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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1056_Библиотеки_им_академика_М_И_Перельмана.pdf
396 P. Meinero
attributes the recurrence after treating simple anal fistulas, with traditional techniques, to the presence of secondary tracts in about 20% of cases (Sangwan et al.,
1994). This is why we use the fistuloscope even in case of simple fistula, but only to
ascertain the absence of secondary tracts or abscess cavities. If they are not found, we
simply perform a fistulotomy, obviously if the sphincter apparatus is not or only
slightly involved. In the rare cases where a secondary tract or an abscess are found,
we treat them using the electrode (VAAFT operative phase), while the main tract is
treated with the fistulotomy.
3.1 Preoperative Assessment
Two weeks before surgery, the patient is asked to do routine blood tests, an
electrocardiogram, and, if smoker, a thoracic X-ray. To appraise the fistula “anatomy,” we prefer the magnetic resonance imaging (MRI), because it is more reliable
and accurate than ultrasound (US). But sometimes, we can do without previous
diagnostic exams, because the fistuloscopy is a part of VAAFT procedure. So, we
already have a diagnostic tool which is intrinsic in the surgical technique itself. A
detailed and specific informed consent is given the patient 1 week before surgery in
order that he may carefully read and well understand the content and sign it without
any outside influence. Once the patient is admitted in the hospital, the informed
consent is discussed again with the surgeon.
No intestinal preparation is done. A single dose of 2 g of cefazolin is intravenously administrated half an hour before starting surgery. Spinal anesthesia is made.
More rarely a general anesthesia is required, depending on the patient’s clinical
condition and/or his will. A local anesthesia is made less frequently, given that the
patients we treat are almost all suffering from very complex anal fistulas. However,
in case of recurrence of a simple fistula previously treated with a traditional technique, the local anesthesia with a mild sedation can be made.
The patient is supine and placed in the lithotomic position with both arms out. But
occasionally, if the internal fistula opening is located anteriorly, a jackknife position
is preferred. The entire operation is recorded and a DVD is made and given the
patient once discharged.
4 VAAFT Procedure
VAAFT is mostly performed in Outpatient Surgery Centers (Day Surgery), and the
patient is normally discharged the same day of surgery. More rarely, an overnight
stay is required. The operation can be performed under either spinal or general
anesthesia, depending on the infection extension and the parameters of the patient.
Two grams of cephalosporin are given I.V. as a preoperative prophylaxis, half an
hour before starting the surgical procedure. In preparation of surgery, the
fistuloscope is connected first to a cold light fountain (KARL STORZ POWER
LED 300) with a fiber optic light cable. Then, a sterile tube, used in conjunction with
25 VAAFT 397
a suspended bag containing 3000 ml of irrigation fluid (glycine and mannitol 1.0%
solution), is connected via the lateral luer stopcocks. Once all connect ions, the white
balance, and the focus have been done, you can start the procedure.
As mentioned above, VAAFT comprises two phases, a diagnostic and an oper-
ative phase.
4.1 Diagnostic Phase (Fistuloscopy)
One of the characteristic of VAAFT technique is the possibil ity to make a diagnosis
immediately before starting the surgical treatment. All we know that the complex
anal fistulas can change their structure overtime. So, it is very important having a
precise definition of the “fistula map” during the surgical treatment.
Aims of the diagnostic phase are to precisely define the main fistula tract, identify
possible presence of secondary extensions and/or abscess cavities, and correctly
locate the internal fistula opening. Very often, the number of the external openings
can be more than one, especially in case of complex anal fistulas. Therefore, the skin
of the external opening(s) is/are removed in order to enlarge the external opening. In
this way, the insertion of the fistuloscope is facilitated. With the washing solution
running, the fistuloscope is inserted through the external opening(s). This is the
beginning of the fistuloscopy. Irrigation with a glycine and mannitol 1.0% solution
has proven useful in exposing the external fistula opening and its main tract, which is
clearly demonstrated on the video screen (Fig. 4).
During the diagnostic phase, proper orientation of the fistuloscope is ensured with
the blunt obturator. Once the obturator itself has been introduced, the halfmoonshaped tip appears in a 6 o’clock position on the lower part of the screen (Fig. 5).
The 6 o’clock position must be maintained throughout the surgical procedure just
to ensure an optimal orientation, especially when other secondary pathways or
Fig. 4 The fistuloscope is
inserted through the external
opening
398 P. Meinero
Fig. 5 Once the obturator has
been introduced, the
halfmoon-shaped tip appears
in the lower part of the screen
Fig. 6 Once the fistuloscope
has been introduced, the
fistula pathway appears on the
screen
Fig. 7 Two typical examples
of the “fork” which are found
in case of secondary tracts
abscess cavities are found, condition for which the sense of direction cou ld be lost
(Fig. 6).
