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7 The Therapeutic Principle ofFistula-in-Ano
107
Antibiotic treatment is especially effective: 90%
of patients respond to the treatment of arilin plus
quinolone antibiotics (at least temporarily).
Limited data have shown that azathioprine,
6-mercaptopurine, ciclosporin, and tacrolimus
can also cure stula in Crohn’s disease. Iniximab
is a human and mouse chimerical antibody that
specically blocks tumor necrosis factor α (TNFα) and has been shown to improve the healing
rate of anal stula to 46%.
Surgical treatment of anal stula in Crohn’s
disease must follow the principle of individualization, and decisions must be based on the
degree of illness and severity of symptoms.
Despite various treatment options, patients with
severe stula in Crohn’s disease may still need to
undergo rectal resection or permanent
enterostomy.
7.5.3.1 Asymptomatic Crohn’s Disease
Anal Fistula Does Not Require
Surgical Treatment
Fistula in Crohn’s disease may be secondary to
Crohn’s disease or crypt infection. Regardless of
the etiology, anal stulas with no symptoms and
local signs of infection can remain in a static state
for a long time without requiring surgical
treatment.
7.5.3.2 Symptomatic Simple Low Anal
Fistula inCrohn’s Disease Can
Undergo Fistulotomy
All simple lower stula in Crohn’s disease
involving or rarely involving the external sphincter can safely and effectively receive an anal stulotomy. In view of the chronic course and high
recurrence rate of that disease, sphincter function
should be preserved as much as possible. All risk
factors, especially the severity of anorectal disease, sphincter function, rectal compliance, presence of active proctitis, history of anorectal
surgery, and defecate concordancy, should be
considered before incision. The appropriate surgical cure rate for patients is 56–100%, the rate of
mild anal incontinence is 6–12%, and the duration of healing requires 3–6 months. Anal incontinence may be associated with a previous history
of anal stula surgery.
7.5.3.3 The Complicated Anal Fistula
ofCrohn’s Disease Can
BeTreated Palliatively
withLong-Term Drain Seton
In patients with complicated anal stula in
Crohn’s disease, long-term (usually more than 6
weeks) seton is aimed at continuous drainage and
preventing closure of the external opening of the
anal stula in order to smooth the drainage and
control the development of inammation. Even
so, the repeated infection rate of patients with
anal stula is still 20–40%, and 8–13% of patients
have different degrees of leakage. Recent data
have shown a healing rate of 24–78% after induction therapy with drain seton combined with infliximab and 25–100% of patients responding
effectively to iniximab maintenance therapy.
7.5.3.4 If theRectal Mucosa Is
Generally Normal, Complex
Anal Fistula ofCrohn’s Disease
Can Undergo Mucous
Advancement Flap Metastasis
The complicated anal stula of Crohn’s disease
without active proctitis can be treated by mucous
advancement ap metastasis, the short-term cure
rate is 64–75%, and the recurrence rate is positively correlated with the follow-up time. The
short-term cure rate of Crohn’s disease complicated by rectovaginal stula is 40–50%. Patients
with active proctitis can be treated by biologics
rst, and then with surgery after the disease is in
remission.
7.5.3.5 Complex Anal Fistula
ofCrohn’s Disease That
Cannot BeControlled May
Require Permanent Neostomy
or Rectum Resection
In a few cases of extensively crescendo complicated anal stulas of Crohn’s disease and in
cases that are ineffective with medications and
thread drainage, in order to control perianal
infection, patients need to undergo enterostomy
or rectectomy. Enterostomy is required in
31–49% of patients with complicated perianal
Crohn’s disease. Risk factors for permanent
enterostomy and rectectomy include accompa-
108
R. Shi and L. Zheng
nied by colonic disease, persistent perianal
infection, previous temporary neostomy, fecal
incontinence, and stricture of the anus. Despite
appropriate medication and minimally invasive
treatments, 8–40% of patients require rectectomy to control persistent symptoms.
7.6 Nonradical Drainage or Drug
Treatment Should BeUsed
inSome Patients
Not all patients are suitable for radical surgery.
Sometimes nonradical treatment or expectant
treatment to remiss symptoms and control the
development of the disease may be more benecial to patients. Expectant treatment is suitable
for the following patients:
1. Those who have important organ diseases
such as heart, brain, lung, liver, and kidney disease or have other surgical contraindications.
