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Ростовский Государственный Медицинский Университет
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PREOPERATIVEPLANNING
Successfultreatmentisdependentonadetailedunderstandingofthe perianalanatomyandthepathogenesisofanalfistula.
Afullmedicalhistoryistakentoidentifysymptomsthatsuggest coexistingdiseaseandtodetermineapatient’sbaselinelevelof continence;itshouldalsoincludeanobstetrichistoryanddetails pertainingtopreviousanalsurgeryortrauma.
Clinicalevaluationisaimedatdeterminingthecourseofthefistula tract(s)inrelationtothesphinctercomplex,identifyingthesiteandthe numberofinternalandexternalopenings,whetherthereareany secondaryextensionsofthetract,andsphincterfunction.Careful inspectionandexaminationoftheperianalskin,digitalanorectal examination,andrigidproctosigmoidoscopyareoftentheonly investigationsrequiredforsimplefistulae.Theinternalopeningmaybe feltasapalpabledefectandthecourseofthetractisindicatedby induration,oftenacord-likethickeningoftheperianaltissues.Thesiteof theexternalopeningisusuallyclear.
Digitalexaminationisaguidetosphincterfunction,andpriortomore invasiveteststheanalrestingtoneandvoluntarysphincter“squeeze” pressureareclinicallyassessed.Sphincterdefectsmaybepalpable,and deformityoftheanorectumduetochronicanorectalsepsisorprevious surgeryisnoted.Proctosigmoidoscopyhelpsexcludeassociatedanorectal pathologysuchasproctitisormalignancy.
Theclinicalfindingsofteninfluencethechoiceoftheoperative procedure.Thepresenceofanorectalstenosis,and/orextensivescarring andrigidityoftherectalmucosaasaresultofchronicsuprasphincteric sepsisforexample,favorsananocutaneousflaprepair,becauseofthe potentialdifficultyinmobilizingarectallybasedadvancementflapinthis situation.
Itistheauthors’practicetoperformacolonoscopyorflexible sigmoidoscopyforcomplexorrecurrentfistulaetohelpexclude associatedgastrointestinaldisease.Thechoiceofinvestigationusually dependsonthepatient’sageandwhethertheyhavetheassociated abdominalsymptoms.IfCrohn’sdiseaseissuspectedonsymptoms,and acolonoscopyisnormal,thenanupperendoscopyandsmallbowel imagingmaybeindicated.
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Complexfistulatractsmaybeimagedbyendoanalultrasound(EAUS)
ormagneticresonanceimaging(MRI).Thechoiceofimagingis dependentonavailability,localexpertise,andthecomplexityofthe fistulatract;thereisalearningcurveintheinterpretationoftheimages withbothmodalities.Fistulographyandcomputedtomographyhave littletoofferinassessment.AlthoughMRIisconsideredthe“gold standard,”ithasbeentheauthors’practicetoassessmostfistulatracts usingEAUS,reservingthemoreexpensiveMRIforassessingfistulas associatedwithCrohn’sdisease,recurrentfistulas,orfistulas,whichhave notbeenclearlydefinedwithEAUS.
EAUSishighlyoperator-dependent,butiftheexpertiseisavailable,it isabletodifferentiatebetweensimpleandcomplexfistulae,detect abscesses,identifytheinternalandexternalopenings,andcategorizethe typeoftract.Hydrogenperoxideinjectedviatheexternalopeningcan enhancevisualizationofthetractbecauseitactsasanultrasoniccontrast mediumbyproducinghyperreflectivegasbubbles.Althoughtheuseof hydrogenperoxidehasbeenshowntoincreasetheaccuracyof assessmentfrom68%to98%,ithasnotbeenourpracticetoneedorto useenhancementroutinely.Aswellasprovidinginformationaboutthe typeoffistulatract,EAUShelpsidentifyprevioussphincterdamageasa resultofthediseaseprocessand/orprevioustrauma,includingsurgical attemptsateradicationandobstetrictrauma,althoughitcansometimes bedifficulttodistinguishbetweenascarandanactualdefect.An advantageofEAUSoverMRIisthatEAUScanbeperformedduringthe surgeryasanadjuncttodigitalexaminationandexaminationunder anesthesia(EUA),aswellasprovideadynamicpreoperativeassessment ofsphincterintegrity.
MRIprovidesexcellentsoft-tissueresolutioninmultipleplanes allowingsepsisandgranulationtissuetobedistinguishedfromsphincter muscles,ismoreaccuratethanclinicalassessmentindetectingpreviously missedsecondaryextensionsoftheprimarytract,andincorrectly determiningthelevelofthefistulawithrespecttothesphinctercomplex. Inaddition,unlikeEAUS,itcanevaluateapathologicalconditionbeyond thesphinctersbothlaterallyandfromabove.
