DETAILED EXPLANATION ON DIFFERENT SURGICAL CONDITIONS OF ANORECTAL REGION

1. DISEASES OF THE ANAL REGION
Dr VIPIN V NAIR
ASSO PROF SURGERY AND PLASTIC SURGEON
AFMC PUNE

2. LEARNING
OBJECTIVES
HAEMORRHOIDS
FISSURE IN ANO
PERIANAL ABSCESS
FISTULA IN ANO

3. HAEMORRHOIDS
BLOOD FILLED VENOUS
DILATATIONS IN THE ANAL CANAL

4. Constipation and prolonged
straining when using the
toilet are thought to
contribute to the formation
of haemorrhoids by
increasing the pressure in the
veins

5. ASYMPTOMATIC

6. BLEEDING PER RECTUM

7. Itching and also
Pain and
Discomfort

8. HAEMORRHOIDS VS VARICES

11. • COMMON POSITONS OF
HAEMORRHOIDS

12. MANAGEMENT

16. MILLIGAN MORGAN HAEMORROIDECTOMY

17. MIPH

18. •FISSURE IN ANO

24. PERIANAL ABSCESS
&
PERIANAL FISTULA

28. Anorectal suppurative disease
Incidence
12.3 per 100000 in men 5.6 per 100000 in women
3rd, 4th and 5th decade of life.

29. PERIANAL FISTULA
Chronic abnormal communication, lined by granulation
tissue, with internal opening in the anal canal and
external opening on the skin of the perineum or buttock
29

30. Cryptoglandular theory 90-95%
30

32. Etiology
• Tuberculosis
• IBD
• Malignancy
• Post op infections
• Superficial skin
infections
32

33. Chronic fissure
•Actinomycosis
•Trauma (Foreign
body)
•Radiation

35. Simple and
Complex
Fistula
35
Simple Fistula Complex fistula
Submucosal Fistula with multiple
external openings
Intersphincteric High transsphincteric,
suprasphincteric,
extrasphincteric
Low transsphincteric Horseshoe fistula
Anterior fistula in
women
Crohn fistula
Radiation induced
fistula

36. Low fistula
• Involve only distal third
part of anal sphincter
High fistula
• Involve the middle
and/or upper third part
of sphincter complex

37. Diagnosis
•History
•Perianal discharge
•Swelling
•Pain
•Bleeding
•Skin excoriation
•External opening
•Previous history of anorectal
suppuration (40%)
37

38. Examination
• Digital rectal
examination
• Proctoscopy
• Examination
under anesthesia
• Examine in awake
state
• Majority – single
primary fistula
tract
38

39. Five essential points of a
clinical examination of an
anal fistula
(1) Internal opening
(2) External opening
(3) Primary track
(4) Secondary track
(5) Underlying disease

40. Goodsall’s Rule
40

41. Investigations
Imaging
•Identify complex fistula
•Define relationship of tract
to anal sphincter muscles
•Plan surgical drainage and
assess risk of sphincter
injury
Meta analysis – EUA always better

42. MRI
• 96% sensitivity and
90% specificity –
internal opening
• Inv of choice for
• complex fistula
• Recurrent fistula
42

43. Endoanal
Ultrasonography
• 360 degree rotating probe
• 7- or 10-MHz transducer with a hard plastic
water-filled sonolucent cone over the
transducer
• Fistula tracts and abscesses - hypoechoic
defects
• Muscular anatomy in relation to abscess and
fistula
• Hydrogen peroxide acts as contrast
• Limitation – cost, availability, expertise
43

44. 3 D endoanal
USG

45. Sigmoidoscopy
and
Colonoscopy
Sigmoidoscopy - In all patients with
anorectal fistula

46. Anorectal
Manometry
Help identify patient at risk
of post op incontinence
Indications
• Suspected sphincter impairment
• H/O difficult labor
• H/O previous fistulotomy
• High fistulas
• Elderly