The “entrance” of a possible secondary tract(s) appears along the course of the
main pathway as a “fork” with two holes, of which one is the main tract “entrance”
and the other leads to the secondary tracts and/or abscess cavity (Fig. 7).
25 VAAFT 399
Fig. 8 The internal opening is identified
Any tissue debris which may obscure the fistula tract can be removed with the
small-diameter optical forceps passed through the working channel, always under
visual guidance. Once inside the fistula, the pathway(s) appear(s) clearly on the
screen. To prevent rupture of the fistulous tract, only gentle pressure should be
applied while advancing the fistuloscope at a slow pace. The rigid shaft of the
fistuloscope (patented design) and the finger placed in the anal canal are moved in
a well-synchronized manner to “straighten out” the fistulous tract. This maneuver
has been shown to facilitate advancement of the fistuloscope, particularly in the
presence of twisted tracts or horseshoe fistulas. Complete muscular relaxation of the
surrounding tissues, as a result of spinal or general anesthesia, is very helpful to
smoothly accomplish the above maneuver. Thanks to the removable handle we can
give a force to the fistuloscope with slowly movements, up-down, left-right, in order
to win the surrounding tissue resistance in case of very curved fistulas. Both the
rigidity of the fistuloscope and the handle allow the curved fistula to be straightened.
Once again we want to stress that it is of key importance that the operative site is
scrutinized for the presence or absence of any secondary tracts and abscess cavities.
Thanks to the excellent view of internal fistula walls and any possible secondary tract
(s), ensured by the continuous flow of irrigation solution, the internal opening is
identified in the anal canal, on the dentate line or in the rectum (Fig. 8).
After inserting an anal retractor, if the internal orifice is open, the irrigation
solution can be seen escaping through it. Such a condition is encountered in about
70% of cases. But in patients underwent surgery several times (even eight, nine, ten
times), who had thus many recurrences, the internal opening might be blocked
completely or severely narrowed by scars and tough tissue. In those cases, the
fistuloscope light is seen shining through the mucosae (transillumination). In such
a situation, not infrequently (about 30% of cases), the site of the internal opening is
determined by mucosal transillumination (Fig. 9).
400 P. Meinero
Fig. 9 The internal opening
site is located even in case it is
temporarily closed or rich in
scar tissue
Fig. 10 Two stitches are placed on either side of the internal opening to isolate it (a). Stitches are
lifted in order to get a sort of “volcano” (b, c)
The transillumination effect can be intensified by intermittent dimming of the
lights in the operating room. In other words, the internal opening can be suspected
viewing the fistuloscope ligh t behind the mucosae. So anyway, two stitches have to
be placed on either side of the internal opening just to don’t lose it during the
operative phase (Figs. 10a, b, c).
This is also advisable even in case the internal opening is closed. The stitches
mustn’t be knotted but left. They have the sole function of a landm ark to relocate the
site in the further course of the procedure.
The fistuloscopy also allows to discriminate between a true fistula and a false
tract, especially in patients with a previous history of perianal fistula surgery. The
common infected tissue of the internal fistula wall is reddish, and is rich in much
embossed areas which “float ” under the pressure of the irrigating solution. On the
contrary, the internal wall of a false tract is rich in fibrosis, and looks flat and
brownish. This finding can be crucial to avoid further operations when a fistula
repeatedly wouldn’t heal. The cause, in fact, could be the continuous attempt to treat
a false tract (Fig. 11).
In the case of a patient already having a seton placed during a previous surgery, its
correct placement can be detected with the fistuloscope. Not infrequently, during the
fistuloscopy, we discover a misplaced seton, that means a seton placed into a false
25 VAAFT 401
Fig. 11 What the internal wall of a true fistula looks like (a). Internal wall of a false tract (b)
Fig. 12 An example of a
misplaced seton detected
during the fistuloscopy
tract. We all well understand the significance of this finding, and how that could have
an adverse impact on the patient’s healing (Fig. 12).
A misplaced seton would lead to mistakenly treat a false tract. From that, we can
understand how some recurrences might be due to a reiterated attempt to treat false
tracts, but not the true ones. An important study on this subject is under way.
4.2 Operative Phase
Aims of the operative phase are the eradication of the fistula(s) and secondary tracts
from within, removal of the necrotic tissue, and closure of the internal opening.
The obturator is removed and the sealing cap is placed to avoid the backflow of
the irrigation solution during the operative phase. The monopolar electrode is
connected to the electrosurgical generator and inser ted through the operating channel. It is very important to see on the screen the tip of the electrode, and at least 1 cm
402 P. Meinero
Fig. 13 The electrode is inserted through the operative channel of the fistuloscope starting the
cauterization
Fig. 14 The endoscopic brush is inserted through the operative channel of the fistuloscope for
removing all necrotic debris
of its blue sheath in order to not irreparably damage the optical apparatus of the
fistuloscope during the cauterizing phase (Fig. 13).
