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FIGURE7-16A.Entirefistulatractunroofedandcuretted.
B.Marsuplizationofthewound. (AdaptedfromGordonPH,NivatvongsS.Anorectalabscesses
andfistula-in-ano.In:PrinciplesandPracticeofSurgeryfor theColon,Rectum,andAnus.CRCPress,2007:191–234,with permission.)
SpecialConsiderations
IntersphinctericFistulawithaHighBlindTract
Mostintersphinctericfistulasarelow,onlyinvolvingasmallportionof theinternalsphincter.However,somepatientswillhavean intersphinctericfistulawithahighblindtract(Fig.7-17).Insuchacase, theentiretractshouldbedividedbythefistulotomy.Formostpatients, thisfistulotomycanbeperformedwithanimpunitytounrooftheabscess orfistulatothesuperiorextentoftheintersphinctertractalltheway
downtothecryptatthedentateline.Occasionally,thetractcontinues distaltothedentateline.Thisshouldbeopenedtoguaranteeacomplete resolutionoftheabscess.
FIGURE7-17Intersphinctericfistulawithhigh-blind
tract. (AdaptedfromGordonPH,NivatvongsS.Anorectalabscesses
andfistula-in-ano.In:PrinciplesandPracticeofSurgeryfor theColon,Rectum,andAnus.CRCPress,2007:191–234,with permission.)
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HorseshoeFistula
Bilateralexternalopeningsareduetoahorseshoefistulathatcanbein theintersphinctericortranssphinctericplane.Theinternalopeningis mostcommonlyintheposteriormidline,whereasananteriormidline openingisrare.Originatinginaposteriormidlineanalgland,thetract extendsanteriorlyinaU-shapedconfigurationandlaterallypiercesthe skin.Overtheyears,surgeryforhorseshoefistulashasdramatically evolvedtowardamoreconservativeapproach.Theclassicprocedure,the Hanleyprocedure,requiredidentifyingandunroofingallthetracts, whichinmostcasesresultedinthedivisionofextensivemuscle,soft
tissues,andskin(Fig.7-18).Recoveryfollowingsuchaprocedurewas prolongedwithpossiblelong-lastingdisability.
FIGURE7-18Hanley’stechniqueforincisionand
drainageofahorseshoeabscess. (AdaptedfromGordonPH,NivatvongsS.Anorectalabscesses
andfistula-in-ano.In:PrinciplesandPracticeofSurgeryfor theColon,Rectum,andAnus.CRCPress,2007:191–234,with permission.)
Currently,whenapatientpresentswithahorseshoeabscess,more conservativeapproachesareused.AmodifiedHanleyprocedure, consistingofposteriordrainagethroughtheanococcygealligament; posteriormidlineincisionoftheinternalsphincterandincitinganalduct; andincisionstothebilateralischiorectalfossaecanbeperformed. Alternatively,alimiteddrainagefortheincitinganalglandcanbe performedviaaninternalsphincterotomy,followedbyincisionstodrain bilateralischiorectalfossaeabscesses.Ifthisisarecurrenthorseshoe abscess,acuttingornoncuttingsetoncanbeplacedintheposterior midlineopening,withsubsequentdefinitivemanagementofthefistulain thefuture.Finally,anevenmoreconservativeapproachhasbeen describedthatinvolvesdissectionintheposteriormidline intersphinctericspacetoidentifytheanalductsource,withsubsequent continuationintothedeeppostanalspacefordrainageandcurettage (Fig.7-19AandB).Thelattertechniqueisadvantageousbecauseithasa shortlearningcurve,dealswiththefistulainonesurgery,anddoesnot affectcontinence.
FIGURE7-19A.Identificationoftheinternalopeningof
thehorseshoefistula.B.Internalopeningbeinglaidopenwith minimaldivisionofsphinctermuscles.
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CuttingSetonTechnique
Setonsareusedtotreatfistulaswhenaprimarylayopentechniqueisnot advisable.Theprincipleofacuttingsetonisthatitallowsgradual divisionofthesphinctermuscles,therebyallowinghealingtooccuras furthercuttingisperformed.Intheeventofhavingafistulatractthat encompassesmoresphinctermusclebulkthanisdeemedsafetodivide andacuttingnon–sphincter-sparingapproachisbelievedtobethebest treatmentstrategy,thenacuttingsetonmaybeconsidered.This precautionmaybethecaseforalow-transsphinctericfistulaandfor somerecurrentfistulasthatfailedsphincter-sparingapproaches.
