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Muscle flap
8 Surgical Treatment ofAnal Fistula
147
Operating instructions: peel off the stula
from the external opening all the way to the primary abscess between the muscles. When there
is no secondary stula, the skin between the
anus and coccyx is incised longitudinally in the
posterior midline and dissociated to its deepest
parts. Since the deep lesions are located above
the levator ani, below the sacrum, and in front of
the coccyx, in order to thoroughly clean the primary lesions, the coccyx should be removed
after separation if necessary and reach the
lesions behind the rectum from above the
sphincter. The lesions in the pelvirectal fossa
are gradually stripped from top to bottom,
excised, and opened for drainage.
Then, the primary stula is stripped and
excised from the inner opening. The inner opening is separated from the surrounding internal
sphincter, and after clamping with a Cochle
forceps, the stula in the internal sphincter is dissected until the primary abscess is stripped and
removed. Then, suture the wound in the internal
sphincter of the inner mouth, and make the drainage wound of external drainage from the anus.
Open drainage is performed on the wounds after
stulectomy of the external orice and intermuscular abscess or after resection of the coccyx of
the sacral anterior rectum posterior (Fig.8.26).
Sometimes the stula leads to the left and
right sides of the anococcygeal ligament, and
Cut Coccyx
Levator Ani M.
Fig. 8.26 Sphincter preservation operation for pelvic
rectal fossa stula. Excavate the stula between the internal opening and the primary abscess from the anus, and
use the method to suture the internal and external active
muscles and the levator ani muscles to close the wounds.
Digging and planing
Open drainage
Muscle flap
tamponade
Suture atresia
Cut all pelvic and rectal fossa from the outer sphincter arc,
and scrape or excise. If there is a large wound after treating the stula in the pelvic rectal fossa, the gluteus maximus ap can sometimes be used
filling
148
R. Shi and L. Zheng
sometimes it extends to the front of the sacrum.
When handling such a stula, it is necessary to
prevent missing branches. If the wound after
excision of the primary abscess is too large, it
will prolong the healing time. The gluteus maximus can be used as a pedicled muscle ap to ll
the wound. Because these deep anal stulas are
likely to be associated with canceration and
Crohn’s disease, it is necessary to send the stula
removed for pathological examination.
Anal Fistula Muscle Flap Filling Surgery
This is mainly aimed at the treatment of high anal
stula (especially open surgery) when there are
large tissue defects and prolonged healing time,
anal local blood circulation is poor, anal deformation is obvious, cavity cannot be completely
closed, or there are other noticeable issues. The
purpose of lling the tissue defect produced by
the operation with the muscle ap is as follows:
(1) lling the dead space; (2) using the blood supply rich in the muscle ap, absorbing the secretion of the abscess and the necrotic tissue, and
exerting the internal drainage effect, so that the
dead space gradually disappears; and (3) using
the muscle ap to block the trafc between the
internal and external wounds so that the muscle
ap acts as a barrier between the intestinal cavity
and the lesion, preventing feces from contaminating the wound and thus promoting healing. It is
suitable for complex anal stula, high intermuscular stula, ischiorectal fossa stula, and so on.
The muscle ap lling method is recommended
in Japan by Iwatari, Kono, and Takano.
Main operating points:
according to the position of the stula and the
amount of excision of the diseased tissue.
(a) Type I (single muscle ap method)
The primary lesion is found by separating the muscle space, the abscess cavity is curetted sufciently, the granulation
tissue and necrotic tissue are removed,
and the scar and hard wall of the cavity
are excised or trimmed to soften the local
area (Fig.8.27). Care must be taken during the operation to protect the anal
sphincter and mucous membrane as much
as possible. When the stula surrounds
the rectum and causes rectal stenosis, as
long as the longitudinal stula is cut off,
the rectal stenosis can be eliminated, and
no stula needs to be completely removed.
For the cavity formed between internal
and external sphincter muscles during
surgery, a segment of the subcutaneous of
the external sphincter near the cavity can
be separated to form a single pedicled
muscle ap, and then the muscle ap can
be inverted 180° from the outside to the
inside to ll the cavity and xed to the
internal sphincter with catgut suture
(Fig.8.28).