2. Those who have anal stula associated with
Crohn’s disease and ulcerative colitis.
3. Those who have anal stula with high posi-
tion, too complex tendency, and the failure
rate of operation greater than the success rate.
4. Those in whom anal stula has not been cured
by multiple operations, but there was mild or
moderate incontinence of the anus, and reoperation may lead to further low anal function
or even severe incontinence.
5. Patients who require expectant treatment.
Suggested Reading
1. Masahino Takano . Shi renjie compilation. Essence of
anorectal diseases diagnosis and treatment. Beijing:
biological medicine branch of chemical industry
press, 2009, 137–166.
2. Cao Jixun. Hemorrhoidology of China. Chengdu:
sichuan science and technology press, 2015, 165–170.
3. Huang Naijian. Chinese Proctology. Jinan: shandong
science and technology press, 1996, 745–766.
4. American Society of Colorectal Surgeons. 2011
American guidelines for treatment of perianal abscess
and anal stula [J]. Chinese journal of gastrointestinal
surgery, 2012, 15(6):640–643.
5. Cao Yongqing. Several ideas on the study of the standardization of anal stula diagnosis and treatment
[J]. Journal of traditional Chinese medicine, 2003,
44(z1):85–86.
6. Ren Donglin, Zhang Heng. Several key problems
needing attention in the diagnosis and treatment of
complicated anal stula [J]. Chinese journal of gastrointestinal surgery, 2015, 18(12):1186–1192.
7. Cao Yongqing, Pan Yibin, Guo Xiutian etal. Clinical
treatment strategies for anal stula [J]. World
journal of traditional Chinese medicine, 2010,
05(4):275–277.
Surgical Treatment ofAnal Fistula
RenjieShi andLihuaZheng
8
Abstract
The anal stula surgeon should be experienced in the necessary skills, including correctly nding and managing the internal
opening and primary lesions, handling the
anal sphincter, working with the complex stula, making the smooth drainage wound,
handling the soft tissue around the stula,
handling the coexisting lesions, handling the
perforation of rectum, etc. There are many
treatment methods for anal stula, which can
be divided into three categories: incision,
seton therapy, and sphincter preserving, each
of which has its own indications and limitations. In China, seton therapy has been widely
used in the treatment of anal stula since the
Ming Dynasty and has undergone six major
changes. The function of anal stula thread is
to cut the anal sphincter chronically so that
the broken end of anal sphincter remains continuous through the scar while acting as the
drainage at the same time. Methods of seton
R. Shi (*)
Department of Anorectal Surgery, Afliated Hospital
of Nanjing University of Traditional Chinese
Medicine, Nanjing, Jiangsu, China
L. Zheng
Department of Proctology, China-Japan Friendship
Hospital, Beijing, China
therapy include low incision and high threadligating therapy, low incision and high virtual
seton therapy, combination of virtual and real
seton, tunnel thread drawing, traditional medicine seton therapy, catheter drainage therapy,
long- term drainage seton therapy, etc. There
are still some controversies about seton therapy. Sphincter preserving surgery is the
development direction of anal stula treatment, which is carried out earlier and has rich
experience in Japan. LIFT and mucosal ap
advancement are the most popular sphincter
preserving methods.
Keywords
Anal stula · Operation · Handcraft
Operation method · Seton therapy · Sphincter
preserving surgery · LIFT · Mucosal ap
advancement
In principle, anal stula needs surgery to achieve
a radical cure. The efcacy of anal stula surgery
and the incidence of complications are related to
the operative method and depend on the operative
skills and experience of the surgeon.
© Chemical Industry Press 2021
R. Shi, L. Zheng (eds.), Diagnosis and Treatment of Anal Fistula,
https://doi.org/10.1007/978-981-16-5804-4_8
109
110
R. Shi and L. Zheng
8.1 Basic Techniques ofAnal
Fistula Surgery
8.1.1 Intraoperative Techniques
forFinding andHandling
theInternal Orice
8.1.1.1 Intraoperative Techniques
forFinding theInternal Orice
Accurate nding of the inner opening is one of
the prerequisites for radical treatment of anal
stula. If the positioning of the internal orice is
not correct, the internal orice treatment will
not be in place, leading to the complete failure
of anal stula surgery. The ability to search for
an internal orice during surgery is largely
dependent on the skill and experience of the
surgeon.
