New minimally invasive operation for fistula in ano - SLOFT (Submucosal Ligation Of Fistula Tract) Has very less morbidity and early recovery with no technology needed, hence economical.

1. SLOFT
(Sub mucous Ligation Of Fistula Tract)
For Fistula in Ano
Dr D.U.Pathak
MS FACRSI
Jabalpur (M.P) India

2. Basic understanding
• The internal opening is always at the dentate
line.
• High opening is usually Iatrogenic.

3. Role of Investigations
• Mandatory in recurrent fistulae and
undetectable internal openings
• MRI is the best one.

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

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

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

7. Seton
• Painful long term
cutting of the sphincter

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

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

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

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

12. SLOFT is nothing
but
simplified LIFT

13. SLOFT
(Sub mucous Ligation Of Fistula Tract)
• 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

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

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

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

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

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

19. FAQ – How far from Internal opening?

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

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

22. Wound
• Can be Primarily closed

23. Fistula at 4-Oclock

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

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

26. What is new in this method?
• Nothing
• In LIFT also the tract was tied and cut.
• I have just made it simple and reproducible.
Aim remains the same
disconnect the internal opening which is like a
funnel pouring infection out.

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

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

29. This study
• This prospective study was carried out from
January 17th 2014, till date.
• 43 patients have been operated of all types of
fistulas with no exclusion criteria.
• Of them, 4 were recurrent cases
• The early results and recovery have been
uneventful.

30. 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.

31. Seriously looking forward
for long term results
Thanks…