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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_923_Библиотеки_им_академика_М_И_Перельмана.pdf
202
Tr
High inter - sphincteric extension
a
High inter - sphincteric
tract up to the rectal wall
Conjoined longitudinal muscle
Internal anal sphincter
b
13 Fistulotomy: Still aGold Standard!
opening into the rectum
Internal opening
External anal sphincter
Dentate line
Curetting of upward
extension of fistula tract
Excision of internal opening
ansanal opening of inter - sphincteric
Fig. 13.4 (a) High intersphincteric stula tract without external opening. (b) Transanal opening of intersphincteric
space extending up to anorectal ring with stulotomy at 6 o’clock
ment of the internal opening. The intersphincteric
extension can be opened upto the anorectal ring
followed by curettage and irrigation (Fig.13.4a, b).
13.3.5 High Intersphincteric Fistula
space with fistulotomy
withPelvic Extension (A5)
the internal anal sphincter is limited up to the anorectal ring, and the pelvic extension is curetted and
irrigated.
13.3.6 Intersphincteric Fistula
Extending fromPelvic
Dentate line
External anal sphincter
Internal anal sphincter
Disease(A6)
The abscess or the stula without the external opening is always approached by the transanal opening
of the internal anal sphincter (Fig. 13.5a, b). The
management approach remains the same as in the
A4 type of intersphincteric stula. The incision of
Eradicating pelvic disease will cure the stula
(Fig. 13.6). Therefore, sphincter division is not
required.
Conjoined longitudinal muscle
e
nal opening
13.3 Management ofIntersphincteric Fistula
a
Inter - sphincteric tract
with pelvic extension
External anal sphincter
b
203
Internal opening
Dentate line
Internal anal sphincter
xtension of fistula tract
Fig. 13.5 (a) High intersphincteric stula with a pelvic extension (A5). (b) Transanal opening of intersphincteric space
with stulotomy
Curetting of pelvic
External anal sphincter
Internal anal sphincter
Excision of inter
Dentate line
Transanal opening of
inter - sphincteric
space with fistulotomy
204
with no communication
sphincter
13 Fistulotomy: Still aGold Standard!
Fig. 13.6 Intersphincteric stula
from pelvic disease
13.4 Management ofTrans-
A trans-sphincteric stula could be either high or
low. Less than 30% of the external anal sphincter
is involved in the low trans-sphincteric stula [6].
In contrast, over 30% of the external anal sphincter
is involved in the high trans-sphincteric stula [6].
However, according to some authors, the differentiation between low and high trans- sphincteric stula depends upon whether less than or more than
66% of the external sphincter is involved [7, 8]. A
low trans-sphincteric stula crosses the lower onethird of the external anal sphincter, whereas a high
trans-sphincteric stula crosses the upper or middle third of the external anal sphincter [7, 8].
13.4.1 B1 Uncomplicated
• The lowermost internal anal sphincter, supercial, and subcutaneous external sphincter are
sphincteric Fistula
Inter - sphincteric tract
with the anal canal
External anal
divided in an uncomplicated low transsphincteric stula. The disturbance to the anal
continence is minimal (Fig.13.7a, b).
13.4.2 B2 Complicated
• Trans-sphincteric stula with high blind tract
or extension to the supralevator space.
Fistulotomy is performed up to the supercial part of the external anal sphincter. If
adequately drained, the upper extension will
heal itself. Whenever probing is done, the
probe invariably goes straight. Because the
trans-sphincteric tract is at a right angle to
the main tract, it is challenging to move the
probe from the external to the internal opening, as shown (Fig. 13.8a–c). Aggressive
probing can lead to the formation of an
extrasphincteric stula. After identication
of internal opening, a transanal approach is
better (Table13.2).