Oncethefistulaisexaminedandthetractissuccessfullyprobed(as describedabove),onlytheskinandsubcutaneoustissuesaredivided usingabladeandelectrocuatery.Aprobewithaneyetothreadsuture material(e.g.,3.0vicryl)isused.Oncethesutureislaidwithinthetract, itistiedtothechosensetonmaterial.Manymaterialshavebeen describedforuseasacuttingseton,withthemostcommonbeing nonabsorbablesuturessuchassilk.Oncethecuttingsetonispulled throughtheentiretract,thesutureiscut.Thesetonisthensecuredso thatitsnugglyencirclestheinvolvedmusclewithextramaterialleft hangingtoenabletighteningofthesetonintheclinicsetting(Figs.7-20 to7-22).Itistheauthors’preferencetotightenthesetonintheclinic usingrubberbandligatureseverymonth,becauseenoughtimeshould lapsetoallowforhealinginbetweentighteningsessions.
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FIGURE7-20Metalprobewithaneye-openinginserted
withinthefistulatract.Theeyeisthreadedwitha3.0suture.
FIGURE7-21Materialtobeusedascuttingseton(e.g.,O-
silk)issecuredtothe3.0sutureandpulledthroughthefistula tract.
FIGURE7-22Theskinandthesubcutaneoustissue
overlyingthefistulatractaredividedwithelectrocauteryand thecuttingsetonissecuredsnugglyaroundthesphincter muscle.
StagedFistulotomy
Analternativetolayopentechniqueisastagedfistulotomy.Oncethe internalandexternalopeningsareidentifiedandaprobeisinserted,a setoncanbeinsertedasdescribedabove.Thesetonissecuredloosely aroundthefistulatract.Itisthoughtthatthesetonwillpromotefibrosis, thusholdingthemusclefiberstogether.Anotherbenefitofthesetonis thatitallowsthesurgeontobetterdelineatetheamountofmuscle beneaththefistulatract.Withthepatientanesthetized,thesurgeon cannotalwaysbecertainoftheamountofmusclebeneaththetract. Reexaminationinanawakepatientmayrevealadequatemuscle remainingabovethelevelofthefistulatract.Finally,anotheradvantage ofusingthesetonisthatitactsasadrain.After4–6weeks,iftheamount ofmuscleinvolvedisdeemedminimalorappropriate,thefistulotomyis performed.Atthispoint,itisthoughtthatthecutendsdonotretractdue tothefibrosiscreatedbytheseton.However,thistechniqueshouldonly beusedwhenminimalmuscleisinvolved.Resultsofthisprocedure comparedwiththoseoffistulotomybylayopentechniquedemonstrate thatthereisnodifferenceinfunctionwithdelayedfistulotomy(Fig.7-
23).
FIGURE7-23Thesetoninplace2weeksaftertheinitial
surgery.
SeparatedSetonMethod
Toovercometherisksofdeformity,delayedhealingandriskof compromisedcontinenceassociatedwithacuttingseton,Akagietal. modifiedanapproachfirstdescribedbyParkasPark’sfistulectomy (describedinthenextsection).Akagietal.describeamodifiedcutting setonprocedurefortranssphinctericfistulas;oncethetractisfully identifiedandaprobeisplacedwithinit(asdescribedintheearlier sections),asmallincisionismadeintheintersphinctericgrooveandthe fistulatractistransectedintotwoportions.Acuttingsetonisinserted intothefistulatractbetweentheinternalopeningandthetransectedend withintheintersphinctericgroove,whereasadrainingsetonisinsertinto thetractbetweenintersphinctericgrooveandtheexternalopeningasa looseseton.Theskinandsubcutaneoustissuesaredividedpriortothe incisiontosnugglysecuretheinternalcuttingseton.Thecuttingsetonis thentightenedatregularintervals.Theexternaldrainingsetonis removedafterthefistulaiscompletelyseparated(Fig.7-24to7-26). Tighteningcanbeundertakenintheofficeusingarubberbandligatorto sequentiallyapplyrubberbandsbetweentheresidualmuscleandthe setonknots.
FIGURE7-24Identificationoftheentiretract(A)andits
separationwithintheintersphinctericplane(B).
FIGURE7-25Insertionofseparatesetonswithinthe
internal(A)andexternalportionsofthefistulatract(B).
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