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264
r
a
communication with the anal cana
16 Hybrid Procedures-Future ofFistula Surgery!
Fig. 16.9 (a, b)
Intersphincteric stula.
(a) Intersphincteric
stula type A6 showing
the pelvic extension. (b)
Laser ablation of the
tract done after removal
of primary infection of
pelvic origin
Inter - sphincteric tract with no
communication with
the anal canal
Dentate line
Internal anal sphincte
External anal sphincter
b
curetting of pelvic extension
Laser ablation
of Inter - sphincteric tract
Inter - sphincteric tract with no
External anal sphincter
I would like to emphasize that no matter which
procedure one opts for, removing the primary
source of infection is crucial.
16.12.1.3 Suprasphincteric Fistulas
These fistulas are pretty challenging to treat.
Their incidence, however, is very low. In these
l
Dentate line
Internal anal sphincter
fistulas, the primary source of infection is first
eliminated. As suggested by Park, the intersphincteric part of the tract can be opened. The
rest of the tract forming a loop over the sphincter complex and extending toward the
perineum can be curetted and laser-ablated.
Fistulotomy at 6 o’clock helps drainage
External anal sphincter
a
e
b
c
16.12 How toSelect aHybrid Procedure
265
Conjoined longitudinal
muscle
Internal opening
Trans - sphincteric tract
External anal sphincter
Fistulotomy for low
trans - sphincteric tract from
internal to external opening
High extension into
the ischiorectal fossa
Conjoined longitudinal
muscle
External anal sphincter
Dentate line
Internal anal sphincter
Conjoined longitudinal
muscle
Excision of internal
opening
Dentate line
Internal anal
sphincter
Upper extension into
the supralevator spac
Internal opening
Internal anal sphincter
Fig. 16.10 (a–e) Trans-sphincteric stula types B1 and
B2 with short distal tracts (less than 4 cm). (a) Simple
trans-sphincteric stula type B1. (b) Diagrammatic representation of stulotomy involving the lower part of internal anal sphincter, subcutaneous and supercial parts of
the external anal sphincter. (c) Trans-sphincteric stula
type B2 showing an upward extension into the ischiorectal
fossa. (d) Laser ablation of upward extension with stulotomy. (e) Fistulotomy with laser ablation of supralevator
extension
Dentate line
266
r
Conjoined longitudinal
d
16 Hybrid Procedures-Future ofFistula Surgery!
Laser ablation of extension of
low trans - sphincteric tract
External anal sphincter
Fistulotomy from internal
to external opening
Conjoined longitudinal muscle
Excision of internal
opening
Dentate line
Internal anal sphincte
e
Curetting of the
supralevator abscess
Laser ablation of upper extension of
muscle
Dentate line
Internal anal
sphincter
trans - sphincteric
tract into the supralevator space
External anal sphincter
Fistulotomy from internal
to external opening
Fig. 16.10 (continued)
(Fig.16.11a–c). Alternatively, a seton can be
placed.
16.12.1.4 Extrasphincteric Fistula
In an extrasphincteric stula, VAAFT with laser
ablation can be considered. Overall, the results
will depend upon the type of etiology one is dealing with (Fig.16.12a, b).
16.12.1.5 Horseshoe Fistula
In a horseshoe stula with two trans-sphincteric
tracts and a single internal opening, it is essential
to tackle the internal opening and the primary
source of infection (Fig.16.13). A stulotomy can
be done from 6 o’clock to the anal verge, separating the two horseshoe tracts. Both the tracts can
be curetted and laser-ablated, followed by coring.
Conjoined longitudinal muscle
a
b
c
16.12 How toSelect aHybrid Procedure
267
Fig. 16.11 (a–c)
Suprasphincteric stula.
(a) Suprasphincteric
stula. (b)
Diagrammatic
representation of laser
ablation of the
suprasphincteric tract.
(c) Diagrammatic
Supra - sphincteric tract
Internal opening
representation of
opening of
intersphincteric space up
to the anorectal ring
with laser ablation of the
Dentate line
tract (Preferred
approach)
External anal sphincter
Internal anal
sphincter
Anorectal ring
Laser ablation of
supra - sphincteric tract
Conjoined longitudinal muscle
External anal sphincter
Internal anal sphincter
Anorectal ring
Laser ablation of
supra - sphincteric tract
Conjoined longitudinal muscle
External anal sphincter
Internal anal sphincter
Excision of internal opening
Dentate line
Fistulotomy at 6 o’
clock position
Fistulotomy upto anorectal ring
Excision of internal opening
Dentate line
Fistulotomy at 6 o’
clock position
268
r
a
b
Fig. 16.12 (a, b)
Extrasphincteric tract.
