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myocardial duct
the intermuscular fistula
ab c
8 Surgical Treatment ofAnal Fistula
Fig. 8.36 LIFT operation indication
157
ter anal stula and recurrent anal stula was only
50 and 33%, and most of the failed cases occurred
within 6 months after surgery. In another metaanalysis of LIFT surgery, the cure rate was 76.5%
with a median follow-up period of 10 months, the
decline rate of anal function was 0, and the incidence of postoperative complications was 5.5%.
It was also reported that LIFT surgery combined
with biological patch or anal plug technology
(bio-lift or LIFT plug) could not improve the success rate of anal stula surgery. There were also
reports of using LIFT surgery combined with
repair of shift muscle ap or intraoperative thread
drawing for anal stula, which did not improve
the success rate of treatment. Comparing the
effect of preoperative thread-drawing drain and
preoperative, nonthread-drawing drain, there was
no statistical signicance in the difference of success rate between the two.
Incision between the
internal and external sphincter
Pick out the fistula after
separating the muscle
de f
Removal of part of
Fig. 8.37 LIFT procedure. (a) Incision between the
internal and external sphincter. (b) Pick out the stula
after separating the muscle. (c) Tie the medial end of the
Suture the lateral end of
intermuscular stula. (d) Removal of part of myocardial
duct. (e) Suture the lateral end of the intermuscular stula.
(f) Suture the wound between the sphincter muscles
Tie the medial end of the
intermuscular fistula
Suture the wound between
the sphincter muscles
158
R. Shi and L. Zheng
Shao Wanjin believed that the types of anal
stula failure treated by LIFT surgery are diverse,
and the causes leading to the continuous existence or recurrence of anal stula may be the
untreated internal mouth, residual stula between
sphincters, and secondary infection between the
sphincters. The history of perianal abscess incision and drainage or the history of anal stula
surgery and the number of stulas and external
orices had no signicant effect on the outcome
of LIFT surgery for high sphincter anal stula. It
is suggested to ligate or suture the internal
sphincter as close as possible to the inner mouth.
Resecting the residual sphincter stula as much
as possible can reduce recurrence. Flap drainage
between the sphincters can reduce the chance of
secondary infection; full-thickness suture of
sphincter intermuscular wounds can reduce the
occurrence of incision dehiscence.
Ren Donglin etal. believed that complex anal
stula in a high position behind the anal canal is
often associated with the involvement of the posterior deep sphincter gap and the superior
puborectalis gap. Most of the recurrence cases
after LIFT surgery are due to residual secondary
infection in this deep space. The causes of residual infection in the posterior deep sphincter space
and superior puborectalis space may include the
following two reasons: (a) the position of the
rst-stage drainage of the hanging line is low so
that the acute stage abscess of the two deep muscle gaps is not well drained and relieved. (b) In
the second LIFT surgery, the longitudinal free
layer of the sphincter gap was insufcient, and
the chronic stula located in the deep slant to
these two deep muscle gaps was not completely
eradicated.
How to improve the LIFT operation method
and improve its cure rate so that it can be more
effectively applied to the treatment of high complex anal stula, etc., still needs further
exploration.
Fibrin Glue Sealing
Medical bio-protein glue is a biodegradable,
absorbable biological preparation. The prepared
biological protein glue is injected into the stula
to ll the defect tissue and seal it. A biological
structure is established in the stula, and the new
granulation tissue accelerates growth along the
structure. The bio-protein glue gradually
degrades, and the stula is eventually lled with
fresh granulation tissue.