Dentate line
Internal anal
sphincter
tract from inter
nal opening
13.4 Management ofTrans-sphincteric Fistula
a
205
Conjoined longitudinal muscle
External anal sphincter
Trans - sphincteric tract
b
External anal sphincter
Fistulotomy for low trans - sphincteric
nal to external opening
Internal opening
Dentate line
Internal anal sphincter
Conjoined longitudinal muscle
Excision of inter
Dentate line
Internal anal sphincter
Fig. 13.7 (a) Uncomplicated trans-sphincteric stula. (b) Fistulotomy for low trans-sphincteric tract from internal to
external opening
206
xtension into the
Fistulotom
13 Fistulotomy: Still aGold Standard!
a
into the ischiorectal fossa
High extension
Conjoined
longitudinal muscle
External anal sphincter
Internal anal sphincter
b
Curetting of the tract
External anal sphincter
y for trans - sphincteric tract
c
Upper e
supralevator space
Internal opening
Dentate line
Conjoined longitudinal muscle
Excision of internal opening
Dentate line
Internal anal sphincter
Excision of internal opening
Dentate line
Internal anal sphincter
Fig. 13.8 (a) Trans-sphincteric stula with high blind
tract and suprasphincteric extension. (b) Fistulotomy of
trans-sphincteric tract followed by excision of internal
Curetting of supralevator extension
Conjoined longitudinal muscle
External anal sphincter
Fistulotomy for trans - sphincteric tract
opening. (c) Fistulotomy of trans-sphincteric tract followed by curetting of supralevator extension
Conjoined longitudinal muscle
k position
13.5 Management ofSuprasphincteric Fistula
207
13.5 Management
ofSuprasphincteric Fistula
This is an uncommon stula and is challenging to
cure.
• The rst and most crucial step is to excise the
internal opening and surrounding tissue. The
intersphincteric part of the tract is opened by
dividing the internal anal sphincter up to the
anorectal ring. The deep part of the external
a
Supra - sphincteric tract
anal sphincter should never be cut. The edges
of the cut internal sphincter are marsupialized
with the anal canal wall. The rest of the tract is
curetted. At 6 o’clock, a stulotomy from the
internal opening to the anal verge is performed
for drainage (Fig.13.9a, b).
Park proposed that such stulas are usually
horseshoe and, after a while, form a crescentic
brous ring, which acts as a sphincter. A staged
stulotomy can be attempted [4] (Table13.3).
Internal opening
External anal sphincter
b
Curetting of the tract
Conjoined longitudinal muscle
External anal sphincter
Internal anal sphincter
Fig. 13.9 (a) Suprasphincteric stula. (b) Fistulotomy at 6 o’clock position with opening of intersphincteric part of the
tract
Anorectal ring
Dentate line
Internal anal sphincter
Opening of inter - sphincteric space
Excision of the internal opening
Dentate line
Fistulotomy at 6 o’ cloc
208
Extra - sphincter
trans - sphincter
nal opening
13 Fistulotomy: Still aGold Standard!
13.6 Management
ofExtrasphincteric Fistula
1. Extrasphincteric Tract Secondary to a
Trans-sphincteric Fistula
One of the openings in this stula is the primary internal opening of cryptoglandular origin
in the anal canal. The second is the transsphincteric stula’s rectal opening extending
a
ic tract
External anal sphincter
from the extrasphincteric region (Fig.13.10a).
In such stulas, stulotomy can be carried out
from the internal to the external perineal opening (Fig.13.10b). The distal tract opening into
the rectum may pose a problem in healing due
to high rectal pressure leading to contamination. A temporary diversion colostomy may be
required to heal the tract completely [4]. These
cases, however, are sporadic.
Conjoined longitudinal muscle
Internal opening
Internal anal sphincter
b
Curetting of the extension
External anal sphincter
Fistulotomy for
ic fistula tract
Internal anal sphincter
Fig. 13.10 (a) Extrasphincteric stula tract extending
from trans-sphincteric tract of cryptoglandular origin. (b)
Excision of internal opening with stulotomy done for
Dentate line
Conjoined longitudinal muscle
Excision of inter
Dentate line
trans-sphincteric tract. The extrasphincteric extension
curetted. Primary sphincter repair can be done incase
more than 30% of external sphincter is divided
Extra - sphincteric
13.6 Management ofExtrasphincteric Fistula
209
2. Extrasphincteric Fistula Due to Trauma
The primary cause is foreign body pene-
tration from the perineum (Fig. 13.11).