(a) Extrasphincteric
stula. (b)
Diagrammatic
representation of laser
ablation of the tract
Extra - sphincteric tract
Conjoined
longitudinal muscle
16 Hybrid Procedures-Future ofFistula Surgery!
Dentate line
External anal sphincter
Internal anal sphincte
Laser ablation of
extra - sphincteric tract
Conjoined longitudinal muscle
External anal sphincter
Dentate line
Internal anal
sphincter
16.13 Core Tips While Performing Fistula Surgery
I would like to share a protocol that I always follow in my practice while operating a stula.
Fig. 16.13 Horseshoe stula with multiple external
openings at 5 and 7 o’clock position
• Always identify the internal opening preoper-
atively by digital rectal examination. Failure
to identify the internal opening is associated
with 80% recurrence of stulas [26].
• Get an MRI stulogram for appropriate ana-
tomical representation of the tracts, especially
in a complex stula. Plan your procedure
16.14 Your Queries! My Answers!
269
before the surgery but be prepared for any
change in procedure as perioperative ndings
may differ from MRI.
• Never probe the tract forcefully, as this may
create an iatrogenic opening.
• Always send the pus for culture sensitivity and
the curetted necrotic material from the stula
tract for histopathology.
• While operating, demarcate the tract with
methylene blue and hydrogen peroxide.
Staining the tracts with methylene blue helps
identify the extensions if any.
• Due to brosis near the internal opening or an
hourglass deformity, sometimes the dye cannot be seen coming out of the internal opening. In such a situation, insert a lacrimal probe
or infant feeding tube through the internal
opening to trace the course.
• For stula surgery with laser, radial ber is
used. Collateral injury is minimized due to the
shallow penetration depth (2–3 mm beyond
the stula tract) [27].
• Thorough irrigation of the tract with normal
saline is mandatory after curetting or laser
ablation to remove the debris.
• Consider the cost-effectiveness of the procedure and explain the chances of recurrence.
• Explain the postoperative wound care management to the patients and call the patients
for regular follow-ups.
16.14 Your Queries! My Answers!
1. How to proceed when there is no internal
opening?
A stula is difcult to cure when it has no orice,
is blind, and has many windings.—Paulus
Rarely may one not nd an internal opening during a digital rectal examination or surgery. When methylene blue is injected through
the external opening, it cannot be seen coming
out of the internal opening. Instead, the stula
tract and surrounding tissue swell when the
dye or hydrogen peroxide is injected. In such
cases, gently insert the probe from the external opening and see the extent to which it goes
smoothly. Give a nick over the tip of the probe
and bring it out. Apply Allis forceps towards
the medial part of the opened tract and give
traction downwards and outwards. If one can
see the pull over the mucosa inside, it
invariably indicates the internal opening site.
Alternatively, saline can be injected into the
mucosa at the dentate line posteriorly. The
part of mucosa which does not lift indicates
the brotic part of the tract.
Still, if the internal opening cannot be
identied, leave the incised part of the tract as
such. It may be a case of a sinus rather than a
stula. When the internal opening or a part of
the duct that opens at the anal crypt becomes
brosed, a sinus is formed (Fig.16.14) [28].
In my practice, if I cannot nd the internal
opening, which is rare, I prefer to give a nick
over the probe at the tip and bring it out as
near the dentate line as possible and separate
the tract, followed by curetting and laser
ablation.
Sometimes, the anal stula tract is narrow
and takes the shape of an hourglass in the
intersphincteric space, making probing
impossible. Even when hydrogen peroxide is
injected through the external opening, the
internal opening may not be identied. It is
better to use a lacrimal probe used by ophthalmologists to probe the tract.
2. What to do if one cannot probe the tract at
all?
It can happen when the tract is narrow,
obstructed, kinked, branched, or has stenotic
segments [26]. Such tracts can be dealt with
stulectomy [26]. The probing of the tract can
be attempted under vision using the VAAFT
scope. However, it is not an easy procedure. If
the probing from an external opening fails, try
to probe from an internal opening, as in a railroad method. If the dissection is done in the
wrong plane and a tract is opened, the presence of necrotic tissue would right away alert
the surgeon to nd the proper plane.
270
Fibrosed tract near internal opening
Conjoined longitudinal muscl
16 Hybrid Procedures-Future ofFistula Surgery!
External anal sphincter
Inter - sphincteric tract
Fig. 16.14 Fibrosed tract near internal opening
3. How to deal with stulas having an exter-
nal opening at the scrotal base?