The fistula cauterization starts from the internal opening to the external opening,
always under endoscopic control, not forgetting any secondary tracts or abscess
cavities, which frequently are found in case of complex anal fistula. It is necessary to
retrieve the fistuloscope step-by-step and repeatedly rotating the electrode on-axis,
with slow movements, to make sure that the entire inner circumference of the lumen
is cauterized. Once the cauterization is completed, all necrotic debris is removed,
always under direct vision, with the aid of the endoscopic brush which is inserted
through the operating channel of the fistuloscope (Fig. 14a, b).
25 VAAFT 403
When the internal opening is completely open, part of the necrotic material is
readily washed out through the anal canal by the continuous flow of the washing
solution.
Once this phase is over, the fistuloscope is removed. The internal opening must
now be closed. We believe that this is a prerequisite and a key point for the complete
healing of any kind of anal fistula. The surgeon needs to choose from various options
the one that is best suited to close the internal opening. This will be addressed and
discussed separately, because there is controversy in the literature as to the modality
to be adopted for this purpose. We currently suggest to use one of the following
methods to close the internal opening (Meinero, 2021).
5 Closure of the Internal Opening
As mentioned above, the hermetic closure of the internal opening remains the first
“head-scratcher” in the field of anal fistula surgical treatment. We are observing that
most recurrences are due to the missed closure of the internal fistula opening. The
high pressure in the anal canal exerted by the sphincter apparatus conditions the
tightness of the suture laid down for closing the internal opening. Besides, this issue
is most evident when the patient has undergone surgery several times, where the
internal opening is surrounded by many scars and tough tissue. Over the years, we
tried to found a solving method for this purpose, but unfortunately, even today, the
percentages of success, although promising, have not led to the expected results yet.
It is clear that the surgeon needs to choose the best method among various options
with which he is familiar. Hereafter, you can see the methods which we suggest,
according to the type of anal fistula and the patient characteristics.
5.1 Use of a Linear or Semicircular Stapler
This is the first methods for closing the internal opening that we proposed in the past.
In patients without a prior history of anorectal surgery, the mucosal surrounding the
internal opening is soft and free of scars. We could say a “virgin tissue” which can be
easily “handled.” In fact, in such cases, the mucosae can be easily lif ted by applying
traction on the two stitches placed on either side of the internal opening at the end of
the diagnostic phase. Once an anal retractor is placed, the traction is applied on the
two stitches by a Kelly forceps. So, a sort of “volcano” is got, as the margins are
raised for at least 2 cm. Depending on the internal opening position and the extent of
the raised mucosae, a linear or a semicircular stapler is applied to the base of this
eminence to achieve a mechanic hermetical suture (Fig. 15).
404 P. Meinero
Fig. 15 The internal opening is closed by a semicircular (a) or linear stapler (b) after lifting the
internal opening
In our clinical practice, this method is now chosen in about 10% of cases, because
the most of our patients has undergone surgery several times. Used in an elective
setting, a successful closure of the internal fistula opening can be achieved. There is a
low risk of postoperative complications related t o mechanical sutures, e.g., fecal
incontinence or soiling. The final result is simply a short wound, and, contrary to
what you might think, the postoperative pain is mild, although the suture falls in
the anal canal or on the dentate line. Obviously, the more the internal opening is
proximal, the less the pain is felt after its stapling closure. Anyway, the pain is
easily treatable with a common painkiller. The stapling procedure remains one of
the best method to close the internal opening, but only in patients never underwent
surgery before.
5.2 Advancement Flap
In patients with a prior history of multiple surgical procedures for perianal fistula,
which is frequently observed in routine practice, the internal opening is sclerotic and
surrounded by tough tissue. For that reason, the use of a mechanical suturing device
is not a feasible option. In these cases, following removal of the entire scar tissue, a
full thickness advancement flap can be performed, exactly well described in the
dedicated chapter of this handbook (Fig. 16).
25 VAAFT 405
Fig. 16 After removing the
scar tissue, an advancement
flap can be performed
Fig. 17 A patch of absorbable mesh is deployed and fixed into the space between mucosae and
internal muscle
In our current routine, we use this closing procedure in about 20–25% of cases,
because, in our hands, the success rate is about 55–60%, despite what reported in the
literature. And more, the postoperative incontinence rate reported from the literature
after making such a flap varies from 8% to 34%, in our opinion, an unacceptable risk
that isn’t worth running if we decide to use a sphincter-saving and minimally
invasive procedure.
5.3 Use of a Bioabsorbable Mesh (Xenograft)
The use of a bioabsorbable mesh (a xenograft made of bovine pericardium), which is
interposed between the mucosae and the internal muscular layer, has been found to
offer satisfactory results. This procedure is indicated in patients with multi-recurrent
anal fistula, when much scar tissue is found around the internal opening. Once
the sclerotic area is completely removed, a linear horizontal incision is made close