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activeinflammatoryboweldisease malignancy
Priordivisionorinjurytotheinternalsphincterisalsoarelative contraindicationbecausetheintersphinctericspacemaybeobliterated. Patientswithaninternalorexternalfistulaopeningnearoratthe intersphinctericgroovearealsonotlikelycandidatesfortheprocedure, giventhetechnicalchallengesofseparatingthefistulaopeningfromthe groovetoallowforligationofthefistulatract.Certainly,therearefistulas thatmaybemoredifficulttotreatwithahigherfailurerateincluding fistulassecondarytoCrohn’sorradiationandrectovaginalfistulas.Given thenoveltyoftheprocedure,relativelyfewstudieshavebeenperformed inthesefistulasubtypes.
PREOPERATIVEPLANNING
Asuccessfultreatmentofcomplexfistula-in-anoutilizingtheLIFT operationisdoneinstagesandbeginswithpreoperativelydefiningthe fistulaanatomyandadequatelydraininganyperianalsepsis.Theauthor routinelydrainsthefistulatractwiththeinsertionofasetonatleast8 weekspriortoperformingtheLIFT.Setondrainageallowsforthe eliminationofsepsisandpromotesfibrosisofthefistulatract,greatly facilitatingdissectionintheintersphinctericspaceaswellasligationof thetract.Theauthorstudiesthefistulawithanendoanalultrasound, oftenaidedwiththeinjectionofhydrogenperoxideintotheexternal opening.Theultrasoundishelpfulinthepreoperativediscussionofthe variousoptionsavailabletotreatfistula-in-ano,aswellasidentification ofhighblindtractsorundrainedsepsis.
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LIFTisperformedasanoutpatientoperation;bowelpreparationcan belimitedtoenemas.However,afullmechanicalcatharticbowel preparationcanbeundertakenatthesurgeon’sdiscretion.No preoperativeantibiotictherapyisrequired.