(b) Type II (double muscle ap method)
In the same way as in the usual anal
stulectomy, the external sphincter is cut
and the lesion is cleaned. For the defect
caused by the treatment of the lesion, the
two ends of the subcutaneous of the external sphincter are cut, and each is made
1. Muscle ap lling surgery of Kazuo Kono
Under general anesthesia and after disin-
fection, a small amount of skin is cut through
the lateral skin of the external orice, the incision is extended upward to the anorectal, and
the diseased anal sinus and mucosa in the
inner mouth are removed. The diseased tissues around the inner opening, including the
anal recess adjacent to the inner opening, are
also fully removed. The low wide upper narrow drainage wound exposes the internal and
external sphincter muscle. Then, different
muscle ap lling methods are adopted
Fig. 8.27 An indication of the treatment of primary
lesions with muscle ap lling
Cavity
Before After
ab
Cavity
Before After
ab
8 Surgical Treatment ofAnal Fistula
Internal anal
sphincter
External anal
Sphincter
(Subcutaneous)
Fig. 8.28 Muscle ap lling operation type I. (a) Before. (b) After
149
Internal anal
sphincter
External anal
Sphincter
(Subcutaneous)
Fig. 8.29 Muscle ap lling operation type II. (a) Before. (b) After
into a pedicled muscle ap, and then the
muscle ap is pulled to the center to be
lled in the defect, sutured, and xed on
the internal sphincter (Fig.8.29).
(c) Type III
When the outer orice is far from the
anus and adjacent to the lateral side of the
external sphincter, it can scratch and peel
off the stula from the outer opening and
remove the primary lesion until reaching
the outer sphincter muscle. After the primary abscess is cleaned, a part of the tissue of the subcutaneous of the adjacent
external sphincter is separated to form a
pedicled muscle ap, which is inserted
into the cavity 180° outward (rear),
sutured and xed on the subcutaneous tissue (Fig.8.30).
150
Before After
External anal
Sphincter
Subcutaneous tissue
ab
Cavity
Before After
ab
Internal anal
sphincter
Cavity
Fig. 8.30 Muscle ap lling operation type III. (a) Before. (b) After
R. Shi and L. Zheng
External anal
Sphincter
(Subcutaneous)
Fig. 8.31 Muscle ap lling operation type IV. (a) Before. (b) After
(d) Type IV (wrapping method)
For cases where the stula is located in
the middle of the external sphincter, after
treating the primary lesion of the stula,
the dead cavity appears in the middle of
the external sphincter. The method is to
cut the subcutaneous of the external
sphincter around the cavity to form a
muscle ap, take the cavity as the center,
ll the muscle ap as if wrapping a parcel, and x it in the dead cavity (Fig.8.31).
(e) Type V (using the gluteus maximus)
In cases where the lesion is too large, the
cavity left after the treatment of the lesion is
also large; or there is external sphincter
atrophy; or after many operations in the
anus, the scar is severe, especially in the
subcutaneous of the external sphincter,
there is a serious scar, and it is difcult to
use the external sphincter subcutaneous to
obtain a muscle ap. Therefore, a gluteus
maximus muscle ap can be used.
Gluteus maximus
Before
ab
Absorbable thread
continuous suture
Mucosal wound margin
8 Surgical Treatment ofAnal Fistula
151
Cut the scar rst and nd the lesion and
then remove it. Then extend the anal margin
incision, expose and separate a portion of
the gluteus maximal muscle bundle on the
left side, and make a pedicled muscle ap of
sufcient length. Between the incision
scars, the muscle ap is pulled and lled in
the dead space that appears after the lesion
is removed, sutured, and xed on the internal sphincter (Fig.8.32). In the preparation
of the gluteus maximus muscle ap, it is
necessary to pay attention to the deep and
upper part of the gluteus maximus muscle,
which is rich in blood vessels and nerves.
However, what is needed to make the muscle ap is the part of the muscle of the gluteus maximus near the anus with a diameter
of 2–3 cm. So there is no need to worry
about damaging blood vessels and nerves.
After the pedicled muscle ap is xed
in the cavity with the above methods, the
wound becomes at. Next, the margin of
the mucosal incision is xed to the internal sphincter by continuous overlocking
suture with catgut and cover most of the
suture line of the muscle ap. Continuous
suture of the easily bleeding submucosa
is also a measure to prevent hemostasis.
In order to prevent blood and uid accumulation in the residual cavity, drainage
strips can be placed in the mouth outside
the anal stula or the newly opened small
incision for drainage (Fig.8.33).