The internal orice is mostly located in the
anal sinus on the dentate line, the internal orice
of horseshoe-shaped anal stula is mostly located
in the dentate line behind the anus, and the internal orice of simple anal stula is mostly located
in the dentate line of the same position as the
external orice of the stula. Although it is possible to infer the approximate orientation of the
interior orice from the position of the outside
orice according to Goethe’s Rule or Solomon’s
Law, this is not accurate. So Goethe’s Rule is
often used to guide preoperative examination and
rarely intraoperative examination. During the
operation, palpation, methylene blue, and probe
examination are the main methods to examine the
internal orice.
During digital examination, the typical anal
stula opening presents a small induration that
can be touched under the mucous membrane of
the dentine line during palpation. The anal recess
with a deep depression can be seen when the anus
is examined by anoscope. If the recess is deep, it
is likely to be the internal opening.
However, sometimes the characteristics of the
internal opening of patients with anal stula are
not obvious, and the typical characteristics of the
internal orice cannot be found before and during the operation. In the intraoperative explora-
tion of such patients, the stula can be extracted
from the outer orice, and a segment of the stula
can be extracted and pulled outward by holding
the outer mouth, and there will be an obvious
depression at the corresponding inner mouth so
that the location of the inner mouth can be
inferred. In the operation, the primary abscess
can be found by cutting open the internal and
external sphincter muscle and then through the
anal duct to nd the internal orice connected
with the primary abscess.
8.1.1.2 Tips forHandling the
Internal Orice
The treatment of the internal orice depends on
the surgical procedure. Most of the existing anal
stula surgical methods need to cut and remove
the internal opening and separate the internal
opening to create both edges and the adjacent
anal sinus ligation, which can improve the thoroughness of the internal orice treatment and at
the same time prevent postoperative bleeding of
the wound mucosa, which is conducive to wound
drainage.
When there is a large scleroma or obvious
inammation in the internal orice, it is necessary to remove the scleroma and severely
inamed tissues. However, excision of these tissues can easily lead to large defects in the inner
mouth and prolong the healing time. In this
regard, some surgical methods advocate suturing
the wound surface of the inner orice or covering
it with a mucous ap. It is very important to eliminate tension when suturing the wound surface
and moving the ap. The transferred ap must
maintain good blood supply and prevent the formation of hematoma.
If the internal orice treatment is not in place,
it can easily lead to anal stula recurrence. In the
anal stula sphincter retention operation, the
treatment method of cutting out the stula at the
inner opening is often adopted. If the treatment is
not good, it will easily lead to partial stula residue, which is the main reason why the recurrence
rate of anal stula retention sphincter operation is
higher than that of open surgery.
8 Surgical Treatment ofAnal Fistula
111
8.1.2 Techniques forDealing
withPrimary Lesions Between
theInternal andExternal
Sphincters
Improper treatment of the primary abscess is the
most common cause of anal stula recurrence,
and good treatment of the primary abscess and
primary stula is the second most important
requirement for the healing of anal stula.
8.1.2.1 Techniques forFinding
Primary Lesions
The primary intermuscular lesion can be found
from the inner or outer opening. The method to
search for the primary lesion from the external
opening is as follows: stula is cut around the
external opening, stula at the external opening
is clamped, and then the stula is exfoliated along
the outer wall of the stula until the exfoliation
reaches the internal and external sphincter muscle, and then the primary abscess lesion is found
between the muscles. The way to nd the primary
lesion from the inner opening is that after treating
the inner opening, the primary abscess can be
exposed by separating it outward along the primary stula and separating the internal and external sphincter muscle. The above two methods can
also be used to nd primary lesions.
8.1.2.2 Management Skills
ofthePrimary Abscess
The basic principle for treating primary lesions is
to remove the primary abscess as thoroughly as
possible. It is recommended to remove the hard
intermuscular tissue until the hard tissue cannot
be touched. However, it is necessary to prevent
excessive excision of tissue from causing unnecessary damage and leading to excessive tissue
loss between the internal and external sphincters.
