SLOFT (Submucosal Ligation Of Fistula Tract) is new minimally invasive method to treat fistula in ano. It is closure of internal opening, It is modification of LIFT with more simplicity, reproducibility and no limitations of those of LIFT

1. SUBMUCOUS LIGATION
OF
FISTULA TRACT
(SLOFT)
Dr D.U.Pathak
MS FACRSI
Jabalpur (M.P) India

2. Development of Ano -Rectum

3. Development of Anus
• Hind gut fuses with
proctodeum below to
make anal canal
• Both carry different Blood
, Lymphatic and nerve
supply
• The mucosa above is
columnar and becomes
gradually stratified below
• Two different cultures
meet each other

4. SURGICAL ANATOMY OF ANO RECTUM
• Anatomical anal canal is 2cms – Anal valves to
anal verge
• Surgical anal canal is 4 cms Anal ring to anal
verge

5. Surgical & Anatomical anal canal
• Surgical anal canal
extends from Ano
rectal ring to anal
verge. It is 4 cms.
• Anatomical anal canal
is only 2 cms from
dentate line to anal
verge.

6. Surgical anatomy of Ano-rectum

7. Ano rectal ring
• The deep fibres of
external sphincteres
and pubo rectalis sling
form the upper end of
Ano rectal margin and
the ring

8. Dentate (Pectinate) line
• It is the junction of
upper 2/3rds and lower
one third of anal canal
• Fusion of hindgut and
proctodeum
• Hence Endoderm above
and Ectoderm below

9. Dentate line
• Blood supply is from superior rectal above and
middle and inferior rectal below
• Nerve supply above is inferior hypogastric
plexus conducting stretch and
• Inferior rectal nerves carrying pain to cut and
burn through pudendal.
• Lymphatics below drain to inguinal and above
to pararectal

10. Hilton’s line
• First landmark above the
anal verge.
• More felt than seen –
inter-sphincteric groove
• It is muco cutaneous
junction
• Below is Keratinized
stratified squamous
epithelium
• Below it the lymphatic
drainage is to inguinal
nodes.

11. Pectin
• A small strip of 1 cm below the Dentate line and is
called Pectin
• It is a transitional zone with cuboidal epithelium and
no skin appendages
• Here the mucosa is very adherent to the surroundings
hence abscesses are very painful
• Ischio rectal abscesses usually drain below this area
• Below this the skin gradually thickens and appendages
develop near the verge

12. Anal verge
• Below the Hilton’s line
• Distal collapsed rugous end of the anal canal
• Surrounded by superficial anal sphincter
• Transitional area of epithelium of the anal
canal and perianal skin

13. Sphincters
Internal
• Pearly white condensed
circular smooth muscle
fibres
• Extend from ano rectal
junction all along the anal
canal.
• Thickest - 3-5 mms at the
verge
• Lower level than external
• Autonomous nerve supply
External
• Skeletal voluntary red
muscles, supplied by
somatic nerve supply
• Divisions have no clinical
significance, all merged

14. Surface landmarks

15. Anal glands
• Lie in the inter sphincteric
and sub mucous planes
• Two to ten in number
• Secrete lubricating
material in anus
• Internal opening is in the
crypts at dentate line
• Highly susceptible for
infection

16. Anal gland

17. Ano-rectal diseases

18. Crypto glandular infection
• The infection usually starts in the crypts
• Common organisms are Staphylococci,
Streptococci, E coli or Proteus
• Recently also anaerobes like Clostridium
Welchii and bacteroids
• Sometimes mixed with tubercular

19. Sites of abscess

20. Spread of sepsis

21. Ano Rectal Fistula
• It is sequel of crypto glandular abscess
• The infection is of anal gland
• Anal glands are 6-8 in number
• Their function is to lubricate the anal canal
• All open at the dentate line

22. Location of Internal opening

23. Basic understanding
• The internal opening is always at the dentate
line.
• High opening is usually Iatrogenic, other
uncommon causes are tuberculosis and
malignancy, rarely Crohns
• The usual pyogenic abscess can never
perforate a normal rectal wall and create a
high opening

24. Formation of fistula
• A crypto glandular abscess with inadequate
drainage from the internal opening spreads in
loose inter sphincteric planes and ultimately
finds its way somewhere to drain out, making
an external opening.
• The collections develop a protective wall
around them, which becomes more firm,
shrinks in size, takes a tubular shape to make a
so called fistula tract.

