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11.15 Supralevator Abscess
a
b
161
Fig. 11.11 (a–d) Diagrammatic representation of the
management of supralevator abscesses. (a) Upward extension of an intersphincteric abscess to supralevator space
drained by the transanal opening of intersphincteric space
followed by stulotomy. (b) Drainage of downward
extension of pelvic pathology leading to the formation of
supralevator abscess by CT-guided transanal approach. (c)
Drainage of extension of the ischiorectal abscess to supralevator space with communicating trans-sphincteric stula with seton placement. (d) Perineal drainage and
placement of tube drain in noncommunicating ischiorectal abscess extending to supralevator
162
11 Evaluation andManagement ofAnorectal Abscess
Fig. 11.11 (continued)
11.15 Supralevator Abscess
163
approach. Alternatively, a transabdominal
approach may also be used (Fig.11.11b).
• The supralevator abscess may be due to the
high extension of the ischiorectal abscess
with communicating trans-sphincteric stula
tract. Drain such extensions through the
perineum. A seton can be placed from an
internal opening of a trans-sphincteric stula
to the abscess drainage site (Fig.11.11c). In
such cases, denitive stula surgery can be
carried out after 3 months when the abscess
cavity has collapsed, and the stula tract has
matured.
• The supralevator abscess can be due to the high
extension of the ischiorectal abscess with the
noncommunicating trans-sphincteric stula
tract. It should be drained into the perianal
region and not into the rectum, as rectal drainage would result in an extrasphincteric stula. A
drain should be placed postoperatively for
drainage and irrigation purposes (Fig.11.11d).
Therefore, it is paramount to establish an
exact origin for supralevator abscesses before
draining.
11.15.2 Principle ofDrainage
ofSupralevator Abscess:
AParadigm Shift
Over a period, a paradigm shift is observed in the
management of supralevator abscess.
Supralevator abscess formed due to upward
extension from the intersphincteric or transsphincteric plane should always be drained
through the anal canal after widening the internal
opening and entering the intersphincteric space.
As mentioned above, drainage of supralevator
abscess through the ischiorectal space may lead
to extrasphincteric stula [27]. Fistulotomy
should be performed at 6 o’clock for drainage
(Fig.11.12a, b).
164
11 Evaluation andManagement ofAnorectal Abscess
Fig. 11.12 (a, b)
Diagrammatic
representation of
drainage of supralevator
abscesses. (a) Drainage
of supralevator abscess
into the rectum or
perineum, as previously
suggested. (b) Drainage
of supralevator abscess
by the transanal opening
of intersphincteric space
with stulotomy from
dentate line to the anal
verge, irrespective of
intersphincteric or
trans-sphincteric
extension, as presently
suggested
a
b
11.16 Deep Postanal Abscess
The rupture of a low intersphincteric abscess
between the supercial and deep part of the
external anal sphincter may form a deep postanal
abscess [28]. The postanal infections often communicate through the ischiorectal fossa on both
sides and may present as a horseshoe abscess
(Fig.11.13). Most of the time, recurrences after
stula occur because the postanal abscess is
either missed or inadequately drained during stula surgery [28].
The patient may present with rectal discomfort or
pain that radiates to the sacrum, coccyx, or buttocks,
which increases on sitting and defecation. Pain is
usually continuous. The patient is febrile. Rectal tenderness may be present on digital examination.
11.16 Deep Postanal Abscess
165
Fig. 11.14 Drainage of the deep postanal abscess.
Extension of posterior stulotomy to deep postanal space
Fig. 11.13 The postanal abscess is inferior to the levator,
posterior to the deep part of an external sphincter, and
superior to the supercial part of an external sphincter
muscle
11.16.1 Managing Deep Postanal Abscess (Hanley’s Technique)
In 1963, Hanley first described the management of deep postanal abscess [28]. This technique divides the lowermost part of the
internal anal sphincter and superficial and
subcutaneous parts of the external to enter the
deep postanal region. Through the internal
opening, a probe is inserted. An incision is
given over the probe from the posterior midline crypt to the deep postanal space. Once
drained, the cavity is loosely packed for 24h
(Fig.11.14).
11.16.1.1 Disadvantages ofHanley’s
Technique
The disadvantage of this technique is postoperative incontinence which may be transient but
associated with signicant discomfort to the
patient [29]. This technique may also result in
keyhole deformity.
11.16.2 Modied Hanley’s
Technique
In 1984, Hanley proposed a staged procedure
[28]. In this technique, no posterior stulotomy is
done, sparing the sphincters. The deep postanal
space is explored by incising the anococcygeal
ligament midway between the coccyx tip and the
subcutaneous part of the external anal sphincter.
Fibers of the supercial external anal sphincter
are separated. A seton is placed and brought out
from the drainage incision through an internal
opening. The seton is loosely secured. An incision is given over the ischiorectal abscess if the
deep postanal abscess extends into the communicating ischiorectal space. The abscess cavity is
thoroughly curetted and irrigated.
Once the cavity heals, a stula remains near
the seton region. Tightening the seton over intervals leads to complete healing (Fig.11.15a–c).
11.16.3 Core Tip
A vertical incision should always incise the anococcygeal ligament. A horizontal incision may
incise the anococcygeal raphe, leading to incontinence [29].
