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314 A. Herold
Fig. 5 Exposure of the dorsal
fistula wall. Separation of the
muscle from the anoderm,
lateral fat and scar to achieve
better placement of the sutures
Fig. 6 Complete excision of
all fistula tissue
performed accurately. To achieve sufficient mobility, the sphincter muscle is
mobilized from the anoderm and the external ischioanal fat. Generally, only a
few millimeters of excision suffice (Fig. 5).
The dorsal aspect of the granulous tract is completely excised, including all
cavities, and leaving only healthy tissue behind. This gives the surgeon a perfect
view of the fistula, enabling a complete excision of all granulation and scar tissue.
This is the only technique besides fistulectomy alone, where all the granulous fistula
tissue can be meticulously excised. Maybe this is one important factor to achieve
healing later on. Due to the inflammation and chronic sclerosis in most cases,
separation of the internal and external sphincter is not possible, but for reconstruction, such a separation is not necessary (Fig. 6).
Reconstruction starts at the proximal part of the dissection; the first stitches are
placed at a 45
angle to the fistula axis to adapt the uppermost tissue. With every
19 Utility of Adding Sphincter Reconstruction to Fistulotomy/Fistulectomy 315
Fig. 7 Reconstruction of the
proximal muscle (stitch1)
Fig. 8 Reconstruction of the
proximal muscle (stitch2)
muscle stitch, you take a deep bite to both sides – external to internal (Fig. 7) and
internal to an external direction (Fig. 8) – and adapt the muscle by suturing a firm
knot. The knots are placed on the outside of the sphincter, so as not to interfere with
the healing on the inside. The stiches are placed 4–5 mm in distance from each other.
Depending on the length of the sphincter that has to be adapted, 2 to 6 single sutures
will be necessary. Figures 9 and 10 show the second stitch of the muscle. In this
manner all muscle stitches were carried out.
After two to three stitches through the muscle, the upper proximal part of the
anoderm, or distal part of the rectal mucosa around or above the dentate line, is
approximated, so the anoderm will also be reconstructed stepwise (Fig. 11). With
this suture you should take a small bite of the underlying internal sphincter muscle to
prevent small cavities under the anoderm. We prefer closing and knotting each suture
immediately after stitching and so stepwise reconstructing the anal canal. It can also
316 A. Herold
Fig. 9 Reconstruction of the
proximal muscle (stitch3)
Fig. 10 Reconstruction of
the proximal muscle (stitch4)
Fig. 11 Adaptation of the
anoderm
19 Utility of Adding Sphincter Reconstruction to Fistulotomy/Fistulectomy 317
Fig. 12 Suturing the distal
part of the sphincter muscle
(m. sphincter ani externus
subcutaneous) (stitch 1)
Fig. 13 Suturing the distal
part of the sphincter muscle
(m. sphincter ani externus
subcutaneous) (stitch 2)
be done if you let all sutures loose and knot them all together finally at the end of the
procedure.
The retractor is then careful ly stepwise closed, so that the next part of the muscle
can be sutured, followed by the anoderm of this section. Polydioxanone sutures
(PDS) sized 0 or 2 0 were used for muscles and the knot lies lateral at the external
side of the muscle. Vicryl sized 0 or 2 0 is used for the anoderm and the knot lying
medial at the internal side of the anal canal.
Coming to the distal superficial part of the reconstruction, we switch to Vicryl for
the m. sphincter ani externus subcutaneous, because the very stiff PDS material
might disturb the healing of the outside skin. Sometimes at this end of the sphincter,
you will find tissue appearing like a fascia. This might enable more stable suturing
(Figs. 12 and 13).
Finally, the entire sphincter complex is anatomically reconstructed, and the distal
wound of the ischioanal space is left open to allow for lateral drainage (Fig. 14). The
operation is completed with a soft gauze dressing. No intra-anal plug is necessary.
318 A. Herold
Fig. 14 Final aspect of the
completed reconstruction.
(Source: Herold
A. Fistulektomie und primäre
Sphinkterrekonstruktion.
coloproctology 41, 267–271
(2019). https://doi.org/
10.1007/s00053-019-0365-x)
No special wound care is recommended, and the wound can be rinsed with a
shower using tab water starting on the first day after the operation. The patient is
allowed to walk, but physical exercises should be restrained for 4–6 weeks. In our
hands only 1% of patients were treated under die security of a covering sigmoid
stoma. But also, this cannot guarantee safe healing, but in any disturbance of healing
and suture rupture, it would be easier to handle. Our recommendation is to create a
stoma if the plan is to reconstruct more than 2/3 of the sphincter complex.