25. Investigations
• To diagnose
• To assess
• To rule out
• To know the synchronous problems
• To follow up the progress of recovery

26. The best investigation remains …

27. If you don’t want to
put your foot in rectum …

28. Fistulography

29. Conventional USG
• Readily available
• Gives information about
the maturity of tract
• Of more help when
combined with other
imaging like
fistulography
• Detects the hidden
abscesses

30. Endo Sonology
Trans sphincteric

31. Endo Sono - Horseshoe

32. MRI
• CT could not give proper
information about the
soft tissues
• It helps in 90% cases to
localize the internal
opening
• Helps in mapping ,
planning and projecting
the prognosis.
• Worth in recurrent
fistulae

33. Chest X Ray

34. Classification
• Vertical
• Parks Simple, Inter
sphincteric and trans
sphincteric.

35. Goodsal’s Rule

36. Extensions

37. Why do we classify an disease??
• To plan the treatment.
• When the treatment is same you do not
bother for classification like – hernia.

38. Existing procedures
• Aim towards separate treatment for different
types.
• The approach is from distal – external opening
to proximal – internal opening
• Hence the knowledge of anatomy of the tract
was compulsory

39. The Aim of treatment
• Control of sepsis
• Prevention of incontinence and recurrence
• Giving him less pain, morbidity and job loss

40. Existing methods
• Lay open
• Seton
• Kshar sutra
• Cut and repair of the sphincter after excision
of the tract.
• Fistula plug
• VAAFT
• LIFT

41. Lay open
• Big painful wound with
long term recovery
• Makes the patient
incontinent at least for
flatus.
• Gives a bad scar and
furrow.

42. Seton
• Painful long term
cutting of the sphincter
with pressure

43. Ksharsutra- Ayurvedic thread
• Chemical cutting with a
formulation of fixed ph
• It is long term painful
cutting with gradual
healing at the same
time
• Leaves behind a bad
scar

44. Excision of the tract
and
Primary repair of sphincter
• Needs high expertise
• Associated with high incidence of
incontinence.

45. Fistula plug
• Very attractive choice
for affluent class
• The zero morbidity way
but associated with
high recurrence rate

46. VAAFT
• It’s a high tech costly
operation

47. LIFT
• Sound surgical principle
• Low morbidity
• No incontinence
But
• Difficult to learn,
to do and to teach

48. Sub mucous Ligation Of Fistula Tract
(SLOFT)
• Basic principle is of LIFT- ligation of the tract
• In SLOFT -
• It is more proximal
• It is more superficial
• Leaves behind a smaller stump of the proximal
tract

49. Submucosal Ligation Of Fistula Tract
(SLOFT)
• The approach is anti grade – from internal
opening to going distal – that too only for 2 cms.
• The tract as it emerges from internal opening is
always straight and superficial
• As is goes distally it changes it’s course like a river
• The distal coarse is unpredictable as regards its
curvatures and depth hence existing methods are
not so easy and effective for elimination of the
tract.

50. Schematic representation of SLOFT
Internal
opening
Tract
hooked
Dentate
line

51. Instruments

52. Probing
• Probe is gently
introduced to come out
from internal opening
• Then it is bent and
pulled out of the Anus.

53. Injection Xylocaine adrenaline
• This blanches the area
and does hydro
dissection around the
tract
Muco-
Cutaneous
Junction

