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Fistula Surgery

Anal fistulas do not heal themselves and surgery is the only curative modality available. The procedural technique depends on the location of the fistula. Perirectal abscesses eventually cause cryptoglandular infections resulting in the formation of hollow, abnormal tracts. They are coated with a granulation tissue that connects the primary opening of the anal canal to the perianal skin. The goal of surgery is to cure the fistula without damaging the internal sphincter muscles. Fistula can significantly affect quality of life making surgery an imperative option. Preoperative workup will include a fistulography, endorectal ultrasonography, MRI, computed tomography, barium enema, proctosigmoidoscopy and digital rectal examination (DRE). Preceding the procedure, general or local anaesthesia with IV sedation is administered. Rectal irrigation enemas are also performed prior to the surgery.

Techniques

Fistulotomy

  • After placing the patient in a prone jackknife position the buttocks are parted for visualization

  • Examination of the area is carried out under anaesthesia to determine the extent of fistula

  • Fistulotomy is a laying-open technique, and is most useful for primary fistulas (submucosal, low transsphincteric and intersphincteric)

  • A probe is inserted through the external and internal openings

  • Electrocautery is used to divide the internal sphincter, subcutaneous tissue and the overlying skin

  • The fibrous tract is opened in its entirety

  • The wound is opened out about 1 – 2 cm adjacent to the external opening

  • The skin is locally excised to aid internal healing

Seton placement

The procedure is carried out either in a stand-alone mode or in combination with a fistulotomy. Complex fistulas, immunosuppressed patients, multiple fistulas, anterior fistulas in women are best treated with a Seton placement.

  • Single-stage Seton – The skin, subcutaneous tissue, external sphincter muscle and internal sphincter muscle are opened. The Seton is passed through the fistula tract to reach the deep external sphincter. A separate silk tie is used to tighten and secure it. As fibrosis occurs above the Seton, the sphincter muscles are gradually cut to exteriorize the tract.

  • Two-stage Seton – This involves draining and fibrosing of the intersphincteric space. In the first stage of the procedure, the Seton is passed into the deep external sphincter muscle after the usual openings and is left to drain the intersphincteric space. Fibrosis occurs gradually healing the superficial wound, which takes about 2 – 3 months. In the second stage, the sphincter muscle bound by the Seton is divided.

Mucosal advancement flap – Patients with chronic fistula are recommended the mucosal advancement flap. A total fistulectomy is carried out removing both the primary and secondary tracts inclusive of the internal opening.

LIFT procedure – Called the ligation of the intersphincteric fistula tract, LIFT is a procedure that is performed on complex transsphincteric fistulas. Preservation of the sphincteric muscles is a major feature of the surgery. The intershpincteric plane is accessed and the internal opening is secured with the removal of the infected cryptoglandular tissue.

Dr. Deepak also specializes in cases where a complex and persistent fistula-in-ano may require the creation of a diverting stoma.

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