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Surgical Steps
1. Patient positioning: prone jackknife position.
2. For elective cases: pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia
to improve relaxation of the anal sphincter muscles.
3. Insertion of anal retractor and circumferential examination of dentate line: identification of primary opening? If not
visible: testing with injection of peroxide into secondary opening (avoid overflow spill)
appearance of bubbling at a
primary opening?
4. Careful probing of fistula tract with curved silver probe taking care to avoid creating new tract by forceful
advancement. If insertion is not easy: placement of Kocher clamp to external opening and centrifugal traction (ie,
away from anus) to straighten fistula tract while trying to insert probe again. If still no success: partial external
fistulotomy to reassess course vs fistuloscopy (using ureteroscope). If primary opening cannot be found despite all
attempts: removal or wide drainage of sinus, but unfortunately high chance of failure and reopening of a fistula later.
5. Fistula tract successfully probed
assessment of the extent of sphincter involvement:
a. Fistulotomy: very superficial tract without relevant sphincter involvement (< 20%)
fistulotomy from
secondary to primary opening along the probe (eg, with electrocautery).
b. Cutting seton: > 20% sphincter involved
cutting seton: devision of mucocutaneous layer between two
openings without cutting through muscle (caveat: no cutting seton over intact skin), pulling in a suture tied to
edge of gauze, scrubbing out fistula tract (with gauze or brush)
pulling in seton (eg, an elastic vessel loop),
which is tied down with three sutures such that it just sits on the muscle without strangulating it.
c. Draining seton: > 20% sphincter involved but seton placement only to cool off suppuration, prevent recurrent
abscesses (eg, long-term setons in Crohn disease), or mature fistula without immediate plan to eliminate fistula
(but, eg, later fistula surgery with collagen plug): seton pulled into tract and tied to itself without division of
mucocutaneous layer between primary and secondary opening.
6. Hemostasis.
7. No dressing needed.
Anatomic Structures at Risk
Anal sphincter complex, anal configuration ( risk of keyhole deformity).
Aftercare
Open wound care until complete healing (fistulotomy), skin closure except for seton (cutting/draining seton): sitz baths or
showers twice per day, after bowel movements.
Cutting seton: tightening of cutting seton in monthly intervals until it has eroded through the involved sphincter complex
(leaving a scar behind): (Figure 5–3).
Complications
Bleeding, urinary retention (sign of sepsis?), recurrent infection, pelvic/perineal sepsis, recurrent/persistent fistula (10–
15%). Fecal incontinence (benchmark < 5%): anal disconfiguration, sphincter weakness.
Cross-Reference
Pain, perirectal (Ch. 1)
Perianal/-rectal abscess (566) (Ch. 4)
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Perianal/-rectal fistula (565.1) (Ch. 4)
Hidradenitis suppurativa (705.83) (Ch. 4)
Modified Hanley procedure for horseshoe fistula/abcess (Ch. 5)
Fistula-in-Ano—Endorectal Advancement Flap (Ch. 5)
General perioperative management—anorectal (Ch. 7)
FISTULA-IN-ANO—ENDORECTAL ADVANCEMENT FLAP
Principle
Closure of the primary fistula opening by means of a plication of the muscle layer and an overlying advancement flap to
cover the site of the opening to induce an obliteration of the fistula tract once it is not fed anymore.
Setting
Outpatient, OR, general anesthesia.
Alternatives
Nonoperative management: generally not indicated if fistula is symptomatic.
Fistulotomy/fistulectomy.
Seton management.
Collagen plug for perirectal fistula, fibrin glue injection.
Modified Hanley procedure.
Indication
Fistula-in-ano.
Preparatory Considerations
Clinical assessment: identification of secondary (external) opening, potentially primary opening; bilateral fistula openings or
scars suggestive of horseshoe fistula; identification helpers—probing, peroxide injection, imaging (ERUS, MRI, etc).
Elective cases: partial/full colonic evaluation per guidelines.
Surgical Steps
1. Patient positioning: prone jackknife position.
2. For elective cases: pudendal/perianal nerve block with 15–20 cc of a local anesthetic in addition to general
anesthesia to improve relaxation of anal sphincter muscles.
