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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 11-10 Bilateral extensions controlled through counterincisions.
If anterolateral external openings do exist, connect them to your
posterior incision.
After draining and irrigating the abscess cavities, curette all the fistula
tracts.
Passing an unrolled gauze square from the midline counterincision
to the anterolateral external opening via the tract is a helpful
debridement technique.
Place Penrose drains (1/4 in preferably) from the external opening to
the counterincision and secure as one would loop a seton. We find that
the Penrose drains that are secured through the counterincision aid in
decompression and reduction of the postanal space cavity (Fig. 11-11).
FIGURE 11-11 Penrose placed through bilateral counterincisions.
If the internal opening is identified, place a medium-sized vessel loop
from the internal opening to the posterior midline incision and secure as
a seton.
Postoperative Care
After resolution of the acute sepsis (usually in 2-4 weeks), we reassess the
perineum in the office. At this time, we typically remove one of the
counterincision Penrose drains. The second counterincision Penrose would
be removed ∼2 weeks following. At times, these tracts will remain open or
partially opened and would need curettage of granulation tissue at the
definitive repair of the fistula at the second stage.
Second stage closure of the fistula can be managed using anorectal
advancement flap or ligation of intersphincteric fistula tract (LIFT). A
cutting seton may also be considered when there is failure of those
techniques (Fig. 11-12). Refer to Chapter 12 for more on the LIFT
procedure.
FIGURE 11-12 Arrows mark healed counterincisions. Seton remains in posterior
midline fistula in preparation for definitive repair (prone position for planned ligation of
intersphincteric fistula tract procedure).
Alternatively, a modified Hanley procedure can be used, although this is
not typically done in our practice.
Suggested Reading
Vogel JD, Johnson EK, Morris AM, et al. Clinical practice guideline for the management of anorectal
abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum. 2016;59(12):1117-1133.
Chapter 12
Complex Anorectal Fistulas
VLADIMIR BOLSHINSKY
STEFAN HOLUBAR
Perioperative Considerations
Fistulas are characterized based on their relationship with the anal
sphincter: intersphincteric, transsphincteric, suprasphincteric, and
extrasphincteric (Fig. 12-1).
FIGURE 12-1 Anorectal fistula types: (A) intersphincteric (type I); (B) transsphincteric
(type II); (C) suprasphincteric (type III); and (D) extrasphincteric (type IV).
Determining the anatomy of each unique fistula is critical to maximizing
healing and minimizing problems with continence. This may involve:
Examination under anesthesia
Magnetic resonance imaging
Ultrasound
A general “rule of thumb” dictates that it is typically safe to divide <onethird the length of the sphincter. Despite this, decreased continence may
occur even when division of the sphincter met this condition, and patients
should be counseled accordingly.
Care must be taken for those with prior anorectal surgery, Crohn disease,
baseline decreased continence, anterior fistula in women, and other
conditions where division of the sphincter may lead to further
deterioration in continence.
Patients should be aware that multiple operations may be required to
ultimately allow fistulae to heal.
Asymptomatic fistula may be surveilled without any operative
intervention.
Sterile Instruments/Equipment
Equipment used for anorectal cases are as follows:
Anal retractors, fiberoptic lighted: small, medium, and large
Hill-Ferguson retractors (Fig. 12-2): often used for perianal cases
placed in lithotomy position (Fig. 12-3)
FIGURE 12-2 Hill-Ferguson lighted anoscopes of various sizes.
FIGURE 12-3 Lithotomy position.
Fansler retractors (Fig. 12-4): small, used selectively for perianal cases
such as those placed in prone (ie, Kraske) position (Fig. 12-5A and B)
or those with large redundant mucosa
FIGURE 12-4 Fansler lighted anoscope.
FIGURE 12-5 A. Operating room table setup with padding for the patient in prone
(ie, Kraske) position. B. Kraske position on the operating room table.
Pratt bivalve anal retractor (Fig. 12-6)
FIGURE 12-6 Pratt bivalve anoscope.
Right-angle retractors
Set of Lockhart-Mummery fistula probes (Fig. 12-7)
FIGURE 12-7 Set of Lockhart-Mummery fistula probes.
Set of curettes (Fig. 12-8)
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