Main operative points: preoperative bowel
preparation is performed according to routine
colorectal surgery. Spinal anesthesia or epidural
anesthesia is used to completely relax the pelvic
oor muscles and sphincters. Routine skin and
anorectal cavity disinfection is carried out and
fully dilates the anus. Preoperative ultrasonography, contrast imaging, and magnetic resonance
examination are performed to determine the
direction of the stula, its position, and the orientation of internal and external orice. First, the
expansion of the external opening of the main and
branch canal and the external opening of the blind
cavity is performed. In some cases, a paracanal
stoma is also required. The inner wall of the stula is scraped to the internal opening with a curet
to scrape away the rotting esh and unhealthy
granulation tissue of the stula wall. The anus
hook is used to expose the inner orice, and use a
probe to reach out from the inner opening. With
the inner opening as the center, the inner opening
and surrounding mucous membrane tissues are
resected, and the infected anal sinus, anal gland,
and glandular duct are completely removed until
healthy tissue is exposed. Repair and separate the
mucosa, submucosa, and some muscular-layer
tissues in the inner opening, and make them into
the upper and lower labellum. The stula and orice are repeatedly rinsed with hydrogen peroxide,
metronidazole injection, and gentamicin injection, and wiped dry with a sterile gauze. Stitch the
muscle layer with a 3/0 absorbable thread “8.”
The brin glue is injected from the inner opening
or the united main external orice tube under
direct vision until the inner and outer orices
overow. After observing for a moment, the upper
and lower label-like mucosal muscle aps are
sutured with absorbable line in the shape of a discontinuous number “8” and knotted to close the
inner mouth. Fibrin glue is injected into each
branch in the same way, the wound and external
orice are covered with saline gauze, and the
wound is xed with an external gauze pad.
8 Surgical Treatment ofAnal Fistula
159
Rehydration only after surgery, and fasting is for
3 days. Keep the anus and wounds clean, and disinfect the wounds daily. Mucosal protection suppositories are inserted into the rectum, and
antibiotics are administered intravenously for 6–7
days. Prevent dry stools and prohibit strenuous
activities within 1 week of surgery.
According to domestic reports, the cure rate of
anal stula treated with brin glue is more than
90%. However, according to reports in previous
literature, the healing rate of anal stula treated
with brin glue ranges from 14 to 90%, and its
recurrence rate ranges from 15 to 86%. The overall efcacy is not satisfactory. A retrospective
analysis of all cases of brin glue-treated composite anal stula by the Department of Anorectal
Surgery at the University of Washington School
of Medicine was undertaken. Patient statistics,
treatment history, surgical information, and early
postoperative follow-up were obtained from the
patient’s medical records, and telephone interviews were used to identify the cure and recurrence of anal stula and even further treatment.
Fishery’s accurate detection was used for data
analysis. Results: a total of 42 patients received
this treatment between 1999 and 2002, including
19 males, aged 20–76 years. The causes of anal
stula were 22 cases of anal cryptitis, 13 cases of
Crohn’s disease, and 4 cases of ileal storage anal
anastomosis. Types of anal stula were divided
into 33 cases of intersphincter stula, 3 cases of
transsphincter anal stula, 2 cases of upper
sphincter anal stula, and 3 cases of rectovaginal
stula. Initially, most patients had anal stula
healing, but the recurrence rate was high. The
cure rates according to the cause were anal cryptitis 23%, Crohn’s disease 31%, and ileal storage
anal anastomosis 75%. According to tissue classication, the cure rates are intersphincter stula
33%, transsphincter anal stula 0, sphincter
superior anal stula 0, rectovaginal stula 33%.
The cure rate for patients who had not received
treatment before was 38%, compared with 22%
for those who had previously received treatment.
Eight patients were treated with brin glue again,
but only one was cured. The average follow-up
period of anal stula healing was 26 months.
Therefore, brin glue is considered to have a low
success rate in the treatment of complex anal stula, and most cases relapse within 3 months after
surgery. However, due to its relative simplicity,
brin glue closure is still recommended as a rstline solution for the treatment of complex anal
stula. The main points that should be mastered
in this operation are that (1) incision is made in
the lower stula and drainage should be unobstructed; (2) scratch the open stula and cavity
until the microvessels of the tube wall ooze
blood. After the removal of necrotic tissue and
debris, rinse with hydrogen peroxide and normal
saline, and dry the residual liquid in the stula
and cavity. (3) The congured brin glue is
injected from the deep part of the open pipe to ll
the pipeline and the cavity without leaving a
residual cavity.