3. Insertion of anal retractor and identification of primary opening.
4. Careful probing of fistula tract with silver probe.
5. Insertion of anal retractor and reassessment of the fistula. Depending on local anatomy, placement of Lone Star
retractor may prove advantageous.
6. Limited excision of primary opening, removal of epithelialized tract within muscle layer, widening/excision of
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secondary opening.
7. Closure of muscular defect with interrupted Vicryl sutures.
8. Marking of U-shaped broad-based flap, base starting distal to primary fistula opening, extending laterally and
proximally (one quarter to one- third of anterior circumference). Atraumatic raising of flap: after adequate
mobilization, flap should cover defect without any tension. Careful hemostasis; avoid traction or diffuse cautery
damage to flap.
9. Suturing flap in place in two layers: deeper muscular layer (Vicryl), maturation of mucosal anastomosis with
interrupted sutures (eg chromic).
Anatomic Structures at Risk
Anal sphincter complex, anal configuration (keyhole deformity).
Aftercare
Open wound care until complete healing of secondary opening: sitz baths or showers twice per day, after bowel movements.
Complications
Bleeding, urinary retention (sign of sepsis?), recurrent infection, pelvic/perineal sepsis, recurrent/persistent fistula (20–
30%), creation of an ectropion, fecal incontinence.
Cross-Reference
Pain, perirectal (Ch. 1)
Perianal/-rectal abscess (566) (Ch. 4)
Perianal/-rectal fistula (565.1) (Ch. 4)
Hidradenitis suppurativa (705.83) (Ch. 4)
Modified Hanley procedure for horseshoe fistula/abcess (Ch. 5)
Fistula-in-Ano—Fistulotomy vs Seton (Ch. 5)
General perioperative management—anorectal (Ch. 7)
FISTULA-IN-ANO—INSERTION OF COLLAGEN PLUG
Principle
Obliteration of the fistula tract by inserting and suturing in place a manufactured collagen plug through the primary fistula
opening in the rectum. More durable than the fibrin glue injection, long-term data on this new method are pending.
Setting
Outpatient, OR, general anesthesia.
Alternatives
Nonoperative management: generally not indicated if fistula is symptomatic.
Fistulotomy/fistulectomy.
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Seton management.
Fibrin glue injection.
Endorectal advancement flap.
Modified Hanley procedure.
Indication
Transsphincteric fistula-in-ano.
Not indicated: very superficial tract, very short tract, very large diameter tract, active suppuration.
Preparatory Considerations
Clinical assessment: identification of secondary (external) opening, potentially primary opening; bilateral fistula openings and
scars suggestive of horseshoe fistula; identification helpers—probing, peroxide injection, imaging (ERUS, MRI, etc).
Elective cases: partial/full colonic evaluation per guidelines.
Surgical Steps
1. Patient positioning: prone jackknife position.
2. Disinfection.
3. For elective cases: pudendal/perianal nerve block with 15–20 cc of a local anesthetic in addition to general
anesthesia to improve relaxation of anal sphincter muscles.
4. Insertion of anal retractor and identification of primary opening.
5. Careful probing of fistula tract with silver probe.
6. Limited excision/enlargement of secondary opening to facilitate drainage.
7. Irrigation of tract with peroxide, otherwise no debridement or curettage.
8. If internal opening is recessed: limited mobilization of mucosal edge.
9. Rehydration of collagen plug for 2 minutes in antibiotic solution.
10. Insertion of silver probe through secondary opening and pulling in a suture that is tied to end of rehydrated
collagen plug.
11. Pulling in plug from primary toward secondary opening until plug sits snugly.
12. Transmuscular absorbable fixation suture to fix plug at primary opening, trimming of excess plug.
13. Trimming of excess plug at secondary opening flush at skin level, no plug fixation.
Anatomic Structures at Risk
Anal sphincter complex.
Aftercare
Open wound care until complete healing of secondary opening: sitz baths or showers twice per day, after bowel movements.
Avoidance of strenuous activity, exercise, heavy lifting, intercourse for 2 weeks.
Avoidance of constipation or diarrhea.