5 Results
In our experience with complete fistulectomy and primary sphincter reconstruction
in more than 400 procedures, the primary healing rate was 88%. When adding a
revisionary surgery with a second sphincter repair, this percentage reaches 96%
(Seyfried et al. 2018 ). The procedure was done in a median time of 21 min ranging
from 12 min to 62 min. The median postoperative hospitalization in these patients
was 2–3 days. Short follow-up visits are recommended, because if any rupturing of
the sutures will appear, it will be within the first 4 weeks. If any dehiscence of the
sutures is detected at the time of the first follow-up visit, a reoperation might
be indicated. During this procedure, the muscle again can be sutured and approximated as in the first operation. In our experience in 32 patients with muscle
dehiscence, 28 of those patients could be repaired and healed without further
complications upon the second reconstruction. In four of these patients, the muscle
could be sutured again and healed, but the fistula proximal of the reconstructed
sphincter persisted. All recurrences were persisting fistulas. No real recurrence after
primary healing occurred.
Because of the large number of patients, it was possible to separate subgroups and
evaluate those in detail. In cases with up to 3 cm of the reconstructed sphincter, the
19 Utility of Adding Sphincter Reconstruction to Fistulotomy/Fistulectomy 319
recurrence and dehiscence rate was below 15%, but in cases where more than 3 cm
was affected, the dehiscence rate only rose to 50%, with surprisingly no recurrences.
But this group of high transsphincteric and suprasphincteric fistulas represents only
less than 5% of all operated patients. A comparable evaluation was done using the
percentage of the affected sphincter. This is much more precise in relation to each
individual patient, e.g., if 1 cm of the dorsal sphincter in a man is 20% or less of his
sphincter complex and 1 cm of the ventral sphincter is 50% of the sphincter muscle
in a woman. In our experience this means that if less than two-thirds of the sphincter
complex is reconstructed, then the dehiscence rate is below 12%, and recurrences
occurred in less than 10%. This is a highly signifi cant correlation concerning healing
rates ( p ¼ 0.0114). Only when more than 70% of the sphincter is affected, dehiscence and recurrence rate rise to around 40%. Again, this group represents 8% of
patients of the total cohort. Conversely in 92% of our patients, very low recurrence
rates could be achieved.
This also demonstrates that the amount of affected muscle in millimeters is not as
precise as the percentage of affected muscle in percent.
With multivariant evaluation, gender and location of the fistula had a significant
influence on the outcome, whereas the number of revisions, patient age, prior anal
operations, and concomitant medication did not.
In a subgroup of patients, we ruled out the results concerning the continence.
Even at baseline, before the operation 10% of patients reported some minor degree
of continence disorders. After the operation, continence disorders were observed in
23% including 15% suffering from flatus incontinence, 10% suffering from liquid,
and 1 patient from solid stool incontinence. But all patients do accept these minor
problems because it is of minor influence on their quality of life and they were
suffering much more discomfort and inconvenience during having a fistula.
In our large cohort of patients, it was possible to demonstrate the practicability
and to achieve very promising initial results, superior to those reported in advancement flaps, fibrin glue, or anal fistula plugs. By using this technique, one normally is
in fear of a rupture of the muscle sutures, but this occurred only in a minority of
procedures. In our experience, all of these insufficiencies could be repaired in a
secondary operation, if performed in the first two to four postoperative weeks. So,
this concern and fear – not present in other procedures, e.g., flap-procedures – is
altogether not neglectable but must be weighed against the benefit of a low recurrence rate, and it can be solved in a second operation.
Meanwhile these very promising good results could be proven by many other
study groups (Table 1).
6 Conclusion
Fistulectomy with primary sphincter reconstruction is a feasible procedure resulting
in a low recurrence rate. No other procedure has shown better results in transsphincteric fistulas. Continence disorders are of minor concern for these patients.