Two to four days before the muscle
ap lling operation, diet control and
bowel preparation should be done.
Antibiotics should be taken orally to prevent infection within 1–2 days before sur-
Internal anal sphincter
Cavity
After
Fig. 8.32 Muscle ap lling operation type V. (a) Before. (b) After
Fig. 8.33 The
completion of the
muscle ap lling
operation
Internal anal sphincter
Drainage tube
152
R. Shi and L. Zheng
gery. Antibiotics should be continued for
2 weeks after surgery to prevent infection
and contribute to the survival of the transplanted muscle aps. A slag-free diet is
given 2–3 days after the operation, and
opioid tincture or codeine phosphate is
given orally for 1–2 days to control defecation. A bath or sitz bath can be taken
2–3 days after the operation to clean the
wound surface.
The wound is usually healed about 2
months after the operation, the induration
basically disappears, the scarring and
deformation of the anus are very light,
and the softness is maintained. Among
the 168 patients with muscle ap lling
performed by Kono, 11 patients had the
following problems: there were four cases
of recurrence (2.4%), of which three
cases were cured by the second operation
and one case was planned for a second
operation. Residual abscess occurred in
three cases (1.8%), all of which were
cured by simple incision and drainage.
One case (0.6%) had residual induration
swelling and was cured by local injection
of antibiotics. One patient (accounting for
0.6%) had partial necrosis of the muscle
ap and was cured by removing the
necrotic part of the muscle ap. Two
cases (1.2%) had residual blood and were
cured by cutting and clearing the blood.
The survival rate of the muscle ap is
very high, and there are no cases of complete failure due to incomplete lling and
suture of the muscle ap, or the muscle
ap came completely out of the dead
space and must be removed. The prevention measures for the above problems are
as follows: the pedicle of the pedicle muscle ap should be broad enough to maintain adequate blood supply; a drainage
strip should be placed between the muscle ap and the dead space for drainage
2–3 days after surgery.
2. Muscle ap lling surgery of Masahiro
Takano
This is suitable for the treatment of whole
horseshoe-shaped anal stula with the inner
mouth at the back.
Main operative points:
(a) Filling method I
The diseased tissue between the posterior inner port and the primary abscess is
removed, and the drainage wound is made
in the same way as the Hanley procedure.
The muscle ap is used to ll the stula
hole leading to the bilateral branches
(Fig.8.34).
(b) Filling method II
Without cutting the sphincter, the diseased tissue between the internal opening
and the primary abscess is removed from
the anus and the defect is lled with a
muscle ap (Fig.8.35). The subcutaneous
portion of the external sphincter can be
used for lling, but the subcutaneous portion of the external sphincter is thin and
supercial, so it is not enough to use as a
lling material, so it is better to use the
supercial portion of the external sphincter as the lling material.
Internal Sphincterotomy (Eisenhammer Method)
Eisenhammer put forward the theory of “intermuscular stula abscess” in 1958. Based on this
theory, for the treatment of intermuscular abscess
Fig. 8.34 Muscle ap lling of ischiorectal fossa stula
1. The internal mouth and the primary abscess were
incised to make a drainage wound and open drainage. Fill
the wound with a nearby muscle ap to prevent dirt from
invading, and insert a drainage strip at the end of the stula to drain
8 Surgical Treatment ofAnal Fistula
153
Fig. 8.35 Muscle ap lling of ischiorectal fossa stula
2. The part between the internal mouth and the original
abscess was stripped sneakily from the anus, and the mus-
and anal stula, he advocated the incision of anal
crypt and intermuscular abscess from the anus
and performed anal drainage without cutting the
external sphincter but only cutting off part of the
internal sphincter.
Operation points: open the anus with a twolobe anoscope, expose the inner orice area,
gently hook the inner opening position with the
crypt hook, and cut the inner opening and the
inner end of the stula under the guidance of a
crypt hook. The length of the incision is
1.5–2cm, scratch the tissue, and trim the wound.
When the posterior hoof-shaped stula is long,
the incision is cut in the posterior middle inner
mouth area, and then the incision is cut at a distance of 1 cm in each of the two sides of the
pipe. The subcutaneous tissue is separated and
the stula is punctured, and a curette is inserted
into the stula to scrape the anal incision and
the distal end of the stula. The wound is open,
and no drainage strips are placed.