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Complications
Bleeding, urinary retention (sign of sepsis?), loss of the collagen plug, infection, pelvic/perineal sepsis, recurrent/persistent
fistula (25–50%).
Cross-Reference
Pain, perirectal (Ch. 1)
Perianal/-rectal abscess (566) (Ch. 4)
Perianal/-rectal fistula (565.1) (Ch. 4)
Hidradenitis suppurativa (705.83) (Ch. 4)
Modified Hanley procedure for horseshoe fistula/abcess (Ch. 5)
Fistula-in-Ano—Fistulotomy vs Seton (Ch. 5)
General perioperative management—anorectal (Ch. 7)
EXCISION OF PILONIDAL CYST
Principle
Elective excision of the pilonidal cyst and its associate fistulous tracts and pits. Multiple approaches are described with
varying degrees of radicality, primarily open (Figure 5–4) vs primarily closed techniques.
Figure 5–4.
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Primarily open excision of pilonidal cyst.
Setting
Outpatient, OR procedure.
Alternatives
Nonoperative expectant approach: quiescent disease, < 2 episodes.
I&D for acute flare-up with abscess.
Flap procedures.
Indication
History of recurrent acute pilonidal disease ( 2 episodes).
Chronic pilonidal sinus/fistula.
Cancer ( combined-modality treatment).
Preparatory Considerations
None except digital rectal exam.
Surgical Steps
1. Patient positioning: prone jackknife or prone position, lateral taping of buttocks is not indicated.
(A) Primarily Open Technique
2. Marking of symmetric elliptical skin incision, which incorporates all openings. Avoid proximity to anus (sphincter
injury!).
3. Incision of skin.
4. Extirpation of whole specimen in such a way that a flat funnel-shaped wound results without undermining of wound
edges.
5. Marsupialization of wound edges is possible, but not needed if shape of wound is as required (see above).
6. Hemostasis.
7. Petroleum jelly gauze and absorbing dressing, no packing needed.
(B) Closed Technique with Lateral Approach
2. Curved lateral incision, potentially with incorporation of eccentric secondary fistula opening.
3. Undermining of subcutaneous tissue toward midline.
4. Debridement of cyst and fistula tracts: it is not necessary to remove all indurated parts, just fistula as such.
5. Excision of midline pits (eg, using punch biopsy).
6. Debridement of fistulous tracts.
7. Hemostasis.
8. Closure of lateral incision and midline wounds with absorbable suture.
(C) Closed Technique with Midline Approach
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2. Marking of symmetric elliptical skin incision, which incorporates all openings. Avoid proximity to anus (sphincter
injury!)
3. Incision of skin.
4. Extirpation of whole specimen in such a way that a flat funnel-shaped wound results without undermining of wound
edges.
5. Hemostasis.
6. Laying of 3–4 strong retention sutures from lateral, through the fascia at bottom of wound, to other side.
7. Closure of wound in midline with interrupted sutures.
8. Compression roll of a few gauzes over which lateral retention sutures are tied.
Anatomic Structures at Risk
Anal sphincter complex (at caudad end).
Aftercare
(A) Primarily Open Excision
No limit to physical activity. Daily showers/sitz baths, scrubbing of wound with cloth, removal of hair around wound (hair
removal cream or razor).
(B) Closed Technique with Lateral Approach
Limited physical activity for 2–3 weeks.
(C) Closed Technique with Midline Approach
Strict limitation of physical activity for 2–3 weeks. Removal of compression roll after 7–10 days. Removal of stitches after 3
weeks.
Complications
Bleeding, infection, dehiscence (of closed wounds), recurrent fistula/sinus formation, delayed wound healing.
Cross-Reference
Pilonidal disease (cyst/sinus/fistula, 685.0/1) (Ch. 4)
General perioperative management—anorectal (Ch. 7)
EXCISION/FULGURATION OF ANAL WARTS
Principle
Surgical removal and/or destruction of anogenital condylomata. Electrocautery and laser are equally effective in terms of
recovery time, pain, and scar formation, but laser is more expensive and associated with higher recurrence rate. Relatively
limited number of warts can be treated with local anesthesia in the office; a larger extent requires systemic or regional
anesthesia.
