Background: Pilonidal sinus disease (PNS) is a potentially debilitating condition. It was first described by Anderson in 1847 and is often seen in the intergluteal region and can cause loss of work time. Several procedures have been advocated for treatment and the fact that no single procedure is superior in all respect. Objective: This study aimed to compare the outcomes of excision and primary closure versus Limberg-flap (LF) techniques. Patients and methods: This randomized, prospective observational study was carried out at the Department of surgery, Al-Zahraa University Hospital, Al-Azhar University, Cairo, Egypt over 2 years (January 2018 to January 2020) on 60 patients out of which 30 underwent rhomboid excision with Limberg flap reconstruction (group A) and 30 underwent excision with primary closure (group B). Post-operative follow up was done till 12 months and complications were recorded. Results: There was no statistical difference between the two groups as regards demographic data, partial wound dehiscence, and time to complete healing. There was a statistically significant difference between the two groups as regards wound complications (3.3% in group A versus 20.0% in group B) and the recurrence rate (13.3% in group B versus 0% in group A). Conclusions: Limberg flap method for the pilonidal sinus is a better choice than midline closure after elliptical excision in terms of postoperative wound complications and recurrence.