1) Fistula-in-ano is a difficult surgical condition to treat due to its recurrent nature. Kshara sutra treatment is effective with benefits like low recurrence, no anesthesia or painkillers needed, and minimal tissue damage and risk of incontinence. 2) Fistulae are classified based on their tract location and can have single or multiple external openings connected to one or multiple internal openings. Kshara sutra placement involves probing the tract and threading an herbal seton. 3) Kshara sutra works both mechanically and chemically to cut the tract while promoting healing, with cutting and healing occurring simultaneously to eliminate dead space for infection.

1. Presented By :
Dr. Naveen Chauhan
B.A.M.S, C.C.Y.P, C.R.A.V (Kshar sutra)
Founder Director : - Shri Dhanwantari Clinic,
Ghaziabad
E-mail: nchauhan.dr@gmail.com
www.ayurvedapilescure.com

2. Lord Dhanvantari - God of Ayurveda

4. Fistula –in-ano is a condition
which has been recognized as a
difficult surgical disease in all the
ancient and modern medical
science of the world. It is the
recurrent nature of this disease
which makes it more and more
difficult for treatment.

5.  Less recurrence rate
 No need of anesthesia
 No chance of anal incontinence
 Less tissue damage and blood loss
 No need of postoperative antibiotic and painkiller
 The procedure can be applied as a day care
 No need of specific dressing

6. Tract lined by granulation tissue which connects
deeply in the anal canal or rectum and
superficially on the skin around the anus

8.  Standard
Classification
 Sub-cutaneous
 Sub-mucous
 Low-anal
 High- anal
 Pelvi rectal

9.  Inter-sphincteric
 Trans-sphincteric
 Supra-levator
 Supra-sphincteric
Parks Classification

10. 1. Inter-
sphincteric
2. Trans-
sphincteric
3. Supra-
sphincteric
4. supra-levator

11. Relates to track between
two opening
Anterior –straight up to
3.75cms.
Posterior-curved

12.  Digital Examination
 Not infrequently a internal opening can be felt as a
nodule on the wall of the anal canal.
 Irrespective of the number of external openings, there is
almost invariably only one internal opening.
 Proctoscopy
 Sometimes will reveal the internal opening of the fistula.
 A hyper trophied papilla is suggestive that the internal
opening lies within the crypt related to papilla.

13.  Probing :
 Probing is painful and is liable to rewaken dormant
infection.
 If patient is experiencing pain, makes a sudden jerk,
a false passage may result.
 Probing should be postponed until the patient is
under anaesthesia.

14.  Fistulography :-
 Very useful for recurrent fistulae.
 Fistulae with multiple opening.
 High Level Fistula
 Fistula of long duration
 Ramification of fistula are suspected
 Horse Shoe fistula
 When origin of the fistula lies elsewhere
 Injection of Lipiodol or other medium along
the sinus, before radiography is some time
likely cause a recrudescence of inflammation

15.  Endoluminal Ultrasonography, Magnetic resonance imaging and
X-Ray
 These two are being developed as techniques for mapping complex
fistulae, showing good results.
 Radiography of the thorax should be undertaken if possibility of
pulmonary tuberculosis is considered.
 Routine investigation.
 Routine Blood and Urine Examination should be undertaken.
 Special Investigation.
 Systemic and associated causes like diabetes mellitus, tuberculosis,
Ch. Ulcerative Colitis, Diverticulosis of the Colon, Prostatic infection
and Crohn’s disease should be ruled out by special investigations.

17.  Written consent
 Anti tetanus as prophylaxis.
 Lidocain sensitivity test.
 Preparation of the part.
a. Shaving of the operative part.
b. Painting of the operative part.

18.  Position – Lithotomy
Procedure of Kshara-Sootra tecnhique-
Step I
Probing – Two conditions
 Where there are two openings
i) Proximal ii) Distal
 When there is one opening
i) Proximal

19. A suitable size of probe is negotiated and
advanced through the proximal opening along the
path of least resistance and withdraw the probe
from the distal opening.

20. A suitable size of probe is negotiated and advanced
through the proximal opening along the path of least
resistance and gently create a distal opening to
withdraw the probe.