Fibrin glue is composed of two reagents, A
and B.Reagent A mainly contains high concentrations of brin and blood coagulation factor X
III, while reagent B mainly includes prothrombin
and calcium chloride. After the A and B reagents
are in contact, the prothrombin activation is converted to thrombin, which hydrolyzes brinogen
and converts it into brin. At the same time, in the
presence of calcium ions, thrombin can activate
blood coagulation factor XIII and nally form a
stable insoluble brin multi-body, which can
bind tissues and block defects and can also stimulate the growth of capillary endothelial cells and
broblasts. The brin network is used as a scaffold to form fresh granulation tissue, which promotes wound healing and accelerates stula
closure. Fibrin glue has good histocompatibility,
rarely produces severe allergic reactions, has no
invasiveness, and does not affect the normal
function of the sphincter.
The use of brin glue alone has a weaker
blocking force on the inner mouth. The method
of brin glue sealing and inner mouth suture xation can enhance the blocking force and block the
communication between the stula and the intestines so as to create the necessary conditions for
healing the stula.
Biological Patch Filling
A biological patch refers to a patch of tissue
taken from the same or different species. After
160
R. Shi and L. Zheng
decellularization treatment, the various cells contained in the tissue are removed and the threedimensional framework structure of the
extracellular matrix is completely preserved. It is
a biological material that can be used to repair
human soft tissues. The main component of a
biological patch is protein, and its repair mechanism is “endogenous tissue regeneration,” which
induces stem cells to enter the biological patch
and secrete extracellular matrix, gradually replacing the degraded implants. Biological patch lling is essentially a new material application. It is
based on the thorough removal of the internal
mouth and the stula. The biological patch is
used to ll the stula after the closure of the internal mouth in order to cure anal stula. At present,
it is mainly used for the treatment of simple anal
stula and rectovaginal stula. The current report
shows that it is mostly used in the treatment of
low anal stula in the nonacute inammatory
phase and complicated anal stula with a single
stula. There have also been successful reports
on the treatment of complex anal stula with
multiple external orices by biological patch lling of the branch canal.
Main operative points: make a circular incision at the inner and outer mouths, and then use a
curette to dig deep into the canal cavity to fully
remove the brous tissue and carrion in the tunnel, and cut off some of the wall if necessary.
Then, rinse the wound cavity with metronidazole
solution, etc. and dry it with gauze. The bio-patch
is then trimmed to the appropriate size, and the
bio-patch is rolled up with a silk thread and
pulled into the anus from the outer mouth. For
patients with complex anal stula with two external orices and sinus channels, the patch materials are cut into two forks and two sinus channels
are lled, respectively. It is sutured with 2-0
absorbable suture and xed on the submucosa at
the inner mouth to seal the inner mouth. Cut off
the excess patch from the outer mouth of the
anus, and open the wound at the outer mouth
without suturing. Control defecation within 24h
after surgery, and have a semiuid diet on the
second day after surgery. Postoperative routine
use of antibiotics should last for 3–5 days usually
in the form of intravenous drip of second-
generation cephalosporin antibiotics. Warm bath
and dressing change two times a day should be
carried out for a few days after the operation.
Note:
1. It is important to choose the indications and
timing of treatment carefully. It is recommended to perform the surgery after inammation of the tissue around the stula has
completely subsided for 3–6 months, as this is
expected to improve the success rate. In the
treatment of rectovaginal stula, a stula
diameter of ≤1.5cm is appropriate.
2. The bio-patch should be soaked in 0.9% physiological saline for one to two minutes before
being placed in the stula. According to the
diameter and length of the stula, the biological patch should be trimmed to an appropriate
size, and the biological patch is closely tted
to the wall of the stula without tension.
Excessive biological patch will form foreign
body stimulation, which is not conducive to
the degradation of the biological patch and
tissue growth, and too little biological patch
can easily fall off.
3. Effective tting of the biological patch to the
tissue is the key to the survival of the biological patch and the success of the operation.