Theinternalsphincterisparticularlyatriskinfistulasurgery;and baselineanalmanometryusedtomeasuretheanalcanalpressuresand functionalsphincterlengthcaninfluencesurgicaldecisionmaking.
Priortodefinitiverepairsurgery,anEUAtofurtherassessthetractsis oftenuseful.TheauthorsprefertouseLockhartMummeryprobes(Fig.
6-1)tothesmaller-caliberlacrimalprobesbecauseofthegreaterriskof
creatingafalsetractwiththelatter.
FIGURE6-1Confirmationofthecourseofthefistulatract
usingLockhartMummeryprobes.
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Definitiverepairshouldonlybeundertakenaftersepsishasbeen controlled,thatis,abscesseshavebeenincisedanddrainedandtherehas beenaperiodofcontrolleddrainagebyplacementofloosevesselloopset ondrains(Fig.6-2).Drainagefromlargechronicsupralevatorcavitiesis bestcontrolledwithsmallmushroomtip(dePezzer)drains.
FIGURE6-2Twoquiescentfistulatractsdemonstrated,
withsepsiscontrolledfollowingtheplacementofsetondrains
(vesselloops).

SURGERY

PerioperativeManagement
Itistheauthors’preferencetouseasodiumphosphateenematoclearthe distalbowel.Afullmechanicalbowelpreparationisrarelyrequired.
Informedconsentisobtained.Therisksspecifictofistulasurgerythat shouldbeexplainedtothepatientinclude:
theriskoffailure/recurrenceasnotedintheresultssectionofthis chapter
inadvertent,orgreaterthanexpected,compromiseofsphincterfunction andincontinence
anorectalsepsis hematomaformation iatrogenicfistulaformationincludingrectovaginalfistulae ectropionfollowingMAFsresultinginmucusdischarge
Positioning
Intheoperatingtheater,thepatient’smedicalhistory,consent,andthe proceduretobeperformedarecheckedbytheoperatingsurgeonand teampriortothecommencementoftheprocedureusingastandardized checklist.Ifthefistulatractisposteriororlateral,thenthepatientis placedinthelithotomyposition;thepronejackknifepositionisusually usedforanteriortracts.Theassistantisbetterpositionedandmore comfortablewhenthepatientisprone.
Theprocedureisusuallyperformedundergeneralanesthesiausinga laryngealmaskwithoutmusclerelaxation.Regionalanesthesiawith intravenoussedationisindicatedonoccasionsbecauseofpatient morbidity.Antibioticprophylaxisisroutine,theauthors’preference beingtheprescriptionofacombinationofgentamicinandmetronidazole orathird-generationcephalosporinandmetronidazole.Thromboembolic prophylaxisisguidedbythepatient’sage,weight,andanyassociated comorbidities,andtheestimatedlengthoftheprocedure,but thromboembolicdeterrantstockings(TED)anti-embolisimstockingsand subcutaneousheparinareroutinelyused.
Theperineum,includingthevaginalandtheanalcanals,isprepped withaqueouschlorhexidineandsquaredraped.Fenestrateddrapes shouldbeavoidedbecausetheytendtoshiftandlimittheaccess.Theuse
ofaheadlightcanoptimizetheview,butisnotusuallynecessary.When performingananocutaneousflap,theperianalbuttockareaisshavedifit ishirsute;anindwellingurethralcatheterisnotusuallynecessary.
Technique
AconfirmatoryEUAisperformed,anddefinitiverepairispostponedif thereisevidenceofresidualsepsis.
Retractionisimportant,sothebuttocksaretapedapartintheprone position.TheLoneStarretractoralone,ortogetherwitheitheraPark’s anal,bivalveretractor(Eisenhammer)orHill-Fergusonretractor, providesadequateexposure.