Setting
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Outpatient, office or OR.
Alternatives
Nonoperative management: small extent, accessible (ie, typically external).
Wide excision with flap reconstruction: almost never primarily indicated, even in presence of confluent warts.
Laser destruction: more expensive equipment, no perioperative advantage, higher recurrence rates.
Indication
Larger extent and/or number of external condylomata.
Internal condylomata.
Treatment-refractoriness with nonsurgical management.
Preparatory Considerations
Clinical assessment of all possible sites.
HIV status.
Rigid or flexible sigmoidoscopy to rule out concomitant STDs; full colonic evaluation per guidelines.
Surgical Steps
1. Patient positioning: any position (prone jackknife, lithotomy, lateral) that allows access to affected sites,
intraoperative change of position may be necessary.
2. Disinfection.
3. Safety precautions: small-pore surgical masks, suction-equipped electrocautery to minimize anecdotally reported
hazard of HPV transmission to surgeon's upper airways.
4. Even if general anesthesia: preemptive injection of long-lasting local anesthetic.
5. Insertion of anal retractor, assessment of internal involvement.
6. Excision: careful grasping of individual warts with forceps and excision at their base with scissors or needle-tip
Bovie. Process all removed tissues for pathology. Even primarily large and confluent-appearing warts often have
multiple individual stalks and healthy skin areas may be preserved in between (Figures 5–5A and 5–5B).
7. Fulguration with needle-tip Bovie: cauterization of smaller and flat warts, scratching off eschar, followed by repeat
treatment.
8. If fistula present, tract often colonized by condylomata
appropriate fistula treatment in conjunction with complete
wart removal.
9. Verification that all foci eliminated (internal and external).
10. Hemostasis.
11. Injection of 5 million units of interferon alfa (suspended in 5 mL of saline) diffusely into anoderm.
12. No dressing needed.
Figure 5–5A.
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Excision of confluent-appearing warts (separate stems as in a forest).
Figure 5–5B.
Excision/fulguration of warts.
Anatomic Structures at Risk
Anal sphincter muscle. Anoderm risk of stenosis.
Aftercare
Open wound care: sitz baths or showers twice per day and after bowel movements.
Review of pathology: 10–20% incidence of carcinoma in situ
watchful waiting vs rebiopsy; rarely invasive cancer wider
reexcision vs other treatment modalities.
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Follow-up in clinic every 3–6 weeks, every 3 months after wound healing.
Complications
Bleeding, infection (rare), delayed wound healing, recurrent wart formation (30–50%), incontinence to stool/gas, anal
stenosis. Dyspigmentation.
Cross-Reference
HIV-associated anorectal diseases (042) (Ch. 4)
Sexually transmitted diseases (STDs, 091, 098, 099) (Ch. 4)
Anal condylomata (078.10) (Ch. 4)
Anal intraepithelial neoplasia (AIN, 235.5) (Ch. 4)
Buschke-Lowenstein giant condylomata (078.10, 235.5) (Ch. 4)
Anal cancer (154.2, 154.3) (Ch. 4)
General perioperative management—anorectal (Ch. 7)
LATERAL INTERNAL SPHINCTEROTOMY (LIS)
Principle
Radial incision of internal sphincter muscle (open or closed technique) to achieve reliable reduction of the resting anal
sphincter tone. LIS is the most successful of all treatment options for chronic anal fissures, but carries a risk of incontinence.
Sphincterotomy may be combined with excision of sentinel skin tag (external end of fissure) and/or hypertrophic anal papilla
(internal end of fissure), or formal fissurectomy.
Setting
Outpatient, OR or office procedure.
Alternatives
Conservative management: stool management, topical nitroglycerin/calcium antagonist.
Botulinum toxin A injection.
Fissurectomy with/without midline sphincterotomy.
Fissurectomy with injection of Botulinum toxin A.
Fissurectomy with anal advancement flap.
Indication
Chronic anal fissure.
Contraindication: preexisting fecal incontinence. Caveat: careful decision for patients with underlying diarrhea (higher
probability of fecal incontinence).