After the patch is placed, it can be rotated 90°
clockwise or counterclockwise to ensure that
the patch ts better with the tissue. The patch
should be properly sutured and xed with the
rectal muscle layer. Several stitches are used
to x the submucosa at the inner mouth with
2-0 absorbable suture. Under the induction of
the reticular scaffold, the local granulation tissue secretes the extracellular matrix as quickly
as possible, gradually replacing the degraded
implant. The composition of the bio-patch is a
copolymer of polylactic acid and polyglycolic
acid, which can be gradually hydrolyzed and
absorbed in about 14 days in the body, and no
stitching is required.
4. When used for the treatment of rectovaginal
stula, the rectal side stula is mostly the primary site, so the intraoperative suture closes
the high-pressure stula on the rectum side.
The vaginal stula is opened without suture
8 Surgical Treatment ofAnal Fistula
161
to facilitate drainage and reduce the chance
of infection.
According to Wang Zhenjun’s report, a small
amount of pale yellow secretion exuded from the
outer mouth of the stula within 1–3 days after
the stula was lled with the acellular dermal
matrix material. The healing time of stulas was
7–14 days, with an average of 12.1 days.
Postoperative follow-up was conducted for 3–6
months (all cases lasted for more than 3 months
and 70% cases lasted for more than 6 months), 40
patients were cured in the rst stage, 3 had
delayed healing, and 7 saw recurrence. The anal
stula cure rate was 80% (40/50), and the recurrence rate was 14% (7/50), no anal malformation
occurred, and anal sphincter function stayed
normal. At present, it has been used to treat more
than 1000 cases in China. Some hospitals have
been following up patients for more than half a
year, and the success rate is about 70%. It is
believed that this minimally invasive, restorative
treatment that does not impair the function and
appearance of the anus, even if it fails, can be
treated again with the same treatment after drainage, and there is still a similar success rate.
Currently, doctors are trying to nd ways to
increase the success rate of treatment and reduce
the recurrence rate. At the same time, the current
bio-patch material is expensive, and ways of
improving the cost-effectiveness of this treatment
are worth looking into.
Endorectal Advancement Flap
Endorectal advancement ap (ERAF) is a method
of treating anal stula by using the mucous ap
or mucous muscle ap above the wound of the
inner mouth and moving it downward to cover
the wound of the inner mouth after suturing and
xing it. This technique was rst used by Noble
in the treatment of rectovaginal stula. In 1912,
Eltmg applied the method to the treatment of anal
stula. In 1948, Laird improved it, and it is currently used to treat anal stula, rectovaginal stula, and rectal rectourethral stula caused by
various factors. In addition, it is also used for the
treatment of anal canal stenosis, rectal cancer,
anal canal defect, and anal ssure.
Main operative points: after successful anesthesia, the surgical eld is fully exposed.
Determine the position of the internal mouth and
completely remove the inner mouth and surrounding diseased tissues. A “U”-shaped mucosal ap is made above the inner mouth, and the
exfoliated mucosal ap includes the mucosa, the
submucosa, and a portion of the internal sphincter, which together forms a mucosal ap with a
bottom wider than the top (the bottom is about
two times wider than the top). After suturing the
sphincter gap at the inner mouth, the mucosal
ap is pulled down to cover the sutured wound.
The mucosal ap is properly freed to relieve tension, and the ap is then sutured with the surrounding tissue with absorbable sutures
(Fig.8.41). The stula can be removed by tunneling, and the stula can also be closed by suture
after resection.
Pay attention to the following three aspects
during surgery:
1. Exposure of the surgical eld: because most
of the ERAF operation is done in a narrow
anorectal cavity, good exposure of the surgical eld is very important. According to the
position of the inner mouth, choose the position that is advantageous for the operator. If
the inner mouth is on the back side of the
anus, the lithotomy position is used; if the
inner mouth is on the front side of the anus,
select the prone position. Both the Parks
retractor and the Lone Star retractor can help
to expose the surgery eld. However, the continuous pulling of the anorectal sphincter by
the Parks retractor may cause the anal function to weaken, while the Lone Star retractor
does not.