In such cases, there is always a fear of
damaging the urethra. One must catheterize
such patients before surgery. Any hybrid procedure may be carried out irrespective of the
length of the tract. The most important aspect
is identifying the internal opening. A VAAFT
scope can be inserted from an external opening to locate the internal opening. One can see
bright light near the internal opening. A combination of LIFT with laser ablation of the
tract may be done at 12 o’clock. Alternatively,
a proximal stulotomy with distal coring or
laser ablation of the distal tract can be done.
If the internal opening is at the 6 o’clock
position and a tract has extended up to the
scrotal base due to anterior and upward
extension, then the tract is curvilinear. In
such cases, a probe is inserted from the external opening at the base of the scrotum, and
the tip can be seen on the anal verge at 6
o’clock. A nick is given over the tip, and the
probe is brought out, separating the distal
tract. The probe is reinserted from the separated tract and brought out through the internal opening (hockey J-shaped tract). A
e
Internal opening
Dentate line
Internal anal sphincter
proximal stulotomy is carried out over the
probe. The separated distal tract is curetted
and laser-ablated. There is no need to create
large raw areas. Since the tract is large and
tissue debris is sometimes present after laser
ablation, a seton can be placed for drainage
for a week.
4. What can be done to prevent bleeding dur-
ing FiXcision?
Sometimes, FiXcision can cause bleeding.
The bleeding is from the surrounding adipose
tissue rather than the tract itself. The chances
of bleeding are more in recurrent stulas as
the vessels may retract due to brosis. The
ideal way to control the bleeding is to insert
the VAAFT scope to visualize the bleeder and
cauterize it.
5. What are the precautions to be taken after
coring the tract?
It is always advisable to insert the guide
through the cored-out tract and take a circumambulation stitch using 2-0 Polyglactin to
avoid fecal matter entering the wound.
Remember, after coring, a tunnel is left behind
with internal communication with the anal
canal. The liquid part of the fecal matter can
enter this tunnel and lead to infection.
16.15 Case Presentations
271
6. How to deal with supralevator induration?
The identication of the supralevator indu-
ration requires expertize [29]. On digital rectal
examination, one can feel bogginess or induration above the anorectal ring. The supralevator
induration is either an upward extension of the
cryptoglandular infection or a downward
extension from pelvic disease. The management will depend upon the type of pathology.
7. How to manage a stula when there is no
external opening?
Managing a stula where the external
opening is absent is challenging for a surgeon.
A stula may be present with no external
opening [26]. The external opening position is
related to the complexity level of the tract
[30]. The intersphincteric stulas of types A4
and A5, with cephalad and high extension up
to puborectalis muscle level, do not have any
external openings [31]. In most cases, it can
be linked to a high supralevator or intersphincteric abscess [31]. In such cases, the entire
internal sphincter up to the anorectal sling can
be divided through the transanal approach
without incontinence.
8. Sometimes the patient complains of pain
near the site of the almost healed stula?
What can it be?
Such complaints should never be ignored,
as the patient will be the rst to know of any
discomfort. He should be examined thoroughly. I had operated on a patient with a
recurrent stula, which had nearly healed.
After 12 weeks of surgery, the patient complained of pain on and off and pus discharge.
On examination, I could not nd any abscess
or pus discharge. I could see only a small
unhealed part of the stulotomy wound. I
curetted the tract hoping it would heal. A few
days later, the patient again came to me with
the same complaints. I could see active pus
discharge this time. I sent the patient for MRI,
which revealed a low intersphincteric tract
approximately 2.5 cm in length. I took the
patient for surgery and subsequently laid open
the unhealed tract, which healed well. The
patient would have had a persistent stula if I
had not listened to his complaint.
In my clinical practice, I have realized that
many patients postoperatively are left in the
hands of inexperienced staff for dressings or
have no proper follow-ups. Regular followups are a must till the stula heals completely.
During the healing process, care must be
taken to relieve the bowels properly. Adding a
laxative in the postoperative period will ultimately render good healing.
16.15 Case Presentations
Case 1
A 50-year-old gentleman came to OPD with the
complaint of pus discharge from an opening near
the scrotal region. He was a known case of HIV
on antiviral therapy. There were two external
openings on examination, one at the root of the
scrotum and second at the penoscrotal junction,
approximately 3cm apart. The total length of the
tract was approximately 10cm. A single internal
opening was present at 12 o’clock (Fig.16.15a).
His MRI revealed a low intersphincteric stula
extending anteriorly and superiorly. His CD4
count was within normal limits. Medical tness
was taken from the attending physician before
surgery. All the necessary precautions were taken
as per HIV protocol.