Detachment Therapy (Insert Medicine Therapy)
This is one of the traditional Chinese medicine
treatments. It is a corrosive drug wrapped with
ne cotton paper, such as Hydrargyrum oxyda-
cle ap taken from the surrounding was transferred to the
dead space to be sutured and closed
tum crudum, Hydrargyrum chloratum compositum, or Kuzhisan, and rubbed into a medicine
twist. Or the above drugs plus appropriate
excipients are used to make medicine sticks or
medicine nails. The medicinal twist or medicine
nail and the medicine stick are inserted into the
stula tube to make the tube wall corrode and
fall off, and the purpose of curing the anal stula is achieved.
The treatment of anal stula by the method of
detachment therapy was rst recorded in the
book “The Peaceful Holy Benevolence
Formulae” in the Song Dynasty. It describes the
method of treating the anal stula by dissolving
arsenic in yellow wax and rubbing it into a sliver
and putting it into the hemorrhoids’ tube. By the
Ming and Qing dynasties, detachment therapy
was widely used to treat anal stula. For example, in “Puji Fang” the paper twist of Danfan San
(Chalcanthite, keel, huangdan, snake exuviate,
musk) was put into wounds, and this was the earliest record of the medicine twist without arsenic. “Wai Ke Qi Xuan” detailed the preparation
method of the medicinal twist: rst probe the
size and depth of the pipeline with a probe, and
then apply the medicinal twist according to the
condition of the pipeline, and the principle of
154
R. Shi and L. Zheng
later dressing change is adopted. The treatment
of anal stula by “San pin yi tiao qiang” medicinal strip created by “Orthodox Manual of
External Diseases” had a great impact on later
generations. The Qing Dynasty’s “Wai Ke Da
Cheng” specially introduced the technical
requirements and prognosis of inserting a medicine nail and the result of the misuse of ointments. According to the book, “do not insert the
medicine into the bottom of the tube, such as a
hole depth of one inch, the insertion depth is
preferably 0.7–0.8 inches for the degree, insert it
twice in the morning and evening, …. When it is
observed that there is no carrion in the wound
and its surroundings, switch to Shengji powder.
When the pus is thick, use pearl to promote healing. Do not stick the ointment for fear that it will
drain and the wound will recover slowly.”
Commonly used drugs for the detachment
therapy include Hong Sheng Dan and Bai Jiang
Dan that are sold in pharmacies. No. 1 detachment nail, No. 2 detachment nail, and shengji
nail are self-made, and these are all from the
book “Treatment of Anorectal Surgical Diseases
with Integrated Traditional Chinese and Western
Medicine.”
The No. 1 detachment nail consists of
Baijiangdan 6g, red powder 9g, cinnabar 4.5g,
coptis 9g, raw gypsum 18g, toad venom 1.5g,
and daemonorops draco 9 g. The medicine is
mixed and ground into a ne powder and is added
into 80% japonica rice and 20% rubber powder to
make an adhesive agent. The ratio of the powder
to the adhesive is 5:1. Mix it evenly to make a
nail with a length of 1.5–5cm and as thick as a
matchstick and make spares. It has the effect of
eliminating necrotic tissues and promoting granulation and is anti-inammatory and analgesic
when used in anal stula treatment.
The No. 2 detachment nail consists of 3g of
red powder, 3g of frankincense (roasted), 9g of
myrrh (roasted), 3 g of realgar, 6 g of Cortex
Phellodendri Chinensis, and 6g of Procaine. The
production method is the same as that of the No.
1 detachment nail. After the detachment therapy,
the tube wall falls off, and it can be used if there
is dirt and necrotic tissue in the wound.
The Shengji nail consists of musk; ampelopsis
japonica 3g each; pangolin 6g; catechu, Bletilla
striata, and Angelica dahurica each 3g; cinnabar;
and mercurous chloride and ivory 1.5g each. The
production method is the same as that of the No.
1 detachment nail. It has anti-inammatory and
analgesic effects and is used for promoting tissue
regeneration for astringency. It is used in patients
with anal stula wall already falling off, and the
wound surface is clean without necrotic tissue
after detachment therapy.
Detachment Nail Detachment Therapy
This is suitable for the treatment of low simple
anal stula (straight stula) and complex anal
stula.
Operating points: use a syringe with a thin
plastic tube and ll it with hydrogen peroxide
and saline and thoroughly ush the stula. Then,
the detachable nail is inserted into the stula to
make the whole stula lled with medicine nails.