2. Freedom and thickness of the advancement
ap: a good blood supply and tension-free
suture are the necessary conditions for the
ideal healing of the ap. Therefore, the
mucous ap should be free to move upward at
least 4 cm, and ensure that the base (head
side) width of the ap is twice the length of
the top (tail side).
Some doctors like to use partial-thickness
ap with a small amount of internal sphincter
162
R. Shi and L. Zheng
muscle. A full-thickness ap containing the
mucosa, submucosa, the full-thickness internal sphincter, and part of the rectum annulus
muscle or a mucosal ap without the muscularis are selected for coverage. Some studies
have found that compared with full-thickness
ap, a mucous ap is more prone to necrosis
in the early postoperative period (within 3
months), leading to surgical failure, and this
may be related to poor blood supply and the
inability to form a strong anti-infection barrier. The full-thickness ap has higher requirements for the surgeon, and a certain degree of
surgical risk in the freeing of the full- thickness
ap, while the partial-thickness ap operation
is relatively simple and safe. Considering that
the muscle structure of the female perineal
body is relatively weak, it is better to choose
the mucous ap without a muscular layer for
female anterior stula.
3. Treatment of the stula and the external orice: the stula treatment methods described
in the literature include coring out or core stulectomy and curetting. To avoid iatrogenic
damage to the sphincter during the treatment
of the stula, the stula between the outer
mouth and the external sphincter can be
treated by coring out, and the stula through
the external sphincter can only be curetted.
After excision of the glandular crypt and epithelial tissue around the internal orice, the
defect produced here can be sutured intermittently with a 2-0 or 3-0 absorbable suture.
This will support and protect the rectal ap
that covers it. Injecting physiological saline
from the outer mouth can verify whether the
suture is secure. Postoperative wound drainage at the external mouth should always be
kept unobstructed to prevent local infection
from accumulating at the suture, resulting in
surgical failure. Most doctors use open drainage, but Uribe etal. used a vacuum suctionassisted approach for closed drainage, and
this also achieves a higher cure rate.
Jarrar etal. summarized the treatment principles of mucosal advancement ap surgery as follows: the precise anatomic morphology and
position of anal stula are dened before the
operation. The stula inammation should subside by adequate drainage. Close the inner orice
rmly by layered suturing. Avoid the occurrence
of dead space, tension, and ischemia. The treatment of the stula should also be just right to prevent abscess formation. In addition, careful
hemostasis should be paid attention to during the
operation. The rectal mucosa or skin ap used for
repair must have a wide base, a wide pedicle, and
a good blood supply. Stitching should completely
eliminate tension.
In order to improve the success rate of mucosal advancement ap surgery, it is very important
to choose the appropriate indication. This requires
a healthy rectal tissue to cover and repair as the
advancement ap. Therefore, patients with
Crohn’s disease with active inammation or
active proctitis are not suited to the advancement
ap treatment. Jarrar et al. believed that local
infection not under control was the main reason
for the failure of the mucosal advancement ap
operation. He advocated routine preoperative
thread-drawing drainage for 6 weeks to fully
achieve stula brosis. Van der Hagen et al.
believed that for refractory anal stula, the initial
hang-line drainage can reduce the inammatory
response before the nal surgery, regardless of
whether or not the fecal bypass is performed,
thereby achieving a better therapeutic effect.
Many studies have shown that the recurrence rate
of mucosal advancement ap surgery treatment
for Crohn’s disease anal stula is higher than that
for glandular anal stula. Sonoda etal. believed
that even if there is no evidence of inammatory
activity in the rectum, patients with anal stula
who need to take large doses of hormones should
not receive ERAF treatment.
The advantage of mucosal advancement ap
surgery is that the free rectal mucosal ap or
mucosal muscle ap is used to cover the wound
at the inner mouth to close the high pressure end
of the stula so that the enteric contents or bacteria cannot enter the stula, thus making the lateral stula gradually shrink until it closes. The
advantages of this technology are that the integrity of the anal sphincter is maximally protected,
thereby protecting its function. The healing time
8 Surgical Treatment ofAnal Fistula
163
is short, postoperative pain is light, and the diversion stoma can be avoided. Even if the operation
fails, it will not affect further reoperation.