If the lacunae that are produced between the
internal and external sphincter muscles after
excising the primary hair abscess are bigger, the
surgeon can break the end with the external
sphincter muscle, external sphincter muscle subcutaneous ministry or gluteus maximus, and nd
a tissue to make the pedicle muscle ap lling
after creating a cavity again. The suture should
then be xed.
In anal stula that is newly formed, when the
tissue does not have apparent hardness between
muscles, the surgeon should only scratch the
local purulent area and clean the tissue, and next
open drainage of wound cavity should take place.
If the stula is small and the primary abscess is
small, the stula can be cut open or removed, and
the wound surface can be opened for drainage
without special treatment for the primary abscess.
8.1.3 Anal Sphincter Management
Skills
Most anal stula operations involve the management of the anal sphincter. Moderation and
necessity should be taken into account when
dealing with the anal sphincter. Improper incision
or resection of the anal sphincter muscle will
increase anal function damage. However, if the
surgeon is too worried about injury to the anal
sphincter muscle and does not make the correct
incision, it may affect the treatment of the focal
point. Because of this, or because of the impact
of drainage, this might also lead to anal stula
recurrence or delayed healing.
Grasping the skills of anal sphincter degree in
anal stula surgery: (1) since the subcutaneous
stula does not involve an anal sphincter, it can be
directly cut. (2) External sphincter muscle subcutaneous and supercial can be cut directly, but the
anterior anal stula and sphincter muscle are particularly weak. Even if only opening the external
sphincter muscle subcutaneous or supercial, the
surgeon should be cautious. (3) In principle, deep
external sphincter muscle and puborectalis muscle cannot be cut directly. If necessary, the method
of thread hanging is usually used for the incision
to maintain the integrity of the anorectal ring. (4)
When incisions are made on the front and side of
the anus, the incisions on the back of the anus are
more likely to lead to postoperative anal deformation and loose closure, thus requiring attention.
Especially in women, care should be taken to
avoid as much as possible cutting too far in the
112
R. Shi and L. Zheng
front of the anus or the side when directly opening
the anal sphincter. It is recommended to use the
method of strangle cut slowly. (5) The anal
sphincter cannot be cut in more than three places
at the same time. Because the anal sphincter has
the effect of continuous closure of the anus, it is
easy for this function to deteriorate if it is cut off,
and some patients will have sequelae such as anal
moisture and overow.
The number and necessity of incisions to the
sphincter muscle are related to the operative style
and the surgeon’s concept and clinical experience.
Even for the same anal stula, the degree of
sphincter injury often varies greatly with different
procedures or by different operators. As surgeons,
we should improve theoretical and clinical literacy, accumulate more experience and skills, fully
weigh the pros and cons while ensuring the cure
when facing specic cases, ensure anal function
as far as possible, and pay attention to protecting
the anal sphincter during the operation.
8.1.4 Management Techniques
ofFistulas
When dealing with stulas, the management of
the main canal is critical. The main tract should
be treated thoroughly, and the drainage of the
wound should be maintained unobstructed. Small
branch ducts can be scratched after the use of
elastic bands, such as loose wire drainage.
Supercial and obvious stulas are easy to follow
up on, but deep stulas depend on the surgeon’s
touch and experience.
In general, when the canal cavity is small or
the wall tissue is soft, only incision or partial
resection of the stula is performed in the anostulectomy. However, when the stula is complex, the tube is large or deep, the contents of
the lumen are dirty, and the inammation of
surrounding tissues is severe, it is necessary to
remove the purulent and rotting tissue in the stula cavity and remove the stula wall as far as
possible.
When necessary, the wound surface after total
resection of the main tract or branch canal can
also be sutured. The key is to ensure that the
lesion is completely removed and tightly sutured
without leaving a cavity.
Fistula under the rectal mucosa or between the
upper muscles may lead to rectal stenosis, which
is difcult to remove completely. If the treatment
of the inner orice and primary lesions is thoroughly advanced, as long as the lumen is scraped
clean, the stula can be cut off longitudinally in
one or two places. The rectal stenosis should also
be relieved after cutting.
8.1.5 Wound Management Skills
The anal wound is easy to be contaminated by
feces, secretions, poor exposure, and poor drainage. Effective countermeasures for these conditions are to make the anal wound drainage
unobstructed. Smooth drainage is a necessary
condition for the smooth healing of anal wounds.