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Flaps
Fundamentaltosurgicalsuccessisfamiliaritywiththebasicprinciplesof flapsurgery,whichare:
thelength:widthratio thethicknessoftheflap theapproximationofwell-vascularizedtissues theabsenceoftension theobliterationofanydeadspace
Transanal/EndorectalAdvancementFlap
ThistypeofflapwasfirstproposedbyNoblein1902fortherepairofa rectovaginalfistulaandlatermodifiedbyEltingandLaird.Thetechnique describedhereisaverticallyincisedor“tongue”flap.ThetermMAFisa misnomerastheseproximallybasedflapsinvariablyincludethe submucosaandatleastthesuperficialfibersof,ifnottheentire,internal sphincter(video).Apartialthicknessflapdoesnotimpairincontinence, butaddsstrengthtotheflap.Thistypeofrepairclosestheinternal openinganddoesnotdividetheexternalsphincterandis,therefore, associatedwithalowerriskofincontinence.Itcanberepeatedandit avoidsakeyholedeformityofthecontouroftheanalcanal,andhealingis alsoquickerthanthatafterafistulotomy.ALoneStarretractorisusedto everttheanalverge,andaPark’sanalretractororbivalvespeculumis usedforexposurewithintheanalcanal.Abroad-basedUflapisraised (Fig.6-3).Theapexshouldstart5–10mmbelowtheleveloftheinternal
openingand10–15mmoneithersideoftheinternalopening.Theflapis raisedwithdiathermy(Fig.6-4).Oftenthemostdifficultpartofthe dissectionisraisingtheapexoftheflap,asinthisarea,theinflammatory changesaroundtheinternalopeningasaresultofprevioussepsismakeit difficulttodevelopthecorrectplane.Ifthedissectionisstartedlaterally, invirginplanes,thenthecorrectdissectionplanemaybemoreeasily identified.
FIGURE6-3Lineofincisionforabroad-basedU-shaped
endorectaladvancementflap(schematic).
FIGURE6-4Incisingtheapexoftheflapwithdiathermy,
starting5–10mmbelowtheleveloftheinternalopening.
Theaimistoraiseabroadbased,tension-freeflapwithanadequate bloodsupply.Theflapconsistsofmucosa,submucosa,andpartof,or occasionally,theentireinternalsphincter(Fig.6-5,video)continuing proximallyasthecircularmusclefibers.Oncetheinternalopeninghas beenpassed,theplanecanbedevelopedbyinfiltratingwithasaline solution,althoughthisisoftenunnecessary.Theauthorsavoid adrenaline-containingsolutionsbecausetheirvasoconstrictiveaction maycompromisetheflap’sbloodsupply.
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FIGURE6-5Developingtheflap,inthiscaseinthe
intersphinctericplane,raisingafull-thicknessendorectal advancementflap.
Thelengthoftheflapshouldbesuchthatitallowsatension-free closure(Fig.6-6).Toaidtheretractionoftheflapwhilemobilizingit,two holdingsuturesmaybeplacedinitsapex(Fig.6-7).Tissueforceps,such asAliceforceps,mayalsobeusedbutcanobscuretheviewandgetinthe way.
FIGURE6-6Fullymobilizedflappriortotheexcisionof
theinternalopening.
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FIGURE6-7Fullymobilizedflapretractedusingtwo
holdingsutures.InternalopeningexcisedalonglineA–A. Internalopeningdefectinthesphincterisclosedwith interruptedsutures(schematic).
Oncetheflaphasbeenmobilized,theinternalopeningandthecrypt-
bearingtissuearoundtheinternalopeningareexcisedandcoredout.The apexoftheflapisexcised,includingtheinternalopening(Fig.6-7). Meticuloushemostasisshouldbesecuredpriortotheclosureoftheflap topreventhematomaformation,whichcouldlifttheflaporpredisposeit torecurrentsepsis.Theinternalopeningisclosedwithalongitudinalline ofinterruptedabsorbablemonofilamentsuturestohelpadvancetheflap down(Fig.6-7).Theflapisthensecuredtothe“neodentate”line coveringtheinternalopeningwithinterruptedabsorbablebraided sutures(Fig.6-8).Theauthors’preferenceis2/0–3/0polyglactin.
FIGURE6-8Suturedendorectaladvancementflap
(schematic).
Iftheexternalpartofthetractislarge,thenitisdrainedwithasmall mushroomtipcatheterorleftopenandcuretted.
AnocutaneousAdvancementFlap
Theanocutaneousflapisamodificationofaflappreviouslyusedinthe managementofanalstenosis.Itispreferentiallyusedinthosepatients whoarenotsuitableforarectaladvancementflapprocedurebecauseof extensivescarringofthepararectaltissuesasaresultofchronic supralevatorsepsis,orpreviousfailedattemptsatrepairusingarectally basedflap.Inthesecases,attemptstoraiseanadequatelengthflapare unlikelytobesuccessful,orectropionandkeyholedeformitiesare presentpreoperatively,orthereisahighlikelihoodforpostoperative complicationstooccur.
Technically,anocutaneousadvancementflapisarelativelyeasy procedure,doesnotcarrytheriskofectropion,andcanhelprepair keyholedeformitiesresultingfrompreviousmultiplefistulotomies.
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