When inserting the nails, attention should be
paid to making the detachable nails not exceed
the inner opening so as to prevent drugs from
corroding the surrounding of the inner opening
and enlarging it. Cut off the excess medicine
nails at the outer orice to make them ush outside. After covering the sterile gauze, x them
with adhesive tape to prevent the nails from
coming out. The medicine nails should be
replaced once a day, and the stula should be
thoroughly ushed when the nails are changed
so that the medicine can fully touch the tube
wall. This operation is carried out until the ber
granulation tissue of the stula wall is corroded
and peeled off by the detachment nail (generally
in 4–5 days). The signs of complete detachment
of the stula wall are that (a) no more purulent
secretions are owing out of the stula; (b) pain
is obvious when inserting the nails; and (c)
bleeding easily when touching the lumen.
Detachment Therapy withDetachment Nail
andHardening Injection toSeal theInternal
Orice (291 Hospital)
This is suitable for high anal stula and posterior
horseshoe anal stula.
8 Surgical Treatment ofAnal Fistula
155
Operating method: this method is based on the
detachment therapy and involves injecting hardener around the inner opening to promote the
adhesion and closure of the inner opening and
improve the curative effect of detachment therapy.
First, the stula is detached with a detachment
nail. After the brous granulation tissue is removed
from the stula wall, the internal orice is closed.
Closing method: when injecting Xiaozhiling liquid with a syringe, choose a ne needle, and inject
two to three points around the inner mouth, inject
0.5ml of medicine at each point, and then put on
Vaseline yarn. If one closure is unsuccessful, the
second closure can be made. After closure of the
internal orice, the stula is not completely healed.
Shengji nails should be inserted at the internal orice to promote the growth of fresh granulation,
which takes about 4–5 days.
Notes: (a) For complicated anal stula or
horseshoe stula, the proximal canal can be
incised by retaining the anorectal ring (the incision site is within the anal skin line). (b) The
external opening should be enlarged to facilitate
the insertion of nails. (c) Avoid inserting nails too
deep to avoid corroding the inner mouth and
causing inner mouth enlargement, thus affecting
the sealing effect.
Detachment Therapy withMedicinal Twist
andThen Suturing theInner Mouth (Aliated
Hospital ofChengdu College ofTraditional
Chinese Medicine)
This is an improved anal stula detachment therapy based on the traditional detachment method.
After removing the primary lesion, the internal
orice is sutured directly to prevent contamination and infection of the wound by feces. Purulent
scavenging drugs are used to remove the stula
wall and necrotic tissue, reducing the possibility
of recurrence, thus improving the cure rate and
better protecting the anal function.
Operating points: carefully ascertain the position of the inner and outer ports, running pipeline, etc. The anal canal is pulled open with an
anal retractor to fully expose the inner orice.
With the inner orice as the center, an oval incision is made in the size of 1 × 1.5 cm. The
mucosa, submucosa, internal sphincter, and internal and external sphincters are incised gradually.
Open the primary lesion located in the intermuscular tissue from the inside of the anal canal. The
necrotic tissues in the primary lesions are scraped
with a small curette. The infected anal sinuses,
anal glands, anal ducts, and proliferated and
thickened intermuscular tissues are removed and
rinsed repeatedly with normal saline. Fissures in
the internal sphincter are sutured intermittently
with 0/3 intestinal suture to close the medial end
of the stula. Then the upper mucosa of the
medial wound is freed properly to form a pedicled mucosal ap. The mucosa ap is sutured
with the anal skin below by 0/3 intestinal thread
or No. 1 silk thread to seal and cover the inner
orice wound. For the remaining stulas, a small
curette is inserted into the stula to scrape the
necrotic tissue in the stula lumen, with emphasis on the main canal, large branches, and dead
lumen. If there are several external holes, they
shall be dealt with separately in the same way. If
the proximal part of the superior sphincter stula
(posterior horseshoe anal stula) is curved and
difcult to scratch, it can be cut at the bend of the
canal behind the anus and scratched in segments.
Then, depending on the size and depth of the
pipeline, select the appropriate Ke Long Ben
Jiang Dan medicinal twist to insert into the pipeline through the outer opening, leaving 0.5-cmlong drug twist at the outer end for easy removal
when replacing, and pay attention to protecting
the normal tissues around the outer opening to
prevent them from being corroded by the Danyao.
