training for the Limberg flap technique for pilonidal sinus through a task trainer.

For this research, the authors adopted a prospective design to evaluate the effect of simulation-based training on surgical performance in Limberg flap reconstruction for pilonidal sinus disease   on   real   patients.

Table I: Details of demographic parameters of patients (n = 32).

Variables	n	Percentage (%)
Gender	-	-
Male	28	87.50
Female	4	12.50
Age
Mean age of male patients	32.32 ± 9.71 (32 Years and 4 months)
Mean age of female patients	26.50 ± 7.72 (26 Years and 6 months)
Mean age of all patients	31.59 ± 9.57 (31 Years and 7 months)
Age in slabs
18-26 years	10	31.25
27-35 years	11	34.38
36-44 years	7	21.88
45-53 years	4	12.50
Surgical operative time (minutes)	56.56 (30-90)
Pain score (VAS)	1.72 (1-4)
Postoperative hospital stay (days)	1.31 (1-7)
Redivac drain retained (days)	11.09 (7-14)

Table II: Distribution of the study patients by postoperative complications (n = 32).

Variables	n	Percentage (%)
Seroma	0	0.00
Surgical site infection	1	3.13
Wound dehiscence	1	3.13
Flap necrosis	0	0.00
Recurrence	0	0.00
Distribution of the study patients by postoperative hospital follow-up (n = 32)
First week	-	-
No complication	30	93.75
Complication	2	6.25
Second week	-	-
Removal of stitches	30	93.75
No removal of stitches	2	6.25
Six weeks	-	-
No recurrence	32	100.00
Twelve weeks	-	-
No recurrence	32	100.00

Figure 1: A task trainer for practice

Purposive sampling was used to include six senior residents and four registrars from the Department of General Surgery, Fazaia Ruth Pfau Medical College (PAF Hospital Base Faisal), Karachi, Pakistan. The training course was designed by a team of 3 senior surgeons, the head of the simulation lab and a medical educationist. The study duration was from 2023 to 2024. The simulation training course was implemented over 2 weeks in the simulation laboratory at Fazaia Ruth Pfau Medical College (PAF Hospital Base Faisal), Karachi, Pakistan. Before the implementation, all participants were provided with pre-reading material, including handouts and videos of the surgical procedure. A task trainer was used to provide participants with practice by replicating the pathological and anatomical features of pilonidal sinus disease (Figure 1). On day 1, one senior surgeon provided a demonstration on the task trainer to all participants. Then the participants were allowed to practice under the supervision of a senior surgeon for two weeks. The practice sessions provided an opportunity for participants to practice flap marking, raising, suturing, and mobilisation. At the end of two weeks, they were evaluated using a checklist to sign them off. After the training course, the participants transitioned to the OR (operating room) to apply the learned techniques on real patients under the supervision of senior surgeons. Each participant performed 04 Limberg flap reconstruction procedures. The total number of cases performed by participants was 40. To assess the outcomes of the simulation training course, data were collected from all patients who underwent surgery performed by trained participants. This included data in terms of postoperative complications, such as infection, flap necrosis, haematoma, wound dehiscence, and recurrence of pilonidal sinus disease. Moreover, this research included data from patients who were followed up for 6 months to assess wound healing, scar formation, and recurrence rates. The analysis included data from 32 of the 40 patients, as these patients provided written consent for the use of their data. The data collected were analysed using SPSS version 23. For descriptive analysis, the mean (standard deviation [SD]) or frequency (percentage) was calculated.

A total of 32 patients underwent Limberg flap reconstruction for pilonidal sinus disease. Most of the patients were male (87.50%, n = 28), while 12.50% (n = 4) were female. The mean age of male patients was 32.32 ± 9.71 years, whereas that of female patients was 26.50 ± 7.72 years. The overall mean age of the patients was 31.59 ± 9.57 years. The highest proportion of patients belonged to the 27 to 35 years age group (34.38%), followed by the 18 to 26 years age group (31.25%). The mean surgical operative time was 56.56 minutes (range: 30-90 minutes). The mean postoperative pain score (VAS) was 1.72 (range: 1-4). Patients had a mean postoperative hospital stay of 1.31 days (range: 1-7 days), and the Redivac drain was retained for a mean duration of 11.09 days (range: 7-14 days; Table I).

Postoperative complications were minimal, with only 3.13% (n = 1) of patients developing surgical site infections and 3.13% (n = 1) experiencing wound dehiscence. There were no cases of seroma, flap necrosis, or recurrence during the follow-up period. During the first week, 93.75% (n = 30) of patients had no complications, while 6.25% (n = 2) experienced minor issues. By the second week, 93.75% (n = 30) had their stitches removed, while 6.25% (n = 2) required extended wound management. At the 6-week and 12-week follow-ups, no recurrence of the disease was observed among the patients, with a 100% disease-free rate (Table II).

The study was conducted to improve the surgical skills of surgical trainees and young surgeons through a simulation- based practice of Limberg flap reconstruction for pilonidal sinus disease. Minimal complications and complete recovery with no recurrence after 3 months are suggestive of a successful simulation training program, which prepares trainees or young doctors for real patients. This low complication rate and the absence of recurrence after 12 weeks also improve the efficacy and reliability of Limberg flap reconstruction for pilonidal sinus disease. With these impressive outcomes, the incorporation of simulation-based training before operating on patients may enhance surgical skills, improve patient safety, and shorten the learning curve. Further research with a bigger sample size and longer follow-up is advisable to confirm the effectiveness of this method.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTIONS:
RN: Substantial contribution to the conception and design of the work; acquisition, analysis, and interpretation of the data; drafting of the work; and critical revision of the manuscript for important intellectual content.
RA and KF: Drafting of the work and critical revision of the manuscript for important intellectual content.
MS: Final approval of the version to be published.
AA: Conception and design of the work; acquisition, analysis, and interpretation of the data; drafting of the work; and critical revision of the manuscript for important intellectual content.
All authors approved the final version of the manuscript to be published.

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