In order to ensure smooth drainage of the anal
wound, it is very important to take the following
steps. In wound drainage, we should extend and
expand the anal wound appropriately. The size of
the drainage site should be determined according
to the size, depth, and length of the anal wound.
In general, the deeper the anal stula is and the
longer it is, the deeper, wider, and longer the
drainage wound should be. Our experience is that
the width and depth of the drainage wound are
closely related to the healing time of the wound,
and the deeper and wider the wound, the longer
the healing time. However, the length of the
wound does not affect the healing time, so we
usually use the method of extending the drainage
wound and not increasing the width of the wound
as far as possible when making the drainage
wound, which can not only effectively improve
the drainage but also facilitate the early healing
of the wound.
In general, if the stula extends outside the
anus for a long time, the length of incision of the
stula and the drainage wound surface is
enough. However, if the stula is short and
deep, the wound needs to be extended and
expanded outward, making the whole wound
appear like a water drop. In the case of horseshoe-shaped stula, the wound surface is often
8 Surgical Treatment ofAnal Fistula
113
made into an arrow shape when it is extended
outward for drainage due to the inuence of the
tailbone. Although the drainage wound outside
the anus looks large, because the drainage is
unobstructed, the healing is much faster than the
wound inside the anus. Therefore, under normal
circumstances, the drainage wound must be
made small inside the anus and a large outside
of the anus. This is expected to achieve the goal
of healing the wound gradually from the inside
out or at the same time.
The surface of drainage wound must be
smooth without depression to ensure smooth
drainage. If the wound has a depression, secretion will be easily retained and will affect the
smooth healing of the wound. Therefore, the bottom and edge of the wound should be trimmed in
order to ensure the smooth drainage of the wound.
8.1.6 Soft Tissue Management
Techniques
The complete function of the anus is not only
related to the anal sphincter but also to the soft
tissue inside and outside the anal canal. When
there is soft tissue defect inside the anal canal,
even though the anal sphincter muscle is retained
very well, it can also decrease anal function and
the anus can easily become wet or leak liquid.
Therefore, in anal stula surgery, injury to the soft
tissues around the anal stula should be reduced
as much as possible, and the soft tissues of the
anus should be retained as much as possible.
8.1.7 Management Skills
ofCoexisting Other Anal
Diseases
Anal stula is often combined with internal hemorrhoids and external hemorrhoids, anal nipple
hypertrophy, anal ssure, etc. Some of these concurrent lesions sometimes have symptoms, and
some have no symptoms all the time. These coexisting lesions cannot be treated at the same time
during anal stula surgery, and these lesions are
prone to postoperative swelling and enlargement,
pain, bleeding, and other symptoms. External
hemorrhoids and hypertrophic anal nipples at the
wound edge can also affect the drainage of the
anal stula wound surface or directly put pressure on the wound surface to make wound healing difcult. Therefore, in anal stula surgery, we
also advocate simultaneous treatment of these
wound edge lesions, even if there are no symptoms, so as to eliminate the impact on wound
drainage and healing and prevent them from happening in the rst place.
In the treatment of coexisting lesions, internal
or external hemorrhoids can be excised or ligated.
Anal papillary hypertrophy can be removed by
ligation or direct resection. Anal ssure can be
treated by excising redundant skin and anal papillary hypertrophy with excising the hard ssure
and changed tissue. However, there is no need to
cut off the anal sphincter muscle because this will
decrease anal function.
8.1.8 Management Techniques
forRectal Perforation
Rectal perforation mainly occurs in cases of high
intermuscular stula and pelvic rectal fossa stula. For rectal perforation, in principle, the
internal orice and the primary abscess should
be treated well, the perforation part is well
drained, and if necessary, the drainage line
should be temporarily suspended. After the perforated part has subsided, the drainage line can
be removed. It can also be treated through fasting and using central venous nutrition to control
defecation. Generally, there is no need to create
a temporary articial anus.
8.2 Classication andSurgical
Methods ofAnal Fistula
Radical operation of anal stula is basically based
on the theory of the “infection of anal recess
gland.” The key aspects of operation include three
aspects: rst, the treatment of the inner mouth and
primary lesions; second, the treatment of the
sphincter; and third, wound drainage.