If the outer opening has been closed, it can be cut
into a small hole and then have the medicine nail
put into it with a ball-head probe, taking care not
to cause a false path. If there is connective tissue
hyperplasia around the outer orice, it can be cut
by appropriate trimming or a small circular incision along the outer edge. Finally, Vaseline yarns
are placed in the anus to cover the wound surface
of the inner mouth, and external tower-shaped
yarns are applied and xed as pressure bandaging. A uid diet is administered for 2 days after
the operation, stool control should last for 2–3
days, and antibiotics should be used appropri-
156
R. Shi and L. Zheng
ately. The dressing is changed once a day, and
arnebia oil yarn is used for drainage in the anal
canal. Change the Ke Long Ben Jiang Dan
medicinal twist on the outside of the pipeline
until the pus is removed and then stop using the
twists. It usually takes 4–6 days for the twist to be
used. Then change the Shengji powder or let it
heal naturally.
Internal Orice Incision andPipeline Drainage
withMedicated Thread (Li Yunong)
This is suitable for complex anal stula with multiple external orices and curvature of the stula
canal, accompanied by many branches, and the
external mouth distance from the anal margin is
above 5cm.
Operational essentials: under the local anesthesia of the anal margin, the inltration anesthesia is performed with procaine or lidocaine
containing a small amount of adrenaline around
the stula. Dye the stula with methylene blue
mixed with hydrogen peroxide. If the inner opening is in the posterior position, open the inner
mouth, anal recess, and part of the anal internal
anal sphincter, and open the deep postanal space.
If the inner opening is elsewhere, only the inner
mouth, anal recess, and part of the anal sphincter
are incised. Use a soft probe with a round head to
slowly penetrate from the outside orice, through
the stained inner orice, and scratch stula with a
curette. Scrape all the stained tube wall granulation, extract the probe, and lead the medicated
line into the stula, loosely ligate both ends of the
drug line, dry the gauze locally, then wrap it with
an absorbent cotton pad, and x it with adhesive
tape. Hot saline sitz bath is used after defecation
after the operation. Change the medicated line
one time on the second day after the operation,
and withdraw the medicated line on the second
day after indwelling. The incision is dressed daily
with Jiuhua ointment gauze until the wound
healed.
Ligation oftheIntersphincteric Fistula
Tract (LIFT)
In 2007, Thai doctor Rojanasakul and others
introduced a new type of sphincter preservation
surgery, namely ligation of the intersphincteric
stula tract (LIFT), in the Thai Medical
Association Journal. After the publication of the
paper, it attracted the attention of the Center for
Colorectal Surgery and Pelvic Floor Diseases at
the University of Minnesota Hospital, and it conducted a multicenter study of LIFT surgery in the
United States to promote this new technology.
LIFT surgery has a high application value for
mature low sphincter anal stula and mature and
unbranched high sphincter anal stula. LIFT surgery is seen as a rst-line treatment and as important as stula incision and thread drawing.
Operation points: use spinal anesthesia or
general anesthesia, take the prone folding knife
position or lithotomy position. First, hydrogen
peroxide is injected from the external opening of
the anal stula to identify the internal opening,
and then a probe is used to probe in from the
external opening and pierce out from the internal
opening, and this is used as a sign for the stula.
An arc- shaped incision about 2–3 cm long is
made along the outer edge of the internal and
external sphincter groove. The combination of
sharpness and bluntness separates the internal
and external sphincter groove. Fully expose and
free the brotic stula, and the stulas are
clamped and ligated as close as possible to the
inner orice (internal sphincter) of the intermuscular stulas. Cut off the intermuscular stula
and remove any excess remaining parts of the stula. Then, clamp, ligate, or suture the external
opening of the intermuscular stula, and use the
absorbable suture to close the defect of the external sphincter at the external opening of the intermuscular stula. The external orice of the anal
stula and the stula outside the sphincter are
excavated down the tunnel, and the wounds are
opened for drainage (Figs.8.36 and 8.37).
A systematic analysis of the study of LIFT
surgery for anal stula by Yassin etal. showed
that the success rate after summarizing the data
was 71%. A total of 183 patients were evaluated
for anal function, and 11 (6%) had mild anal
incontinence. A randomized controlled trial with
the repair of shift muscle ap showed no statistical signicance in the difference of success rate
between the two. After stratied analysis, the
cure rate of LIFT surgery in high complex sphinc-