54. Hooking the tract
• Incision is at the muco
cutaneous junction
• The tract is hooked
• Here it is superficial.

55. Site of ligation
• It is Sub mucous and is
medial to the internal
sphincter

56. FAQ – How far from Internal opening?

57. Division of the Tract
Anus
Anus
Hooked
tract
Tract
transacted

58. Distal tract
• Cored out and sent for
HPR .
Coring of
external
tract
EAL near internal
opening

59. Wound
• Can be Primarily closed

60. Fistula at 4-O clock

61. Fistula at 2-O clock

62. Multiple tracts – method is the same
Opening at
6-O clock
Opening at
2-O clock
Opening at 2-
O clock
passing gas
from scrotum
All the three tracts
EAL done separately

63. Cored after SLOFT
All three
external tracts
removed by
coring
Healed in
20 days

64. Immediate post op picture
This patient had two
tracts with one para
rectal blind extension.

65. Post operative period
• Discharge in a day
• No post discharge dressings

66. Post op first morning
can sit without pain

67. They are happy

68. Case -1- 091797-60854
Multiple tracts
• 45 yrs male came with
recurrence after two
operations in 2 ½ yrs.
• He came with
• 1. impending rupture of
perianal abscess at 4-O
clock
• 2.External opening at 2-O
clock and
• 3. External opening at the
base of scrotum from where
he was passing flatus

69. Internal opening at 2-O clock
• Probe coming out of
opening from 2-O clock
• SLOFT done

70. SLOFT
• SLOFT at 2-O clock

71. Internal opening at 4-O clock
• SLOFT at 4-O clock

72. Probe from scrotal opening
• Probe from scrotal
opening

73. Internal opening 2-O clock
• SLOFT 2-O clock

74. Coring
• Coring done after
confirmation of the
ligation
• Wounds left open to
heal

75. Healed in 20 days
• Patient did not come for
follow up
• He had to be called on
request and the wounds
were seen to be healed
in 20 days

76. Post op 3 weeks
• He had to be called for
documentation because
as such he had no
problem

77. Case -2 - 097132-50531
• The post op picture
• SLOFT hidden in the
anal verge
• Pt did not come for
follow up as the wound
healed and he had no
problem
• Mr Kamlesh Jharia
c/o Dr R.P.Gupta
097132-50531

78. Case-2-
Inter sphincteric fistula-per op
• Per operative photo
after SLOFT
• Hydrogen peroxide seen
leaking through the
peri-anal space

79. Case -3- 089323-09290
Recurrent fistula
• 50 yrs/M controlled
DM, came with
recurrence of fistula .
• SLOFT done and distal
abscess cavity
marsupilised

80. Insertion of probe

81. Ligation

82. SLOFT

83. Abscess marsupilised

84. Post op 20 days-healing

85. Almost healed

86. Post op 2 months
sudden perianal abscess

87. Seton tied – superficial fistula

88. Abscess and rupture

89. Seton cut after 15 days under LA

90. Case-4- 078285-13112

91. Healed in 25 days

92. Post op 40 days - recurrence

93. Spontaneous rupture of abscess

94. Spontaneous healing

95. Case-5-093031-62144

96. Incision over probe

97. Indwelling probe

98. Tract hooked

99. Ligated and transacted

100. Probe in distal tract

101. Distal tract excised

102. Painless P/R next morning

103. Next morning

104. Post op 10th day

105. Healed

106. Post op visit

107. Case-6- 098273-71437
Acute abscess fistula complex

110. • In spite of the acute and fragile tract, SLOFT
could be done as the probe was indwelling
and ano-rectum could be kept virgin

111. Healed within few days
with intact anus

112. Case-8
Internal opening not demonstrable

113. Had to core, shorten the tract and gently
negotiate with the probe to come inside the
internal opening.

116. Follow up on request ( 094251-52818)

117. First put in cradle
by Dr Radhakrishna Patta

119. First workshop
at Mujaffarnagar

120. Reproduced
Dr Naveen Agrawal – 097603 36161

121. Recurrences ??
• Time only will tell the percentage but
• They are bound to occur
Recurrence bothers the patient
if
the procedure was either costly
or the recovery was painful.

123. Seriously looking forward
for long term results
ధన్యవాదాలు