21. Step II
 A seton of suitable length and size is placed in the eye
of probe and the probe is pulled out through distal
opening, in order to position the seton in the tract.
 Both ends of the seton tied loosely outside the tract.

22.  Dressing of the wound with medicated oil.
 Application of bandage.

23. Step –IV
Technique for changing of Ksharsutra
 Application of Ksharasutra after 3 or 7 days by Rail Road Technique.
 New Ksharasutra is tied to the lateral side of knot.
 Thread is cut between the knot and clipped artery forceps.
 Artery forceps is gently pulled out along with the old thread such that
thread (old) comes out leaving the new ksharasutra in tract.
 Cut old Ksharasutra and ends of the new one are tied firmly.
 Cotton soaked in Anu Taila is placed locally and bandage applied.

24.  Nil orally up to 3 hours.
 Analgesics as per required.
 Shothahara drugs as guggulu.
 Hot sitz bath

25. 1. Mechanical action
2. Chemical action

26. Wire on ice block
bearing weight
both side
Mechanism of Kshara Sutra
Wire cutting
through by
pressure
Ice block
reform and
healed block

27. 1. Latex of Euphorbia (Snuhi) is proteolytic, therefore,
dissolves the fibrous tissue of Fistulous tract.
2. Apamarg Kshar is a Alkali, which clears the fistulous
tract and liquidates the thick pus. It keeps the tract
clean and helps in drainage of pus. It causes chemical
fistulectomy.
3. Turmeric powder is anti-allergic, anti septic and a
wound healer.

28. 4. Special linen thread holds the medicines with the
help of latex for 3-4 days in the fistulous tract.
5. Physical presence of Ksharsutra in the fistulous
tract keeps the passage patent and helps in the
drainage of pus.
6. Ksharsutra legation exerts mechanical pressure
along with chemical cauterization. Therefore, in
the initial 3 days there is cutting of the tract.

29. 7. After cutting the fistulous tract by Ksharsutra
in initial days the follow-up of 3-4 days is the
healing time for the wound.
8. As cutting and healing go side by side, there
is no gap or recess for accumulation of pus
in the cavity.
9. In case the abscess cavity is large -
Ksharsutra can be packed in the cavity till all
the accumulated pus is drained out and
wound is clean for healing.

30. 10. Keeping in view the healing progress of the
tract – surgeon can tight or loose the
Ksharsutra ligation.
11. Alkali of Ksharsutra when applied with
medicated oil it forms soap, which cleans the
tract.

31.  Hence we can conclude that the Kshar sutra
therapy is a ‘chemical fistulectomy ‘ rather than a
surgical ‘fistulectomy ‘ proved to be free from
complications.
 The application of Kshar sutra in to fistulous
tract was capable of dissolving the tough fibrous
tissue and ultimately draining it out creating a
healthy base of healing.
 The ksharsutra treatment of fistula in ano is now
an accepted technique and has also found a
place in the text books of colorectal surgery.

32. Fistula with multiple external opening
Causes
 Some times superficial healing of
single external opening occurs,
pus accumulate and abscess
reforms and discharges through
another opening. In this way
multiple opening are created,
though the fistula is free of any
associated cause like -
 Tuberculosis Proctitis.
 Crohn’s Disease of the colon
 Lymphogranuloma Venereum.
 Bilharziasis
Multiple fistulae

33. Treatment of Fistula in ano with
multiple external opening
 To exclude Tuberculosis, Crohn’s disease, Bilharziasis and
Lymphogranuloma Venereum and treat accordingly. Fistula will also
respond to the treatment.
 If no specific pathology is found, Ksharsutra ligation is undertaken.
 Method :
 If main tract is connected to single internal opening and other tracts
joins to the main tract and to each other, then Ksharsutra is placed in
the main tract and other tract are join to each other and to the main
tract with separate Ksharsutra.
 If it is not possible to connect multiple opening with each other or to
the main tract because of the depth of tracts then they are connected
with the same internal opening separately.

