Background: The ideal operation for pilonidal sinus disease should be a simple one with low complication and low recurrence rates. This is achieved by flap techniques which flatten the natal cleft with an off-midline closure. The aim of the present study to determine the better procedure in treatment of pilonidal sinus disease, compare the efficiency and short-term results of conservative treatment, open excision, Karydakis flap and Rhomboid flap in treatment of pilonidal sinus disease. Patients and methods: A randomized controlled study included 56 patients with pilonidal sinus disease were admitted to General Surgery Department, Zagazig University Hospitals. The patients were allocated equally into: group (1) were treated with conservative method with medical treatment and drainage if needed; group (2) were operated by open technique; group (3) were operated by Limberg flap technique and group (4) were operated by Karydakis technique. Patients were subjected to full history and clinical examination, preoperative investigations and postoperative assessment. Results: The present study showed no significant difference regard age distribution as age was distributed as 30.71±5.73, 32.21±6.58, 32.57±6.47 and 32.42±8.2 respectively among groups. Conservative group was significantly shorter duration of symptoms than other groups with no significant difference. Operative time was significantly longer among Limberg group than Karydakis group and finally open group as it was significantly shorter than other group. Visual analog scale (VAS) was significantly higher among open cases. Healing and return work were significantly higher among open groupg compared to other groups. Recurrence was significantly associated with open and conservative groups while there was only one case in Limberg Group and no case in Karydakis Group. Bad and good satisfaction were significantly associated with open and conservative groups while excellent was significantly associated with Limberg Group & Karydakis Group. Conclusion: The four techniques are effective in treatment of pilonidal sinus while Conservative is preferred at early stage of the disease and flap techniques has better results and satisfaction than Open one. The Karydakis flap is prefered the Limberg flap for treating uncomplicated Sacrococcygeal pilonidal disease due to shorter operative and healing time with superior patient satisfaction.