Removing the foreign body is necessary.
However, an iatrogenic stula may also
develop by aggressive probing. No sphincter
cutting procedure is required. The patient
may require a temporary diversion colostomy
[4].
Fig. 13.11 Extrasphincteric
stula tract following trauma
External anal
sphincter
3. Extrasphincteric Fistula Due to Anorectal
Diseases
The underlying pathologies like Crohn’s
disease, ulcerative colitis, or malignancy must
be treated in this type of stula [4].
4. Extrasphincteric Fistula Due to Pelvic
Inammation
The primary source of infection in the pelvis should be managed [4] (Table13.4).
tract
Conjoined longitudinal
muscle
Dentate line
Table 13.4
stula
Extrasphincteric
Internal anal
sphincter
Type of stula
Extrasphincteric
stula
Sphincter involvement and
amount of sphincter cut Outcome and alternatives
No sphincter cutting The laser procedure is
better in iatrogenic
extrasphincteric stulas
210
13 Fistulotomy: Still aGold Standard!
13.7 Simple Fistulotomy Technique
The patient is placed in a lithotomy position
under spinal, regional, or general anesthesia.
Hydrogen peroxide is injected through the external opening, and bubbles are observed owing
out of the internal opening (Fig.13.12a). The stula tract is demarcated by injecting methylene
blue (Fig.13.12b).
A probe is gently inserted into the tract
through the external opening and brought out
through the internal opening, and the overlying
tract is divided (Fig.13.12c, d). Unipolar cautery
or bare laser ber is used to open the tract over
the probe. Once the tract is laid open, the base
can be seen stained with methylene blue, an afr-
mative sign of the stula tract. The tract should
be followed to see other branches demarcated by
methylene blue. In a low intersphincteric stula,
the subcutaneous part of the external anal sphincter is divided. In a low trans-sphincteric stula,
the subcutaneous and the lower part of the supercial external anal sphincter are always divided.
If the supercial part of the external anal sphincter needs to be cut, primary sphincter repair
should be done to avoid anal incontinence. The
division of the lowermost part of the external anal
sphincter can be associated with acceptable postoperative incontinence. The internal opening and
the nidus of primary infection in the intersphincteric space are scooped out (Fig.13.12e, f). The
wound base is then curetted and left open to heal
by secondary intention. The curetted unhealthy
Fig. 13.12 (a–h) Steps of stulotomy. (a) Injecting
hydrogen peroxide through external opening. Bubbles
seen coming out of internal opening at dentate line. (b)
Demarcation of stula tract by injecting methylene blue.
(c) Probe is entered via the external opening and brought
out through the internal opening. (d) Laying open of stula tract over the probe using monopolar electrocautery.
(e) Excision of internal opening including mucosa, submucosa, and surrounding tissue up to intersphincteric
space to eradicate the source of infection. (f) Fistulotomy
wound showing bers of internal sphincter. (g)
Marsupialization of stulotomy edges using Polyglactin
2-0. (h) The nal wound as seen at the end of procedure
ef
13.7 Simple Fistulotomy Technique
211
Fig. 13.12 (continued)
granulation tissue is sent for a histopathology
examination. Finally, marsupialization of stulotomy wound edges is done (Fig.13.12g, h). No
packing of the wound is required.
• Prevents the bridging of the margins of the stula tract.
• Prevents early skin closure. The skin heals
faster than mucosa; the underlying raw area
13.7.1 Advantages
ofMarsupialization
Marsupialization is not a part of the stulotomy
technique but has the following advantages [9]:
• Decreases the size of the wound.
• Maintains hemostasis from the edges of the
wound.
• Avoids trapping of the fecal matter underneath
the wound margins.
13.7.2 Results
Ho et al. reported faster healing in stulotomy
with marsupialization [10]. Interrupted sutures
for marsupialization of margins are taken using
2-0 or 3-0 Polyglactin. Continuous sutures, on
the other hand, are recommended by Pescatori
etal. because they provide better obliteration of
perianal wounds, reducing the risk of bleeding
and suppuration after surgery [9].