320 A. Herold
Table 1 Results of several studies
Author Year n Type Dehis. Recurr. Cont. Healing
Parakash (Ind) 1985 120 Distal – 2.5% – 97%
Lux (D) 1991 46 Mixed 0% 0% 20% (1 + 2
Christiansen (DK) 1995 14 Mixed – 15% 21% (1 + 2
Gemsenjäger
(CH)
Lewis (GB) 1996 32 Mixed – 9.5% – 90%
Roig (E) 1999 31 Mixed 4% 10% 24% (1 + 2
Perez (E) 2006 30 Mixed – 7% 17% 93%
Ruppert (D) 2010 153 Trans 6% 21% 12 88%
Herold (D) 2009 148 Mixed 4% 15% 18/14/1.5 94%
Kraemer (D) 20211 38 Mixed 3% 4% 5 97%
Arroyo (E) 2012 70 Trans 0% 8.5% 17 91%
Ratto (I) 2015 72 Mixed 1.5% 4.1% /14/1.4 96%
Hirschburger (D) 2014 50 Mixed 0% 12% /17/2.7 88%
Herold (D) 2014 285 Mixed 4.2/
Seyfried (D) 2018 439 Mixed 7.5% 4.2% 11/1.5/0 96%
Litta (I) 2019 203 Mixed – 7% 13% 93%
De Hous (B) 2020 24 Distal 25% 4.2% – 96%
n, number of patients; type, type of fistula; distal, distal third of the sphincter; trans, transsphincteric;
mixed, all types of fistulas; dehis., dehiscence; recur., recurrence; cont., continence disorder; 1,2,3,
incontinence for gas, liquids, solids; healing, overall healing rate)
1996 21 Mixed 5% 5% 5 95%
0%
6.7/
3.9%
no 3
) 100%
) 86%
) 89%
95%
7 Cross-References
▶ Anorectal Anatomy Related to Anal Fistula and Abscess
▶ Integration of Surgery with Medical Therapy in Treating Anal Fistulas
▶ Treatment by Over-the-Scope-Clip
▶ Utility of Marsupialization Following Anal Fistula Surgery
References
Arroyo A, Pérez-Legaz J, Moya P et al (2012) Fistulotomy and sphincter reconstruction in the
treatment of complex fistula-in-ano: long-term clinical and manometric results. Ann Surg 255:
935–939. https://doi.org/10.1097/SLA.0b013e31824e9112
Christiansen J, Rønholt C (1995) Treatment of recurrent high anal fistula by total excision and
primary sphincter reconstruction. Int J Colorectal Dis 10:207–209
De Hous N, Van den Broeck T, de Gheldere C. Fistulectomy and primary sphincteroplasty (FIPS) to
prevent keyhole deformlty in simple anal fistula: a single-center retrospective cohort study. Acta
Chirurgica Belgica. https://doi.org/10.1080/00015458.2020.1753151
Gemsenjäger E (1996) Results with a new therapy concept in anal fistula: suture of the anal
sphincter. Schweiz Med Wochenschr 126(47):2021–2025
19 Utility of Adding Sphincter Reconstruction to Fistulotomy/Fistulectomy 321
Herold A (2014) Fistulectomy with primary sphincter reconstruction. In: Abcarian H (ed) Anal
fistula: principles and management. Springer, New York. https://doi.org/10.1007/978-1-4614-
9014-2_10
Herold A (2019) Fistulektomie und primäre Sphinkterrekonstruktion. Coloproctology 41:267–271.
https://doi.org/10.1007/s00053-019-0365-x
Herold A, Joos A, Hellmann U, Bussen D (2009) Treatment of high anal fistula: is fistulectomy with
primary sphincter repair an option? Colorectal Dis 11:15
Hirschburger M, Schwandner T, Hecker A et al (2014) Fistulectomy with primary sphincter
reconstruction in the treatment of high transsphincteric anal fistulas. Int J Colorectal Dis 29:
247–252. https://doi.org/10.1007/s00384-013-1788-4
Lewis A (1996) Anal fistula. In: Phillips RKS, Lunniss PJ (eds) Surgical evaluation and manage-
ment. Chapman and Hall, London, pp 81–86
Lux N, Athanasiadis S (1991) Functional results following fistulectomy with primary muscle suture
in high anal fistula. A prospective clinical and manometric study. Chirurg 62:36–41
Ommer A, Herold A, Berg E et al (2011) Cryptoglandular anal fistulas. Dtsch Arztebl Int 108:707–
713. https://doi.org/10.3238/arztebl.2011.0707
Parkash S, Lakshmiratan V, Gajendran V (1985) Fistula-in-ano: treatment by fistulectomy, primary
closure and reconstitution. Aust N Z J Surg 55(1):23–27
Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63:1–12
Perez F, Arroyo A, Serrano P et al (2006) Randomized clinical and manometric study of advance-
ment flap versus fistulotomy with sphincter reconstruction in the management of complex
fistula-in-ano. Am J Surg 192:34–40. https://doi.org/10.1016/j.amjsurg.2006.01.028
Ratto C, Litta F, Donisi L, Parello A (2015) Fistulotomy or fistulectomy and primary
sphincteroplasty for anal fistula (FIPS): a systematic review. Tech Coloproctol 19:391–400.
https://doi.org/10.1007/s10151-015-1323-4
Ritchie R, Sackier J, Hodde J (2009) Incontinence rates after cutting seton treatment for anal fistula.
