Fistula in ano is a tedious problem. It needs lot of expertise to cure any patient without making him incontinent. Understanding comes before expertise. We have come a long way from fistulotomy to the latest sphincter saving method SLOFT innovated by Dr DU Pathak from India. It super reds LIFT in simplicity and ease of doing it.

1. Understanding the fistula in ano
and management till date
Dr DU Pathak MS FACRS
Anorectal surgeon, Metro hospital, Jabalpur ( India)

2. I am into fistula since a decade
This presentation is dedicated to my
teachers during this journey
Few of them mentioned, this presentation
They are not only our but international
stalwarts
We rule fistula in ano globally

3. Usual presentation
● An opening in the buttock, may
be near to the anus or far away
which intermittently bursts out
and emits pus
● Clinically on DRE it has an
obvious internal opening also

4. Unusual presentation
● All crypto glandular abscesses convert into fistula
● Some may not have obvious internal opening
● All have to be treated on the line of management of fistula
Hence
● Perianal and Ischiorectal abscesses can be the unusual presentation of
fistula in ano

5. Basic anatomy of anorectum
● Surgical anal canal extends from Anorectal angle to the anal verg
● Anatomical anal canal extends from the dentate line to the anal verg

6. Basic anatomy of the Anorectum
(relevant to fistula)
Surgical anal canal is from anal verge to the
anorectal junction
Anatomical anal canal is from the anal verge to
the dentate line

7. Dentate line
● The junction of hind gut and proctodeum
● Crypts of morgagny and the openings of
anal ducts are here
● This is the line where you find internal
opening of the fistula in ano

8. Basic clinical examination
● History to rule out comorbidities
● DRE to identify the internal opening
And
● To rule out if any concomitant disease specially any growth sitting above
the fistula disease

9. Anoscopy vs recto sigmoidoscopy
● Routinely most of us are doing Anoscopy routinely
● But
● Very few are doing rigid sigmoidoscopy in OPD
● It is a doable procedure at no cost and time
This slide is dedicated to my respected teacher Dr Ashok Ladha from Indore who
has been following it since decades and inspiring all of us

10. Investigations
● Routine blood tests and X Ray chest to rule out comorbidity
● Fistulography is now outdated
● Most of the information is gained at low cost and convenience with USG (
this too Dr Ladha sir is propagating)
● MRI - necessary in all complex fistulas
● Only minus point is its high cost and less availability

11. USG vs MRI

12. MRI is now the gold standard
to assess the fistula in ano

13. Classification
● There are many classifications
● Most needed modifications with
advancement of science
● The latest, convenient, realistic and helpful
is made by my friend Dr Pankaj Garg who
is global authority in Fistula

14. Management
● We have come a long way from fistulotomy to stem cells
● Now the management is either sphincter cutting or sphincter conserving
techniques
The sphincter sparing techniques make it more liable for recurrences
whereas cutting the sphincter leads to incontinence
Ideal management is to achieve the golden mean
That is decided by the disease and expertise of the surgeon

15. Basic management of abscess fistula disease
● It lies in 3Ds - Drain ( Abscess) / Divide (itract) and Divert the external tract
● Internal opening has to be defined clinically/ USG/ MRI and dealt according
to the choice of the surgeon
● It can be laying open in fistulotomy, Ligation in LIFT and SLOFT, Mucosal
advancement or laser ablation in FiLac
● My friend and elected President ACRSI Dr Prof Pradeep Sharma from Pune
is doing meticulous mucosal advancement flap closure of the IO
● Mostly it is at 6 O'clock
● Always at the dentate line, may the fistula be high. It is the extension, not the
opening
No issue if you cannot find IO, but please don't make one

16. Draining an ischiorectal abscess
● All have internal opening
● If not dealt, 50% concert into fistula at a later date
● But … no problem if you are not expert.
● Just give incision as near to the anus possible.
● If at all it becomes a fistula, it will be short and straight
● Extensive deroofing is not necessary
● Thorough curette and drain for few days is enough

