continence,themuscle,subcutaneoustissues,andtheskinthatlay beneaththetractaredivided(Figs.7-27to7-30).

Theprimarytractisthencarefullyexcised,sothattheentirefistulais excisedwithoutanydamagetothesphincters(Fig.7-31to7-34).Usually, thisprocedureisfollowedbyeithersimpleclosureoftheinternalopening oranadvancementflapisperformed.Thetechniqueofadvancementflap isdescribedinchapter40.

Patientsaretypicallydischargedonthesamedayoftheprocedure. However,forpatientswhoundergoanextensivefistulotomyforalong fistulatract,ashortperiodofhospitalizationmayberequiredfor adequatepaincontrol.Postoperatively,patientshaveanunrestricteddiet andanalgesicsaregivenasnecessary.Inmostcases,antibioticsarenot necessary,andareonlyusedifthereisextensivecellulitisfroma concomitantabscess.Patientsareinstructedtomaintainahigh-fiber diet,andstoolsoftenersareprescribedasneeded.Patientsareseeninthe outpatientclinic4–6weeksfollowingtheprocedure.

Priortodischarge,patientsaregivendetailedinstructionsregarding woundmanagement.Dailypackingwithgauzeisunnecessaryandpainful forpatients;thus,werecommenditsavoidance.However,patientsare taughtthatthegoalistoachievehealingfrominsidethewoundtothe outsidewithoutprematurehealingoftheopposingskinedges.Warmsitz bathsorusingwarmwaterwithawaterpikorshowerhead,threetimesa dayandaftereverybowelmovementarerecommendedtokeepthe woundsclean.

Earlycomplicationsfollowingfistolotomyandfistulectomyare infrequent.Prematurehealingoftheskincancauseswellingor accumulationofpusinthewound.Ifthisoccurs,thewoundhastobe reopened.Thus,patientsshouldbeinstructedthatthewoundmighttake amonthtohealandifitprematurelyclosestheyareadvisedtoreturnto clinic.

Forsimplefistulas,includingintersphinctericandlow-transsphincteric fistulas,fistulotomyisveryeffective.Typicalhealingtimefollowinga fistulotomyis6–8weeks,butthistimeframecanbeshortenedby marsupializationofthewound.Recurrenceandincontinencearethetwo majorcomplicationsoffistulasurgery.Forfistulotomy,recurrencerates areacceptablylow.Recurrenceratesvarydependingonthereport; however,theyrangebetween0%and32%(Table7-2).Intheauthors’ experience,including156patientswithamedianfollow-upof9.1years, fistulotomyforintersphinctericandlow-transsphinctericfistulasresulted ina19.3%recurrencerate.Fortunately,forappropriatelyselected patients,fistulotomycanresultinminimaltonoalterationofcontinence. Thereportsintheliteraturearevariedwithfecalincontinencerates between0%and39%andvarieddefinitionsofincontinenceandfollow­upperiod.Inourexperiencewithfistulotomy,overamedian9.1-year follow-up,17.6%ofpatientshadanalterationintheircontinence(median Wexnerscoreof0,range0–15);however,onlytwopatients(1.7%)had moderatetoseveresymptoms.Furthermore,forthesepatientswith alteredcontinence,medianFecalIncontinenceQualityofLifescores (range1–4;4=notaffected)werelifestyle4.0(2.0–4.0);coping4.0 (1.33–4.0);depression4.0(1.30–4.0);andembarrassment4.0(1.33–