34.  These threads partly traverse through the separate tracks while in
the deeper part they traverse together in the same tract.
 These threads usually cut through the internal and external sphincter
at the same place and because the cutting and healing go slowly and
simultaneously the development of incontinence is not appreciable .
 Multiple openings with separate fistulous tract creating multiple
internal opening .
 Each fistulous tract is threaded separately in such a way that no two
threads pass through the sphincter at the same time because if the
sphincter is cut at two places in the same period, its fibres will
contract and may lead to incontinence. Hence the timing of the
thread should be adjusted in such a manner that only one thread cut
through the sphincter at one time

35. Multiple fistulae kshar sutra ligation

36. Horse Shoe Fistula
 It is a type of high anal fistula with two external opening usually on the
posterior half of the anal orifice on either side of midline.
 The track is usually curved and open with single internal opening at 6
O clock position in the anal canal posteriorly.

37. Recurrent Fistula in Ano
 Causes
 Faulty surgical technique where in some branch of the main fistulous
track has been over looked.
 Persistent infection in the fistulous track for long long time.
 Specific diseases like TB, Crohn’s Disease, Ulcerative Colitis, Carcinoma
Rectum etc are being over looked previously.
 Immuno Compromised patients like Diabetes Mellitus, HIV etc.
 Jaundice and Uraemia patients because of poor wound healing as
fibroblastic repair is delayed in them.
 Patients with Malnutrition, Deficiency of Vitamin C and zinc, heralds the
synthesis and maintenance of collagen.
 Patient on Cytotoxic drugs
 Patients on Corticosterioid
 Patient suffering from any generalized infective disorder.
 These all factors affect healing process so that we get a immature scar
tissue and recurrence is always possible.

38. Treatment
 Surgery is not indicated in these
cases.
 Because repeated surgery
amounts to lot of fibrosis so
much that the entire soft cusion
of pad of fat is turned into hard
fibrous tissue making the
application of Ksharsutra and
latter initiation of healing process
more and more difficult

39. Long Perineal Fistula
 External opening is sometimes located in
perineal area below the scrotum.
 This fistula is generally of high anal
variety with tract running a direct course
and internal opening is found in the
anterior half of the anal canal, above the
dentate line.
 Other conditions like periuretheric
abscess because of severe urithritis,
prostatic abscess because of acute
prostatitis, Tuberculosis of the prostate
and seminal vesicles which results into
cold abscess and may rupture into the
anal canal or rectum creating a fistulous
tract should also be kept in mind.
 Ksharsutra ligation is carried out in these
fistulae excluding the above associated
causes.

40. Blind Internal Fistula
 These are the fistulae where internal opening get closed
somehow,
 These are of intersphincteric variety of fistulae running straight
course.
 Probing has to be done very cautiously as it can easily be
converted into high level fistula where in a false internal opening
is created above the ano rectal bundle.
 Ksharsutra can be applied in these fistula by creating an internal
opening at the level of dentate line which will be the seat of
primary internal opening

41. Blind External Fistula
 Usually the patient with the
history of painful purulent
discharge per anum.
 No external opening is found.
 An indurated fistulous tract
may sometimes be palpable.
 Treatment
 Ksharsutra ligation can be
done by probing the tract in a
retrograde fashion usually, the
tip of the probe is felt under
the skin and a small nick is
made to create an external
opening.

42. Fistula connected with Chronic
Anal Fissure
 It is a complication of chronic anal fissure.
 Fissure heals superficially leaving a potential space underneath.
 Infection persist in that space leading to chronic inflammatory
condition, suppuration and abscess formation which burst or
rupture resulting into Fistula formation.
 External opening is usually hidden under the sentinel tag. Internal
opening is found at dentate line which is the upper end of the
fissure.
 Pain and purulent discharge are the leading features
 Exclude Crohn’s Disease if the patient is European / North
American as fissure is generally associated with this disorder.

43. Treatment
 Whole of the fistula tract along with sentinel tag and
fissure and can be excised without any fear of
incontinence
 Ksharsutra ligation can be applied

44. Dr. Naveen Chauhan
Shri Dhanwantari Clinic
568 Harason Enclave
Opp. J 64 Govindpuram
Ghaziabad 201002
Phone: +91-9818069989
E-mail: nchauhan.dr@gmail.com
www.ayurvedapilescure.com