166
ab
11 Evaluation andManagement ofAnorectal Abscess
c
Fig. 11.15 (a) Opening of ischiorectal abscess communicating with deep postanal space. (b) Incision over anococcy-
geal ligament to open the deep postanal space. (c) Placement of seton from deep postanal space to the ischiorectal space
11.17 Deep Anterior Anal Space Abscess
Rupture of the abscess into the lower part of
the vagina can lead to a rectovaginal stula.
Another abscess mentioned by Hanley was a deep
anterior anal space abscess [16]. The intersphincteric abscess ruptures through the supercial and
11.17.1 Management ofDeep
Anterior Abscess
deep part of the external anal sphincter into the
deep anterior anal space. The pus extends superior
to the triangular ligament between the bulbospongiosus and the ischiocavernosus muscles.
The pus may extend:
• In males, manage the deep anterior space
abscess by anterior stulotomy.
• In females, avoid the anterior stulotomy as it
may lead to incontinence. As described by
Hanley, a staged procedure is a better option
• Posteriorly to involve ischiorectal fossa
• Anteriorly to the perineum to the labia in
females and scrotum in males
[16]. The abscess is drained, and a rubber
band seton is placed. The seton can be tightened every 3–4 weeks (Fig.11.16a, b).
• Anteriorly into a rectovaginal septum
• Laterally to the anterior abdominal wall, the
vaginal vault, or medial part of the thigh
11.19 Horseshoe Abscess
a
b
167
Fig. 11.16 (a) Anterior stula in female. (b) Diagrammatic representation of deep anterior abscess drainage. Placement
of seton in between subcutaneous and supercial part of external anal sphincter
11.18 Supercial Postanal Space
Abscess
ond most common abscess constituting 15–20%
of the abscesses [29].
The posterior horseshoe “abscess originates in
The abscess is managed in the same way as a
perianal abscess.
the postanal space in the midline crypt
(Fig. 11.17a). Since both ischiorectal spaces
communicate with the postanal space,” the pus
extends into these spaces [16]. The pus may
11.19 Horseshoe Abscess
extend anteriorly to encircle the lower anorectal
area. It may form a stula tract with secondary
Horseshoe abscess can be anterior or posterior,
occurring below the anorectal ring [25]. The pus
is present inferior to the levator ani and the deep
part of the external anal sphincter. This is the sec-
openings in the labia or scrotum and the thigh
(Fig.11.17b).
The origin of the anterior horseshoe abscess is
similar. The deep anterior anal space, like the
168
11 Evaluation andManagement ofAnorectal Abscess
Fig. 11.17 (a) Extension of horseshoe abscess anteriorly and posteriorly. (b) Anterior abscesses with opening toward
scrotum
deep postanal space, has a direct connection with
the ischiorectal spaces [30]. The horseshoe
abscess stula is considered trans-sphincteric,
occurring below the anorectal ring.
On digital examination, there is excruciating
pain. Under anesthesia, pus can be seen oozing
out of an internal opening from the posterior mid-
line crypt after inserting a proctoscope.
Clinically, the pain is severe when an abscess
is restricted to the postanal space. There may be
associated fever and increased leucocyte count.
When the infection extends into the ischiorectal
11.19.1 Managing Horseshoe Abscess
space, rubor and cellulitis may be evident on both
sides. Many patients have multiple external openings with all ramications intercommunicating
with each other.
On examination, in the early stage, the diagnosis is difcult to make as the abscess is small,
deep, and tense. An MRI may help in diagnosis.
The technique described below is the original
Hanley’s procedure.
Under spinal or general anesthesia, the patient
is placed in a lithotomy or jack-knife position. The
rst incision is in the posterior midline, and a
counter incision is made in the ischiorectal spaces
ab
11.19 Horseshoe Abscess
169
Bubbles at 6
o’ clock position
Dye injected
Injecting H
and methylene
blue
2O2
through E.O. and
seen coming out
from I.O. at 6
o’clock position
c
Opeining of deep
postanal spac
e
d
Drainage of
abscess by giving
radial incision
Fig. 11.18 (a–d) Horseshoe abscess with trans-
sphincteric stula. (a) Injecting hydrogen peroxide and
methylene blue through abscess at 3 o’clock. Bubbles are
seen coming out at 6 o’clock position from an internal
opening. (b) Through an external opening, the dye is
injected at the 7 o’clock point, and bubbles are seen coming out from an internal opening at the 6 o’clock position,
indicating a horseshoe tract. (c) Deep postanal space is
opened for pus drainage. (d) Radial incision is given over
the most medial part of the abscess, and pus drained
on either side to drain the abscesses. The posterior
midline incision is made, exposing the supercial
external sphincter. It is carried down into the deep
postanal space by dividing the anococcygeal liga-
ment (Fig.11.18a–d). It results in the drainage of
pus. A drain is placed for 24–48h. Subsequent
incisions are given over the most medial parts of
the horseshoe abscesses, and the pus is drained.
170
11 Evaluation andManagement ofAnorectal Abscess
11.20 A Word About Retrorectal Abscess
If a high intramuscular abscess is left unattended,
it may rupture the longitudinal muscle above the
level of puborectalis and form a retrorectal
abscess [16].
11.20.1 Management
Pass a probe from the internal opening into the
retrorectal abscess. Internal sphincterotomy over
the probe is done, thus preventing stula formation [16]. The abscess cavity is drained. A drain is
placed for irrigation [16] (Fig.11.19).
Fig. 11.19 (a) Insertion of probe in the retrorectal space followed by internal sphincterotomy for drainage of abscess.
(b) Placement of penrose drain for drainage and irrigation