SURGERY

Thepatientisplacedinthepronejackknifepositionundergeneral anesthesia;tapeisusedtoretractthebuttocks.Theperianalareaisthen preppedanddraped.Alocalanestheticisinfiltratedinascleanafieldas possible,andabilateralpudendalnerveblockisperformed.Athorough examinationunderanesthesiaisundertakentoexcludeanysepsis presentandtoconfirmtheanatomy.
Technique
toidentifytheinternalopening.
peroxideintotheexternalopeningcanbehelpfulinaiding identification.
(Fig.9-1):
sphincterongentlestretchwiththeoperatinganoscopeandusingthe backofadissectingforcepstodemonstratethegroove.
(CooperSurgical,Inc.,Trumbull,CT)canbeutilized.Rojanasakulhas alsomanufacturedhisownLIFTretractors.
FIGURE9-1Theskinincisionismarkedoutoverlyingthe
intersphinctericgroove.Thefistulaprobeisexitingthrough theinternalopening.
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proximal(deep)tothefistulatract.
attentiontohemostasisandtoavoidinjurytothesphinctermuscles.
theintersphinctericspaceasthedissectionproceedsproximally,aidsin exposure.
intersphinctericgroovetoidentifythetract.
define.
tracttomoreclearlydelineateit.
FIGURE9-2Thefistulatract,withtheprobethroughitfor
easeofidentification,isdissectedfreeintheintersphincteric space.
placedoneithersideofthetractandaportionofthetractcanbe removed,althoughsimpledivisionmaybepreferred.
entranceintotheexternalandinternalsphincteroneachsideofthe intersphinctericspace.Thismaneuverisdonewithanabsorbable suture,oftenutilizingaUR6needle.
ensuretherehasbeenasecureligationontheexternalsphincter portionoftheintersphincterictract.
ensuretheclosureofthetracttraversingtheinternalsphincter.
FIGURE9-3Theprobeisremoved,andfistulatractis
ligatedanddivided.
sourceremainsandtheopeningintheanalcanalclosedwithfigure-of­eightsutureorleftopen.
curettedtoremovethegranulationandtheepithelializedtissue.
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suture.
sutures.
AnumberofvariationstotheoriginalLIFTtechniquehavebeen described.Thesealternativesincludesimpleligationofthefistulatract,
excisionoftheintersphinctericportionofthetract,concurrentinternal sphincterotomyinvolvingtheinternalopening,insertionofa bioprostheticfistulaplugintotheportionofthetractcrossinginthe internalsphincter,andinsertionofabioprostheticmeshintothe intersphinctericspace.LIFTwithconcurrentinsertionofbioprosthetic plug(LIFT-Plug)orbioprostheticmesh(BioLIFT)isdescribed.
IntheLIFT-Plug,thesamedissectionisundertakeninthe intersphinctericplane.Oncethetracthasbeendivided:
Theportionofthetractinvolvingtheinternalsphincterisligated. Theportionofthetractextendingthroughtheexternalsphincteris
curettedoutclean. Abioprostheticfistulaplugisthenbroughtthroughthetractfromthe
intersphinctericspacetotheexternalopening.Theplugissecuredtothe externalsphincter.
Thewoundandtheintersphinctericspacearethenclosed.
TheBioLIFTissimilarlyperformed. Thedissectionisextended1–2cmcranialtothefistulatract,andwide
enoughtoaccommodateasmallpieceofmesh. Thefistulatractisdividedintheintersphinctericspace.
Theportionofthetractinvolvingtheinternalsphincterisligated. Asmallpieceofbioprostheticmeshiscuttosizeandlaidwithinthe
intersphinctericspace.Themeshoverlapsthefistulatractby1–2cmand issecuredtotheexternalsphincterwithabsorbablesutures.
Thewoundisreapproximatedattheouteredgeoftheintersphincteric grooveoverthemeshafterthemeshistrimmedtofitinthe
intersphinctericspace.
POSTOPERATIVEMANAGEMENT
Patientsaredischargedwithappropriateanalgesiaincludingoral acetaminophen,paracetamol,nonsteroidalanti-inflammatorydrugs,or opioid-basedanalgesics,aswellastopicalanesthetics.Patientsare instructedtopreventconstipationwiththeuseoffibersupplementation andlaxatives.
Patientsareusuallyseenapproximately1monthafterthesurgeryand dependingontheprogressmade,asecondfollow-upvisitisscheduled approximatelythe2monthslater.

COMPLICATIONS

ComplicationsafterLIFTcanincludebleeding,abscessformation,failure toheal,recurrentfistula,woundseparation,andurinaryretention. Fortunately,aneedforurgentreoperationandalterationofcontinenceis rare.

RESULTS

AnumberofauthorshavepublishedtheirresultswiththeLIFT proceduresinceitsdescriptionin2007.Table9-1summarizestheresults ofthesestudies.Majorityofthestudiesarecaseseriesandrepresenta varietyofdifferenttechniques.Follow-upisvariable,althoughseveral studiesnotefollow-upgreaterthan1year.Reportedsuccessratesvary from47%to94%.Althoughsuccessratesvary,thereislittlechangein continencewiththeprocedure.
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TABLE9-1 ResultsoftheLIFTProcedure
Leadauthor Year
Study
type
Sample
size
Primaryhealing
(%)
Follow-up
(mo)
Pathasarathi 2016 P 167 94 12.8
Khadia 2016 R 52 71 6
Chen 2016 R 43 83.7 2.5
Han 2016 RCT 235 94–84 6
Hall 2015 P 43 79 3
Schultze 2015 R 75 88 14.6
Ye 2015 R 43 87 15
Bastawrous 2015 R 66 71 5.25
Madbouly 2014 P 70 94.2 12
Tan 2014 R 13 68.8 6.5
Gingold 2014 P 15 60 11.2
Sirikurnpboon 2013 P 41 81–85 5
Liu 2013 R 38 61 26
Sharma 2013 R 18 83 3
vanOnkelen 2013 P 22 82 19.5
Lehmann 2013 P 15 47 4
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