The cure rate of treating anal stula with the
mucosal advancement ap to cover and close the
internal mouth is 67.0–80.8%. Through literature
research, Jacob et al. conducted a retrospective
analysis of anal stula cases operated on from
1950 to 2009 according to surgical methods and
concluded that the rate of anal incontinence after
treatment of anal stula with brin glue and rectal
advancement ap is lower than that of other surgical methods. Uribe et al. observed 90 cases of
patients with complex anal stula treated with stula resection and rectal advancement ap to close
the internal orice, and the maximum resting pressure and maximum systolic pressure of the anal
canal after the operation were signicantly
reduced, and the recurrence rate was low. Abbas
etal. treated 36 patients with complex anal stula
with rectal advancement ap and observed the
long-term efcacy. Results: two patients were
unhealed, and all the others were cured. Mitalas
et al. found that the success rate after the rst
ERAF failure was the same as that after the second
ERAF failure (67% vs. 69%), and the overall success rate of the two repairs was 90%. Jarrar etal.
treated 21 patients with failed initial treatment of
ERAF with more than one repair advancement
ap treatment, and the cumulative success rate
reached 76%. Stremitzer et al. performed ERAF
on nine patients who had previously failed treatment with a success rate of 78%. Mizrahi et al.
also obtained similar results using the same strategy. The patient should be evaluated for etiology,
imaging, and anal function before reoperation. If
there are concerns about tissue blood supply and
tension, a full-thickness ap can be used as the
covering tissue to improve the treatment success
rate. Some authors believe that after the failure of
the mucosal advancement ap treatment, a wide
scar is formed in the surgical area. To ensure a
good blood supply, it is recommended to adopt a
full-thickness ap tissue when repairing again. In
order to avoid mucosal ectropion, some authors
chose the advancement ap during the second
repair, which also achieved a high cure rate.
In China, Li Shengming retrospectively analyzed 23 patients with high anal stula treated
with transanal rectal mucosal advancement ap
internal mouth repair. All the patients were cured.
Hooker etal. treated 15 patients with high anal
stula with the ap of the distal end of the inner
mouth advancement inward and closed the internal mouth. Compared with the traditional low cut
high thread surgery, the former had shorter course
of treatment, less pain, and no obvious complications. Gong Aimin reported that 20 cases of high
anal stula were treated with gluteus maximus
muscle advancement ap, and the cure rate was
100%. In addition, it has been reported that the
application of rectal mucosal advancement ap
for the treatment of anal stula in children has
also achieved good results.
Wang Zhenjun believes that ERAF has the
longest history in the clinical application of
“retaining sphincter” technology in treating anal
stula. According to reports from different pieces
of literature, the median cure rate of this surgical
approach is about 70%. But technically, this surgical approach does not fall into the category of
the “completely preserved sphincter technique.”
The process of dissociating the rectal ap requires
the injury of part of the internal sphincter.
Therefore, this surgical method also has a certain
degree of inuence on postoperative anal function. In some pieces of literature, the rate of
decline in anal function can reach about 35%. In
addition, ERAF surgery is also a skill-dependent
procedure. Postoperative complications such as
hematoma formation under rectal ap, rectal
valve rupture, or necrosis are often closely related
to the surgeon’s experience and surgical skills.
Although ERAF surgery and various modied
procedures are relatively “minimally invasive”
procedures that have long been clinically validated and proven effective, ERAF surgery has no
signicant advantage in the treatment of most
cases of adeno-derived complex types of anal stula compared with cutting in stages and the
hanging line therapy. Therefore, Ren Donglin
believes that ERAF should not be advocated as a
rst-line surgical method for the treatment of
complex anal stula. But for experienced sur-
164
R. Shi and L. Zheng
geons, it is reasonable to select suitable patients
for ERAF surgery.