As the patient was immunocompromised, I
planned for a minimally invasive procedure,
Distal Laser Proximal SLOFT (DLPS). The tracts
and the openings were demarcated by injecting
diluted methylene blue from the external opening.
The dye could be seen coming out from the internal opening. The whole tract was curetted, the
necrotic material was removed and sent for a histopathology examination. Submucosal ligation of
the stula tract was performed, followed by laser
ablation of the distal tract. The wound was irrigated from the scrotal opening with normal
saline. Normal saline could be seen coming out
of the separated tract (Fig. 16.15b). The small
tract between the two external openings was laid
open.
Discussion
The patient with an external opening near the
scrotum should always be catheterized before
272
External opening at penoscrotal junction
Magnified view
a
b
External opening at base of scrotum
16 Hybrid Procedures-Future ofFistula Surgery!
External anal
sphincter
Internal anal sphincter
External opening at base of scrotum
Laser ablation of distal
tract
External anal sphincter
Internal anal sphincter
Magnified view
External opening at penoscrotal
junction
Internal opening
Dentate line
Fistulotomy
SLOFT
Internal opening
Dentate line
Fig. 16.15 (a) Two external openings, one at the peno-
scrotal junction and second at the base of scrotum. Internal
opening at 12 o’clock position. (b) SLOFT at 12 o’clock
surgery to prevent urethral injury. As the patient
was immunocompromised, the least invasive procedure was performed. The part of the tract near
the penoscrotal junction was spared from laser
ablation because of its proximity to the urethra.
with separation of distal tract. A small stulotomy at the
site of two external openings
Case 2
Mr. Y, a young male, was very much disturbed
with pus discharge in the anal area. He was from
a village and consulted a local physician for his
disease. He was given some medication, but there
t
16.15 Case Presentations
273
was no relief. He then consulted me about his
problem. On examination, two stula tracts were
seen, one anterior and another posterior, with two
internal openings. The anterior tract was transsphincteric, about 4–5cm long, with an internal
opening at 12 o’clock and an external opening at
1 o’clock. The posterior tract was intersphincteric, approximately 2.5cm long, with an external opening at 7 o’clock and an internal opening
at 6 o’clock. It was a case of synchronous stula,
a rare but known presentation. The condition was
explained to the patient, and routine investigations for the surgery were done.
The patient was taken for surgery. I decided to
operate on the anterior tract rst. Methylene blue
was injected from the external opening at 1
o’clock and could be seen coming out from 12
o’clock. The tract was laser-ablated, and the deep
intersphincteric space was explored to remove
the primary source of infection, followed by coring out the distal tract using FiXcision.
The second part of the surgery was to deal with
the posterior tract. The posterior tract had an internal opening at 6 o’clock and an external opening at
7 o’clock. A dye was injected at 7 o’clock and was
seen coming out at 6 o’clock. Fistulotomy followed by marsupialization was done after excising
the internal opening. The patient was discharged
the next day (Fig.16.16a, b).
Discussion
A synchronous stula is a tract with two external and two separate internal openings. One must
differentiate it from a complex stula as the latter
may have multiple external openings, but the
internal opening is single. It was not as easy a
case as it initially appeared. Performing stulotomy for both the tracts was impossible because it
would have caused incontinence, even if transient. As I was not comfortable cutting the internal and external sphincters, both anteriorly and
posteriorly, and wanted to create the least raw
area, I decided on a hybrid procedure for the
anterior tract, a combination of coring and proximal stulotomy without cutting the external
sphincter. The laser ablation before coring out
caused shrinkage of the tract, making it easier to
core. As the posterior tract was small, stulotomy
was an ideal procedure.
a
b
Coring out of the trac
Fistulotomy
Fig. 16.16 (a, b) Synchronous stula. (a) External open-
ings at 1 o’clock and 7 o’clock positions. (b) Coring for
the long tract at 1 o’clock and stulotomy for small tract
at 7 o’clock
Case 3
Mr. F, an army personnel, who had been operated
on twice for stula, came for consultation. The
patient had a recurrence and wanted another
opinion. His complaints were pain and pus discharge from the anus. He was in despair. There
was an external opening at the penoscrotal junction and an internal opening at the 12 o’clock
position (Fig.16.17a). His MRI revealed an intersphincteric stula with an internal opening at 12
o’clock, extending superiorly with an external
opening at the base of the penile shaft. The length
of the tract was approximately 9cm. After getting
all the preoperative investigations, surgery was
planned. The procedure I planned was a distal
laser with proximal LIFT.The tract was identi-