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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 12-17 Deeper dissection to the level of the muscle in the fistulotomy tract.
We perform the fistulotomy with electrocautery by dissecting onto the
probe (Fig. 12-18).
FIGURE 12-18 Completed opening of the fistula tract.
The tract is then curetted and left open; we do not pack the wound
routinely.
Suspicious tissue should be biopsied and sent for histologic examination.
In the case of large defects, the wound edges may be marsupialized (Fig.
12-19).
The superficial aspect of the wound is saucerized to prevent a
recurrence of a subcutaneous fistula.
FIGURE 12-19 Marsupialization of the tract, typically with 3-0 chromic or Vicryl
sutures.
ENDORECTAL ADVANCEMENT FLAP
Perioperative Considerations
We offer this procedure for patients with a higher transsphincteric fistula,
suprasphincteric fistula, or extrasphincteric fistula, where fistulotomy is
not suitable.
It may also be needed to manage the internal opening of a horseshoe
fistula following appropriate control of sepsis.
Patients are scheduled for fistula repair a minimum of 6 weeks after
draining seton insertion, which we consider a mandatory precondition
for ERAF.
The day before surgery, the patients undergo a full cathartic bowel
preparation with oral antibiotics.
Prophylactic intravenous antibiotics are given.
We avoid using a narrow “U-shaped” flap as these are more likely to
become ischemic. We believe that broad-based symmetrical flaps
distribute the tension better, reduce ischemia, and are a contributor to
improved results (Fig. 12-20).
FIGURE 12-20 Endorectal advancement flap.
Note: Flaps can be mucosal, of partial thickness, or of full thickness. We
prefer to include some muscle in the flap.
Positioning
Positioning of the patient is dependent on the site of the internal opening,
with Kraske being optimal for anterior internal opening (ie, rectovaginal
fistulae) and lithotomy for fistulas with a posterior internal opening.
A fiberoptic-lighted Hill-Ferguson retractor is used to visualize the
pathology.
A Pratt bivalve retractor may also be used, as previously mentioned.
Technique
The procedure is commenced by removal of the seton and circumferential
excision of the internal opening with electrocautery (Fig. 12-21).
FIGURE 12-21 Endorectal advancement flap. Circumcise and de-epithelialize the
internal opening.
The track is de-epithelialized with use of a cervical brush or small curette,
followed by 50% dilute H2O2.
The site of excision is extended laterally 7 mm on either side of the
internal opening (Fig. 12-22).
FIGURE 12-22 Endorectal advancement flap. Create a transverse, partial-thickness
flap for approximately 5 mm.
Traditionally, two horizontal, full-thickness broad-based flaps are raised
(one proximal and one distal to the incision), approximately 1 cm deep.
An alternative is to use a broad-based semicircular proximal full-thickness
flap.
The internal opening is closed with interrupted 2-0 absorbable sutures on
an UR-6 needle (Fig. 12-23). The needle is grasped at the back near the
suture, at a 45-degree angle to provide maximal articulation and curve of
the needle for deep bites until closed (Fig. 12-24).
FIGURE 12-23 Endorectal advancement flap. Close the internal opening as it passes
through the internal sphincter with a series of interrupted sutures (eg, 2-0 Vicryl). Tip: Take
big bites.
FIGURE 12-24 Endorectal advancement flap. Muscle layer closed.
Integrity of the repair is leak tested by injecting fluid into the external
opening. We use the plastic sheath from a 14- to 16-gauge cannula
attached to a 10-mL syringe of normal saline of 50% dilute H2O2.
Alternatively saline can be used alone, although H2O2 may demonstrate
subtle openings.
The partial-thickness flaps are closed, ablating the dead space with
interrupted 2-0 absorbable sutures (Fig. 12-25A-C). We prefer to use a
UR-6 semicircular, strong needle.
FIGURE 12-25 Endorectal advancement flap. A. Mucosa being closed. B. Stitches in
place. C. Repair complete.
Depending on the length of the track, the external opening is either left
widely open (ie, enlarged) or drained with a mushroom catheter for 7-10
days.
Postoperative Care
Typically, patients are discharged the same day.
Patients are discharged with a week of oral antibiotics and are informed
that drainage from the external opening is expected for up to 6 weeks.
LIGATION OF INTERSPHINCTERIC FISTULA TRACT
Perioperative Considerations
This procedure was described in 2007 by Rojanasakul et al. from
Bangkok, Thailand, for similar indications as an ERAF.
The pre- and postoperative management of this may be interchangeable
with that of an ERAF, which presently is preferred at our institution,
although the use of LIFT procedure is increasing.
An indwelling draining seton for 6 weeks is typically a prerequisite.
In the case of LIFT for transsphincteric fistulae, patients are advised that
the success rate is approximately 50%, but in the event of failure, half
(50%) of the failure will recur as an intersphincteric fistula, which would
then be amenable to fistulotomy in many cases.
PEARLS AND PITFALLS
Particularly in women, performing a LIFT procedure for an anterior
fistula is extremely difficult. The external anal sphincter is deficient in
women, so the surgeon is likely to misidentify the plane and dissect
between the external sphincter and the vagina.
Positioning
Positioning of the patient is dependent on site of internal opening, with
Kraske position being optimal for anterior internal opening and lithotomy
for fistulas with a posterior internal opening.
A Lone Star Retractor System (Cooper Surgical, Trumbull, CT) may aid
in exposure of the intersphincteric grove. If unavailable, we find that 00silk effacement sutures are an acceptable alternative.
Technique
The procedure is commenced by exchanging the indwelling draining seton
for the probe with the help of a silk tie.
The probe is secured by bending the tip.
The track is de-epithelialized with use of a curette or cervical brush
(preferred), followed by 50% dilute H2O2.
A curvilinear incision is made at the perianal region, just outside the
intersphincteric groove (Fig. 12-26).
This incision is similar to that of an open lateral internal
sphincterotomy although larger.
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