Perianal Skin Advancement Flap Repair
This is a method for treating anal stula by using
the anal canal skin ap under the inner mouth
wound surface and moving upward, covering the
inner mouth wound surface, and suturing and xing it, and the indications are the same as that of the
mucosal advancement ap surgery. In the 1980s,
the technique of the advancement ap was widely
used in the treatment of anal stula in Japan.
Operation points: make a trapezoidal incision
in the perianal skin, the base should include the
internal opening, and the side wall should include
the external opening. Free the ap in the subcutaneous fat layer to ensure no tension, completely
remove the stula, move the ap to the proximal
end, and suture and x it with the mucosa above
the anal canal inner mouth. The lower wound of
the ap is opened and drained (Fig.8.38).
Compared with the mucosal advancement
ap, the skin advancement ap has a lower
requirement for anal canal exposure, but the
blood supply is relatively poor, and patients with
skin inammation and fragile skin are not suitable for treatment with skin advancement ap. In
addition, after the skin advancement ap is used,
feces can easily enter the wound surface below
the suture between the ap and the rectal mucosa,
leading to infection and thus failure of the
operation.
In China, Song Yinggang reported that the
short-term cure rate and long-term cure rate of 50
cases of complex anal stula were 96% and 78%,
respectively.
The author believes that both the rectal mucosal advancement ap and the perianal skin
advancement ap to repair the internal orice of
the anal stula are only the technical means of
treating the internal mouth wound in the treatment of anal stula, rather than an anal stula
treatment technique with an essential breakthrough in treatment principle. The key to the
cure of anal stula is the complete removal of the
internal orice and the primary lesion, and the
treatment of the stula and the external orice in
the sphincter. If these key steps are not handled
correctly and are not in place, the anal stula will
not be cured even if the internal mouth wounds
are repaired well. Therefore, we should avoid
emphasizing the decisive effect of one treatment
technique in the treatment of the efcacy,
although one part of the procedure in the surgery
will affect the overall efcacy.
Minimally Invasive Video-Assisted Anal Fistula Treatment
Video-assisted anal stula treatment (VAAFT) is
a technique that combines the concept of endoscopic surgery and the concept of minimally
invasive treatment with the treatment of anal stula endoscopic.
Operation points: anal stula mirror and supporting equipment should be used to complete
the operation. The set of instruments includes
the anal stula mirror, sealing rod, unipolar electrocoagulation, endoscopic grasping forceps,
endoscopic brush, and three-leaf anoscope. The
anal stula lens is an 8° bevel mirror with an
optical channel, operation channel, and perfusion channel. The two interfaces with valves are
Fig. 8.38 Anal stula moving ap repair operation
8 Surgical Treatment ofAnal Fistula
165
connected to a 1.5% glycine solution and a vacuum suction.
The operation is performed under intraspinal
anesthesia. According to the position of the external mouth, the patients are placed in the lithotomy position or the folding knife position. The
surgical procedure can be divided into two parts:
the diagnosis stage and the treatment stage.
1. Diagnosis stage: the goal is to accurately
locate the internal orice and explore the possible stula branches and abscess cavity.
Under the continuous perfusion of glycine
solution, the anal stula lens is introduced
from the external mouth. Sometimes it is necessary to remove scar tissue around the external mouth to facilitate the insertion of the anal
stula mirror. Keep the sealing rod at the bottom of the display as a guide, and the stula
situation can be clearly presented on the display (Fig.8.39). Introduce the mirror slowly
until the position of the stula end inner opening is found. At this time, the three-lobed anoscope is inserted, and the light source of the
anal stula mirror can be seen under the rectal
mucosa, which is the position of the inner
mouth (Fig.8.40). Sew two to three stitches
around the inner mouth to isolate the inner
mouth. Be careful not to close the inner mouth
at this time.