17. Fistulotomy - still a gold standard
● For simple low lying
● Sphincter cutting should not be beyond
1/3rf
● Marsupialization speeds up the healing

18. Sphincter saving DLPS (Distal Laser Proximal
SLOFT)
● We dropped this at Karan hospital
Jalandhar
● My friend Dr Kamal Gupta is doing
wonderful job in laser surgery.
● He also has written an only book on lasers
in coloproctology by Springer
● This method had better results due to the
transaction

19. Laser is a good tool to reach depths of fistula tracts
● My friend Dr Ashwin Porwal is doing great
job in complex fistulas in his (chain) of
healing hands clinic
● If judiciously used laser is a boon
otherwise in the hands of novice it is a
curse
Very senior surgeon Dr SK Nigam has innovated
a no cost alternative of laser. Hats off to him

20. Preop
● Do not miss the co morbidity
● MRI is mandatory in recurrent fistulas
● Learn to identify the complex fistulas
More than 1/3rd sphincter complex, female
anterior, with comorbidity, like crohn's and
tuberculosis or post radiotherapy recurrent and
pre existing fecal incontinence
The pic by Dr Pankaj Garg shows how bad a
tubercular fistula can be.. He has done
extensive work on it.

21. Per operative
● Never cut without repair more than 1/3rd of
the ext sphincter complex ( fistulotomy)
● Never leave it without repair if you need to cut
further 1/3rd ( Sub plus sup,) - FPR -
Fistulectomy and Primary Repair of the
sphincter
● Search for all the secondary extensions of
abscess and sister tracts
No fistula surgery is complete without
identifying the internal opening. It amounts to 20
times more chances of recurrence
The intention of this pic is, please assess many
times during surgery that you are not damaging this
puborectalis sling

22. Sphincter cutting and repair if
done well in fact improves the
continence after surgery
Dr Parvez Shiekh Mumbai

23. Sphincter sparing procedures
Fistula plug
● It is a collagen plug developed by Cook’s
● Though costly but real non invasive
My friend Dr Ashish Ganatra from Rajkot is the
world leader in it. He has the largest series and
best results globally.

24. Role of setons
● Draining setons - Life saving, ensure
drainage and built up a strong fibrotic
tract which is easier to deal later but they
ensure that it will not heal completely
because it keeps the internal opening
patent
● Cutting Seton either by mechanical
pressure - tightening, or
● A gift to the world by Sushrut is ksharsutra
Prof Manoranjan Sahu from BHU is doing
great research in it. Dr Mahesh Singhvi
from Mumbai has developed the thread of
appropriate OH to lessen the pain

25. Sphincter sparing - LIFT
● Innovated by Prof Arun from Thailand
● Dr Prof Arshad Ahmed from KGMC
Lucknow is expert in this technique. In
his hands it looks so simple

30. S.S VAAFT ( Video Assisted Anal Fistula
Treatment)
● It is Video Assisted fistula treatment
● Unfortunately it was recognised after Carl
Storz developed this fancy instrument
● But
● I am proud to submit that my Resp
teacher, the great innovator has been
doing the same - Endoscopic treatment of
fistula with 5 mm scope since many years
● Sad - he didn't publish and glorified it
Our Dr Kushal Mittal from Mumbai is doing
great work in VAAFT

31. Stem cell treatment
● Mesenchymal stem cells are prepared and
injected in to well curretted fistula tract
● Selection of the ideal donor is still
unknown
● Specially useful in IBD

32. Take home message
● Learn to identify the complex fistulas and leave them to the experts
● In those, putting in the draining Seton will do good to patient by ensuring
drainage and helping the tract to mature
● Underdo in case of doubt
● Recurrence is acceptable but incontinence is not.

33. Thanks a lot to Lybrate and you the keen learner
I am running a serious group on Anorectal
surgery since 2015
We would appreciate if you join us in sharing
your wisdom
Regards
Dr DU Pathak ( India)
94251-52747
dupathak@gmail.com