Colorectal Dis 11:564–571
Roig JV, Garcia-Armengol J et al (1999) Immediate reconstruction of the anal sphincter after
fistulectomy in the management of complex anal fistulas. Colorectal Dis 1:137–140. https://
doi.org/10.1046/j.1463-1318.1999.00021-x
Seyfried S, Bussen D, Joos A, Galata C, Weiss C, Herold A (2018) Fistulectomy with primary
sphincter reconstruction. Int J Colorectal Dis 33:911–918. https://doi.org/10.1007/s00384-
018-3042-6
Utility of Marsupialization Following Anal Fistula Surgery
Isaac Seow-En and Francis Seow-Choen
Contents
1 Introduction . ............... .................................................................. 324
2 Marsupialization ................................................. ............................ 324
3 Clinical Evidence ............................................................................ 325
4 Conclusion ................................................................................... 326
References ............................ ............................................... ............ 327
Abstract
The surgical management of anal fistula is a perennial challenge. Fistulotomy
leaves a raw un-epithelized wound which can require considerable postoperative
wound care, with risks for bleeding, poor or prolonged healing, and recurrent
sepsis. Marsupialization closes the gap between the exposed fistula tract and skin.
Current evidence consistently proves that marsupialization in addition to
fistulotomy reduces wound healing times, by improving drainage and decreasing
the size and depth of the wound. While it may take slightly longer to perform
operatively, it is an extremely easy and safe technique with a negligible risk
profile. Although not conclusively proven, marsupialization can decrease wound
bleeding and pain and recurrence, as well as improve continence by minimizing
anal deformity. In our experience, the advantages of this technique may be
particularly pronounced in obese patients, for whom anal fistulotomy woun ds
tend to be deeper and more difficult for the patient and health professionals to
manage.
20
I. Seow-En
Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
e-mail: isaac.seow.en@singhealth.com.sg
F. Seow-Choen (
Seow-Choen Colorectal Surgery, Singapore, Singapore
e-mail: seowchoen@colorectalcentre.com
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_22
*)
323
324 I. Seow-En and F. Seow-Choen
Keywords
Fistulotomy · Fistulectomy · Lay open · Marsupialization
1 Introduction
Surgeons have been treating patients with anal fistula for a long time. Hippocrates,
writing in the fifth century BC, argued for the laying open of anal fistula, stressing
that those who are left without treatment die (Adams 1849). More than a millennium
later in 1376, John of Arderne described anal fistula as a troublesome condition that
brought little credit to surgeons as it required prolonged and recurrent treatment
(Arderne 1983). The situation had not improved more than 300 years later, when
Lowe in 1712 stated that complex fistula should not be operated on as anal incontinence was a grave danger (Lowe 1612). The craft of anal fistula surgery was greatly
elevated for the better in the eighteenth century, when Felix the Paris ian surgeon,
after extensive experiments on the inmates of Parisian jails, cured King Louis XIVof
his anal fistula and was very richly rewarded.
Over the last 200 or so years since the time of Felix, our understanding of the
management of anal fistula has improved exponentially. A multitude of different
surgical methods and technologies are now employed by surgeons to approach this
common yet perennially challenging problem. In this chapter we will examine the
simple yet often poorly understood technique of marsupialization for anal fistula.
2 Marsupialization
An extensive and thorough review of the treatment of anal fistula in 1992 discussed
all the available options at that time; marsupialization of anal fistula after lay open
was not routinely practiced nor considered necessary (Seow-Choen and Nicholls
1992). The reference textbook on anal fistula made only two passing remarks on
marsupialization (pp. 77 and 99, Phillips and Lunniss 1996). Nevertheless, an early
retrospective study of 19 consecutive cases lauded the “tissue-conserving” properties of marsupialization and advocated its regular use following fistulotomy (Yang
1992). At least one tertiary US center had been routinely performing fistulotomy
with marsupialization from 1988 as well (Garcia-Aguilar et al. 1996).
Fistulotomy for anal fistula leaves a raw un-epithelized wound which can require
considerable postoperative wound care, with increased risks for bleeding, poor or
prolonged healing, and recurrent sepsis. Efforts to improve these parameters have
rarely proven clinically significant. Marsupialization is a technique most often
described for the treatment of Bartholin cysts following incision and drainage. The
edges of the cyst are sutured to the adjacent tissue to allow unimpeded drainage and
prevent the accumulation of fluid content. This logic can be similarly applied to anal
fistula following fistulotomy. An added advantage is that the laid open fistula tract
can be made more superficial following marsupialization as it closes the gap between