2. Treatment stage: the purpose of this is to
destroy the stula tissue from the inside,
clean the stula, and then nally close the
inner mouth. The sealing rod is removed, and
the electrocoagulation electrode is introduced. The stula is removed from the inside
to the outside under direct vision (Fig.8.41),
and the necrotic tissue adhering to the wall of
the stula is electrocauterized. Endoscopic
brush or endoscopic grasping forceps are
Fig. 8.40 Internal opening by video-assisted anal stula
treatment (VAAFT)
Fig. 8.39 Fistula seen by video-assisted anal stula treatment (VAAFT)
Fig. 8.41 Treatment of stula under video-assisted anal
stula treatment (VAAFT)
166
R. Shi and L. Zheng
used to remove necrotic materials. The exfoliated necrotic material can also be ushed
into the rectal cavity through the inner mouth
and discharged. Carefully explore to avoid
missing possible branch stulas and abscess
cavities. After the stula is cleaned, lift the
inner opening and close it with a stapler or
suture it with an absorbable suture. The biological protein glue is injected into the stula
from the outside mouth. The outer mouth is
opened for drainage.
3. Postoperative treatment: a uid diet is started
six hours after surgery, and oral parafn oil is
administered at the same time. On the rst day
after surgery, the perineal dressing is removed,
and a semi-liquid diet is given after defecation.
Antibiotics are not routinely used after surgery. Different from traditional surgery,
VAAFT surgery treats the stula by endoscope
without incision or resection of the stula, so
there is no obvious damage to sphincter function. VAAFT surgery can accurately locate the
anatomical position of the internal orice and
stula under the direct vision of the anal stula
mirror, and it is easy to nd potential stula
branches and abscess cavities. The stula wall
is damaged by electrocautery, and the necrotic
tissue is removed under the direct vision. The
inner port is usually closed by a stapler or
hand-stitched, and the inner port is further
sealed by glue. Foreign literature has reported
that VAAFT surgery has a high cure rate for
complex anal stula and can protect the function of the anal sphincter well.
In order to ensure the smooth operation of the
VAAFT surgery and reduce postoperative complications, the following key points should be
noted during the operation.
1. Exploration of the stula: all possible stula
branches and abscess cavities are carefully
explored to distinguish true stulas and pseudostulas. Granulation tissue with red edema
can be seen in the true stula, and the pseudostula is white and has no edema.
2. Treatment of stula: the wall of the stula
should be fully cauterized from the inside to
the outside. Since the operation hole is located
below the anal sinus mirror, the lower wall
treatment is convenient, while the lateral wall
or upper wall may need to be rotated completely to facilitate the treatment.
3. Processing of the inner mouth: use the threeleaf anoscope to expose and locate the internal orice under the instruction of the anal
stula mirror. There is currently no clear evidence that Endo-GIA closes the inner mouth
better than hand stitching, but Meinero etal.
believe that the former may work better. Other
researchers used rectal mucosal advancement
ap or perianal advancement ap to close the
internal orice.
4. Prevention and treatment of postoperative
complications of VAAFT: electrocoagulation
can cause thermal damage to the normal tissue next to stula granulation tissue, so the
power of high-frequency electrotome should
be about 40W, and the monopolar coagulation mode should be used. The submucosal
tissue around the inner mouth is relatively
loose, and care should be taken to avoid the
formation of false passages here. In addition,
hypotonic glycine irrigating uid often leads
to edema in the surrounding tissue of the stula and may also bring necrotic material in
the stula into the surrounding normal tissue
resulting in delayed healing or recurrence of
the stula. Therefore, reducing perfusion
pressure, shortening operation time, and
avoiding the formation of false passages are
helpful to reduce edema of the stula’s surrounding tissues and thus reduce the risk of
postoperative infection.
According to Liu Hailong, of the 11 patients
that successfully completed VAAFT surgery, 10
were treated with the suture method and 1 patient
with Endo-GIA. The operation time was
42.0 ± 12.4 minutes, and hospital stay was
4.1±1.5 days. One patient had anal hemorrhage
after defecation on the third day after the operation. The rectal mucosal tear was seen at the
internal suture after reoperation; the patient was
discharged after the wound electrocoagulation
occurred. During the follow-up period of 1.0–3.2