47. Treatment Modalities-Aims
47
Eradicate disease
1
Preserve continence
2
Prevent recurrence
3

48. Surgical Options
1. Seton
2. Fistulotomy
3. Advancement flaps
4. Fibrin glue - 1990
5. Anal Fistula plug – 2006
6. LIFT (ligation of
intersphincteric fistula tract)-
2007
7. Autologous Adipose
derived stem cells -2009
8. Fistula Laser Closure -
2011
9. VAAFT – 2011
10. Fistula clip closure
11. Hybrid techniques
48

49. Seton
Materials
• Silk , Nylon, Prolene, Vessel
loops, Rubber bands
Draining seton
Cutting seton
50
Success rate – 80%, one third – disturbance of incontinence

50. Fistulotomy
• Identify the tract
• Assess extent of sphincter
involvement
• Division of all structures lying
between external and internal
opening
• Tract laid open and the tract
curettage done
• Surest way of getting rid of fistula
• Success rate – 93 to 100% ,
Incontinence – 11.5 to 20%
51

51. Fistulectomy
• Generally not recommended
• Larger wound and sphincter
damage
52

52. Fibrin Glue
• For complex anal fistula
• Thrombin and fibrinogen
• Stimulate growth of fibroblasts
and endothelial cells
53

53. Fibrin Glue
Antibiotic impregnated – no
difference
Advantage
• Safety
• Ease of application
• Inexpensive
• Low risk of sphincter injury
Meta-analysis (success rate 50
to 60%)

54. Anal Fistula Plug
• Lyophilised porcine derived
small intestinal submucosa
(Surgisis®)
• GORE BioA fistula plug
(polyglycolic acid/
trimethylene carbonate)
• Success rate 55%

56. Anal Fistula Plug
Complications
•Plug dislodgement
•Infection
•Failure rate – high

57. Advancement
Flaps
Endorectal advancement flaps
• Flap raised
• Mucosa+ submucosa + Int. Sphincter
• Internal opening excised/closed
• Flap advanced & sutured
• External component treated by curettage or
fistulotomy
58

59. Advancement
Flaps-
Advantage
One stage
Quick healing
Limited sphincter damage
Minimal anal canal deformity

60. Advancement
Flaps
Success – 59 to 72%
Multiple session - 90%
Incontinence – 9 to 14%
Efficacy similar with fistula plug

61. LIFT
62
Ligation of intersphincteric fistula tract (LIFT)
2007 – Rojanasakul et al
Based on closure of internal opening,
removal of infected tissue
Disconnection of internal opening from
fistula tract at level of intersphincteric plane
Injection of hydrogen peroxide – help
confirm completeness of procedure

63. LIFT
• Anal sphincter preservation
• Minimal tissue injury
• Shorter healing time
Advantage
• Healing rate – 40 to 95%
• For recurrent fistula – success rate
47%
Success rate

64. VAAFT
65
Video- Assisted Anal Fistula Treatment
Dr P Meinero in 2006
5 mm fistuloscope, irrigation, diathermy
Diagnostic phase – tract and opening evaluated with fistuloscope
Operative phase - cauterize

65. VAAFT
Steps
• Identify tract under vision
• Cauterise & debride fistula wall with bipolar energy
• Endobrush to extract necrotic material
• Internal opening sutured by semicircular/linear stapler or
mucosal flap
• 0.5 ml cyanoacrylate glue to reinforce suture line
Healing rate – 73.5% at 3 months and 87.1% at 12
months

67. VAAFT
Advantage
No sphinter injury
Post op pain less

68. Fistula
Laser
Closure
69
FiLaC
Radial emitting laser probe
Destroys the fistula epithelium and obliterates
the tract by shrinkage effect
Includes closure of internal opening with
anorectal flap
Steps – identify – debride – 14 fr catheter-400
micron laser fibre with tip at internal orifice

70. THANK YOU
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