114
R. Shi and L. Zheng
With regard to the treatment of the internal
orice and primary lesion, most surgical methods
adopt the method of incision or excision. Only
the coring-out operation of Takao Moriya, the
submucosal primary lesion resection of Yasuo
Yamamoto, the subcutaneous primary lesion
resection of Shoji Sumie, and the intersphincter
stula ligation (LIFT) of Arun are special in the
treatment of the inner opening (detailed discussion is given in the following corresponding surgical procedures).
Regarding the treatment of the sphincter, the
main difference lies in the method of incision and
treatment. In the author’s opinion, according to
the different treatment methods of the sphincter,
the radical operation of anal stula can be divided
into three categories: anal stulectomy, anal stula thread-drawing and incision seton therapy,
and the anal stula retained sphincter method. As
for intraoperative wound healing techniques,
such as open suture, partial suture, full suture,
bag suture, ap or mucous ap coverage, biomaterial lling, anal stula endoscopic video auxiliary treatment, etc., the target is basically to
provide the best condition for wound healing.
The author believes that these techniques are not
the core techniques for the treatment of anal stula, but in essence, they are auxiliary methods in
the treatment of anal stula. Therefore, according
to the different treatment methods of anal sphincter in this book, the author divides anal stula
surgery into three categories: incisional surgery,
thread-drawing incision seton surgery, and
sphincter retention surgery.
Operation points: routine disinfection, local
anesthesia, or Yaoshu anesthesia. If there is an
external orice, a small amount of methylene
blue can be injected from the external orice to
check whether there is staining and the staining
position of the preset gauze in the anal canal so as
to conrm whether the stula is perforated and
the position of the internal orice. The probe
should be inserted from the outer opening and
gently probed along the pipeline. Under the guidance of nger touch, it should be pierced through
the inner mouth and then tightened. All stulas
should be cut along the probe (Fig. 8.1). If the
tube is bent, or the lumen is small, it can be cut at
the same time as exploration and forward to the
inner orice until all stulas are cut.
If there is no external opening or closure of the
external opening, a small incision can be made at
the top of the external end of the pipe or at the
closed external opening to open the stula, and
the probe can be put into the pipe through this.
Then, all the stulas can be cut out after the probe
is out of the internal opening.
If there is no outside mouth, but there is purulent in the inside mouth, one end of the probe can
be bent into a hook. Under the guidance of the
crypt hook, the probe can be probed into the
inside mouth and tube, and all stulas can be cut
along the probe or from inside out.
After incision of the stula, the tube wall should
be scraped and trimmed to scrape away the necrotic
tissue and cut off the very rough tube wall and
uneven tissue (Fig.8.2). Generally, it is not neces-
8.2.1 Anostulectomy
8.2.1.1 Anal Fistula Incision (Excision)
It is mainly applicable to low simple anal stula
and high anal stula where some anorectal rings
have become stiff. However, for anal stula in the
front and anal stula with weak sphincter muscle,
especially those of female patients, special caution should be taken in the operation of anal stulectomy, and it is recommended to adopt the
surgical method of resecting and hanging the line
or retaining the sphincter.
Fig. 8.1 Anal stula incision
8 Surgical Treatment ofAnal Fistula
115
sary to remove all the tube walls in order to reduce
tissue defects and shorten the course of treatment.
During operation, the branch should be carefully
explored. If there is a branch tube, the branch tube
can be cut if the branch tube is relatively short. If
the branch tube is long or bent, it can be treated
with anal stula incision and drainage.
After stula incision, the wall of the tube
should be scratched and repaired to remove corrupt tissue, and the thick and hard wall and
uneven tissue should be cut off (Fig.8.3). In gen-
eral, it is not necessary to remove all tube walls to
reduce tissue defects and shorten the course of
treatment. The branch canal should be carefully
explored during the operation. If there is a branch
tube, it can be cut short. If the branch tube is longer or bent, it can be treated as an anal stula
incision and drainage should take place.
Hemostatic treatment of the wound should be
performed before the operation is completed, and
the edge and bottom of the wound should be
repaired. The cross section of the wound should
be shaped like a “V” with a large inner and outer
side, so as to make the wound smooth and facilitate drainage and create favorable conditions for
the smooth healing of the wound.
