anal fistula power point presentation

1. Anal Fistula
By
Dr. Islam M. Al-Atiar
MRCS (london), MSc

4. Anatomy

5. Anatomy of the anal canal

6. Anatomy
• Anal canal is 4cm devided by the
dentate line into upper part 2cm
and lower part 2cm.
• Anteriorly : urethra, vagina and
perineal body
• Posteriorly: coccyx.
• Bilaterally: ischio-rectal fossa
(????????).

7. Two sphincters control the anal canal…
• 1. Internal, is a condensation of the circular muscle layer of the
rectum (????).
It is involuntary formed of whitish smooth fibers.
• 2.External, skeletal muscle ,voluntary, consists of 3 parts
subcutaneous, superficial and deep parts which is continuous
with pubo-rectalis and levator ani.

8. Definition:
Fistulas are defined as an abnormal communication
between two epithelialized surfaces.
In our issue the anal fistula is an abnormal communication
between the ano-rectal epithelium
and the peri-anal skin .
?????? (or other epithelial surfaces e.g vagina).

9. pathology
• The condition starts as, inter-sphincteric suppuration that opens after
that either spontaneously or by surgical drainage into the skin (or
rarely to vagina) forming a well established tract .
• Ano vaginal fistulas from obstetric trauma are classified into low,
mid or high fistula.

11. Pathology animation

12. Why the fistula persist ??
• Anal glands are reservoir for the infection
• Fecal material
• Chrons, ulcerative colitis or TB.

13. How to classify anal fistula???
• Parks classification
1.Intersphincteric 45%.
2.Trans-sphincteric 30%.
3.Supra-sphincteric 20%.
4.Extra-sphincteric 5%.

14. Parks classification ( sabiston, 2017)

15. Classification of the shape
• There is a predictor o the shape o the tract that helps in
management called Goodsall”s rule.
• Fistulas anterior to the transverse line connecting both ischial
tuberosities tends to be straight.
• While other fistulas that are posterior to it tends to be curved.

16. Anterior straight, posterior curved

17. Goodsalls rule

18. Presentations
• Most patients give history of previous anal abscess that
discharges spontaneously and then they notice
intermittent discharge .
• Pruritis.
• Perianal pain.
• On examination, there is solitary or multiple openings
around the anus and there is internal opening on DRE. If
the fistula is active there is granulation tissue around the
external opening.

19. Management of anal
fistula
• Investigations
1-MRI, the mainstay in diagnosing fistula
2-Endo-luminal Ultrasound, (( experienced hand!!!!!!))
3-Fistulogram, should not be practiced used only in 20% of
cases.

20. Normal MRI of anal canal

21. Fistulous tract on MRI

22. Ultrasound image showing normal anal canal

23. Fistula on ultrasound

24. Fistula on fistulogram

25. Fistulogram in your
experience
What are the preoperative benefits????

26. TREATMENT

27. Treatment
• For simple inter-sphencteric and low trans-sphincteric perform
lay open fistulotomy and marsipulization.
• Low recurrence, low rate of incontinence.
• If the identification of the internal opening is difficult inject
methelene blue or hydrogen peroxide.

28. Probing of the fistula

29. • For complex fistulas or if the external sphincter is included for
more than 30% perform seton ( suture or elastic ), placed for
drainage or may be used as cutting seton which is periodically
tightened to induce fibrosis then cutting .
• Success rate (60-100%) (sabiston, 2017).
• Some patients develops flatus incontenence.

30. Rubber seton

31. Cutting seton

32. Seton suture and fistuloscopy

33. Seton suture placement vedio

34. Other options
• Fibrin glue injection, from the internal opening to the
external one not the reverse.
• It contains plasma fibrinogen and thrombin.
• Success rate of (15%-60%) (!!!) (sabiston, 2017).

35. The newest technique
LIFTtechnique
Ligation of the Inter-sphincteric Fistula Tract

36. Procedure
• Incision in the inter-sphincteric space after probing the
tract.
• Identify the tract.
• With right angle forceps dissect around the tract.
• Ligate the tract above and below then cut in between.
• Curettage to the external sphincter.
• It is a new promising procedure.

37. LIFT

38. Figure explaining LIFT
procedure

39. Intra operative LIFT

40. Vedio illustrating the LIFT procedure

41. N.B : ttt of ano- vaginal fistula is by
closure of the high pressure
opening (internal one) by
advancement flap.

42. Will we Be still resistant to the new lines of
management?

43. Questions

44. What cases should I refer to
anal surgeon?

45. How to deal with the
recurrent cases?

46. Thank You