Fistula in ano

Dr. V.V. Shahapurkar Professor, Department of Surgery D.M.I.M.S.

Learning objective

Definition Etiology Types Presentation Investigations Management

Fistula-in-ano

Abnormal communication between perianal skin and anal canal or rectal lumen. 90% of cryptoglandular origin, most are preceded by surgical or spontaneous drainage of an abscess.

Fistula in Ano

Classification

Type I Intersphincteric (70%) Type II- Transsphincteric (23%) Type III- Suprasphincteric (5%) Type IV- Extrasphincteric (2%)

Exam Under Anesthesia

Goal is to identify the external, internal openings, the course of the tract, presence of secondary connections, presence of other rectal disease.

Exam Under Anesthesia

Scope placed in such a way as to view the known or predicted location of the internal opening. A curved probe is gently introduced and guided to the internal opening. Occasionally you can pass it the other way. Can place small catheter into external opening and flush with methelyne blue, peroxide, sterile milk, or air. Identification successful in 86%.

Goodsalls Rule

Fistula Management

Goal is to abolish the primary fistula, secondary tracts, prevention of fistula recurrence, preservation of continence. Investigations Endo anal ultra sound, MRI is the gold standard for fistula imaging Fistulogram

Fistula Management

Management depends on the anatomy of the fistula. If it is apparent that the fistula is simple, and low, and the location of the internal opening can be inferred by probing, fistulotomy can be performed over the probe thru the predicted site of the internal opening at the dentate line. The entire tract is opened along its length. This should be reserved for low intersphinteric fistulae, which are short, posterior, and in which the external sphincter is not involved.

Fistula Management

Fistulotomy should be avoided anteriorly, especially in women. Anal fistulae that involve a large portion of the external sphincter are considered complex, as are multiple fistulae, IBD patients, impaired preoperative continence. These may require use of a seton.

Seton Fistulotomy

Fistulotomy is accomplished gradually. The muscle contained in the seton is slowly divided due to pressure necrosis, with the divided ends separating only minimally because of the fibrosis that develops behind the seton. An elastic seton (vessel loop) is drawn thru the tract a loosely secured to itself, tighten sequentially over time. Repeat every two weeks until division of the muscle is complete. Cutting seton s

Advancement of flap technique Glues(fibrin glue) ? doubt

Summary

Common and may be simple or complex Classified according to the relationship with the anal sphincters May be associated with underlying diseases such as TB or crohns disease. Laying open is the surest method of eradication but sphincter division may result in incontinence