8.2.1.2 Anal Fistula Incision
andDrainage
It is also known as open anal stula surgery. It is
mainly suitable for the treatment of low position,
long pipeline, or curved anal stula.
Operation points: the treatment of the main
pipeline and internal orice is equivalent to low
anal stulectomy. In order to reduce injury to the
sphincter, it is not suitable to open the stula
obliquely. The main part of the sphincter is radially cut, and the drainage is extended outward.
The branches are carefully explored, and all
stulas are managed one by one. If the stula is
long but no more than 3cm, a radial incision can
be made at the end of the tube to loosen ligation
between the incision and the main incision to
facilitate drainage. If the length of the pipelines
exceeds 3cm, all openings can be made every
2–3cm in the pipelines, and the rubber bands or
skin sheets are relaxed with respect to drainage
between all adjacent incisions (Fig.8.4).
8.2.1.3 Anal Fistula Resection
andSuture
Anal stula resection is mainly used for the treatment of straight low simple anal stula without
obvious signs of infection.
Operating instructions: make the wound fresh
and soft after incision of the stula and excision of
all the wall tissue. Then stop the bleeding completely, rinse the wound, and suture the wound with
a full layer. Do not leave dead cavity when suturing
and try to be tension-free. Defecation should be
able to be controlled within 3–5 days after surgery,
and stitches are removed 1 week later.
Anal stula resection and suture can easily lead
to anal stula recurrence and operation failure due
to postoperative infection, which may complicate
the condition and prolong the course of treatment.
Therefore, it is necessary to strictly adhere to the
Fig. 8.2 Anal stula incision to ligate the wound on both
sides of the inner opening
Fig. 8.3 After anal stula incision has removed part of
the wall
116
bc
R. Shi and L. Zheng
a
Fig. 8.4 Anal stula incision and drainage. (a) After
injecting methylene blue from the left front outer port,
there is methylene blue overow at the posterior tooth
line. (b) The main incision is made on the posterior side.
indications and conduct adequate doctor–patient
communication. In order to prevent postoperative
infection, the intestinal tract should be prepared
before the operation, and appropriate antibiotics
should be used between 3 and 5 days after the
operation to prevent incision infection.
8.2.1.4 Anal Fistula Resection
andSemi-suture
It is suitable for the treatment of low anal stula
that is longer or has more branches.
Operation method: the main canal should be
opened for drainage after the treatment of anal
stulectomy, and the stulas or branches outside
the main canal should be treated with resection
and suture to reduce the wound surface and
shorten the wound healing time. The wound
treated in this way is half open and half stitched.
Semi-suture of anal stula resection is suitable
for the treatment of low anal stula that is longer
or has more branches.
8.2.1.5 Hanley Method
Also known as the open orice drainage method,
mainly applied to the internal orice in the anus
behind the sciatic rectal socket stula or posterior
horseshoe stula. The Hanley operation is suitable for anal stula with small bilateral branches
but not for those with large bilateral branches.
Operation points: after excision of the inner
mouth, the wound should be made to extend out-
After opening the posterior stula, a stained stula is
seen. (c) A rubber band is placed between the front and
rear incisions drainage
ward, part of the internal sphincter and external
sphincter are cut open, and the posterior anal
space is exposed to deal with the primary lesion.
After scratching and trimming the scar tissue, the
wound is extended outward to make its drainage
smooth. The necrotic tissue in the stula extending to both sides is usually not treated by incision, but a small incision drainage can be made at
the end of stulas if necessary (Fig.8.5).
8.2.1.6 Goligher-UI Method
It is also referred to as the open drainage of anal
stula. In 1970, Goligher designed this method
for horseshoe anal stula, and in 1982, UI
improved the Goligher method, so it is called the
Goligher-UI method in Japan. It is suitable for
the treatment of complex anal stula such as
ischiorectal fossa stula.
Operation points: the treatment of the internal
orice, the treatment of the primary intermuscular lesion, and the treatment of the drainage
wound are the same as the Hanley method. A
wide and narrow open wound is made behind the
anus to remove infected and necrotic tissue,
remove scar tissue, and scratch clean the wound.
For the branches on both sides, Goligher adopts
the method of cutting open stulas that extend to
both sides. The improvement of the Goligher
method is to make triangular cutting and cutting
in the middle sections of the stulas that extend
to both sides so as to reduce injuries. The stulas