1) Anorectal fistulas are abnormal connections between the anal canal and perianal skin that usually form after an anorectal abscess bursts spontaneously. 2) Park's classification system categorizes fistulas as intersphincteric, transphincteric, suprasphincteric, or extrasphincteric based on their path through the anal sphincter muscles. 3) Treatment options include fistulotomy, seton placement, advancement flaps, fibrin plugs, and the LIFT procedure. The goal is to drain infection and eradicate the fistula tract while preserving sphincter function and avoiding recurrence.

1. Dr.Vidya

2.  FISTULA - Abnormal connection b/w two epithelium lined
organs or vessels.
It is generally a disease condition.
It may be surgically created for therapeutic reasons.
 ANORECTAL FISTULA - Abnormal connection b/w
epithelialised surface of anal canal & the Perianal skin.
 Internal opening- Anorectal lumen
 External opening- Perianal skin
 Pre-existing anorectal abscess burst spontaneously .
 Other: rectovesicular, rectovaginal, rectourethral fistula.

3. Etiology
 Non specific - cryptoglandular in origin
 Specific :
- Crohn’s disease
- tuberculosis
- lymphogranuloma venereum
- actinomycosis
- rectal duplication
- foreign body
- malignancy

4. Anatomy – Muscles
 Internal sphincter
 External sphincter
 Intersphincteric groove
 Puborectalis (Levator
ani)

6. Park’s Classification of Anorectal
Fistulas
 Type 1 - Intersphincteric (45%)
 Type 2 -Transphincteric
 Type 3 – Suprasphincteric
 Type 4 - Extrasphincteric

7.  Intersphincteric – through the dentate line to anal verge,
tracking along the intersphincteric plane, ending in the
perianal skin.
 Transsphinteric – through the external sphincter into the
ischiorectal fossa, encompassing a portion of internal &
external sphincter ending in the skin.
 Suprasphinteric – through the anal crypt & encircling the
entire sphincter ending in ischiorectal fossa.
 Extrasphinteric – starting high in the anal canal, enclosing
the entire anal sphincter & ending in the skin.

8. Park’s Classification of Anorectal
Fistulas

9. Clinical Presentation
 H/o
 Chronic drainage from
“nonhealing abscess”
 Pain with defecation
 Pruritus ani
 Systemic symptoms if
abscess gets infected.
 Physical exam
 Draining pustule
 Erythema, induration,
excoriated skin

10. Goodsall’s Rule
 Goodsall’s rule is a guideline for internal opening & path of
fistula track & aids in Rx.
 Fistula can be described as anterior or posterior relating to a
line drawn in the coronal plane through ischial spines across
the anus - called transverse anal line.
 Anterior fistulas - have a direct track into the anal canal.
 Posterior fistulas - have a curved track with their internal
opening lying in the posterior midline of the anal canal.
 An exception to the rule - anterior fistulas lying more than 3
cm. from the anus, which may have a curved track (similar to
posterior fistulas) that opens into the posterior midline of the
anal canal.

11.  Goodsall's rule may not be
applicable when the fistula is
more than 3 cm from the anal
verge, as mostly these fistula are
indirect.
 If there are multiple anal fistulae,
the course would be similar to
that of posterior-opening fistulae
because of branching and
communication between these
openings

12. Diagnosis
• Exam under anesthesia (EUA)-
anoscopy, proctoscopy; assess for
internal opening and occult
abscess
– Injection of Hydrogen peroxide or
povidone iodine allows to visualize
bubbles at internal opening(s)
• Endo anal ultrasound
• MRI – gold std
• Fistulography
• CT

13. Management
 Goals of Therapy
 Drain local infection
 Eradicate fistulous tract
 Avoid recurrence while preserving native sphincter function
 Surgical management
 Fistulotomy
 Fistulectomy
 Seton technique
 Advancement flaps & glues
 LIFT procedure

14. Fistulotomy
 lay open fistula tract, make incision over entire length of fistula
using probe as guide
 intersphincteric fistula & trans-sphincteric fistulae involving
less than 30% of the voluntary musculature .
 Avoided for anteriorly placed fistulae in women
 Staged Fistulotomy – seton passed across the fistula & left in
place with tie
 Fistula granulates & heals from above to close completely.

15. Fistulotomy

16. Cutting Seton (Staged Fistulotomy)

17. Fistulectomy
 involves coring out of the fistula by diathermy cautery
 Better for fistula that cross level of sphincters and the
presence of secondary extensions.
 Post-op: sitz bath, antibiotics, analgesics, laxatives

18. Setons
 non-absorbable, nondegenerative, comfortable.
 Silk or linen ligature
 m/c intersphincteric fistula.
 Kept for 3 months replaced by rail road tecq.
 loose setons: no tension, no intent to cut the tissue.
- for recurrent, post operative fistulas.
 Uses of loose setons.
- For long-term palliation to avoid septic and painful exacerbations by
effective drainage
- before ‘advanced’ techniques (fistulectomy, advancement flap,
cutting seton)
- staged fistulotomy
- preserve the external sphincter in trans-sphincteric fistulae.

19. Tight or cutting setons :
 placed with the intention of cutting through the enclosed
muscle.
 Used if the fistula is in a high position and it passes through a
significant portion of the sphincter muscle
 high fistula eradication rates a/w fistulotomy.
 Minimising sphincter dysfunction due to least scar formation.
 cheese wiring through ice -such that the divided muscles do not
spring apart.
 site of the fistula track is replaced by a thin line of fibrosis as it
is brought down.

20. Advancement flaps
 Endorectal advancement flaps:-coring out of the entire
track; and closure of the communication with the anal lumen
with an adequately vascularised flap consisting of mucosa and
internal sphincter, sutured without tension to the anoderm.
 Success rate is variable.
 high recurrence rates are directly related to previous attempts to
correct the fistula.

21. Mucosal advancement flap

22. Fibrin plugs & Glues :
Fibrin plug-
 Plugging the fistula with a device made from small intestinal
submucosa.
 The fistula plug is positioned from the inside of the anus with
suture.
 Success rate with this method is as high as 80%.
 Fistula plug procedure requires hospitalization for only about
24 hours.

23. Fibrin plugs

24. •Fibrin glue:
- Fibrin glue is currently the only non-surgical option for
treating fistulae.
- The fibrin glue is injected into the fistula to seal the tract.
The glue is injected through the opening of the fistula, and
the opening is then stitched closed.
-long-term results for this treatment method are poor.

25. LIFT Procedure
 Ligation of intersphinteric fistula tract procedure.
 Based on secure closure of the internal opening and removal
of infected cryptoglandular tissue through the
intersphincteric approach.
 Essential steps -
 incision at the intersphincteric groove
 identification of the intersphincteric tract
ligation of intersphincteric tract close to the internal opening
and removal of intersphincteric tract
 scraping out all granulation tissue in the rest of the fistulous
tract
suturing of the defect at the external sphincter muscle

26. Differential diagnosis
 Anal carcinoma
 Anorectal abscess
 Constipation
 Diverticular Disease
 Foreign Bodies, Rectum
 Herpes Simplex
 Inflammatory Bowel Disease
 Pilonidal Cyst and Sinus
 Proctitis

27. Thank you