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Dr. Shamim Khan
HMO, Surgery Unit – 1, Ward - 24
    A fistula-in-ano, or anal fistula, is a chronic
      abnormal communication, usually lined to
      some degree by granulation tissue, which runs
      outwards from the anorectal lumen (the
      internal opening) to an external opening on the
      skin of the perineum or buttock.




Ref: Bailey & Love’s Short Practice of Surgery
     25th edition.
A doctor and a patient
                      with fistula in ano. Sketch from a
                      15th-century Flemish copy of Jan
                      Yperman's Cyrurgie.




External opening of
a fistula-in-ano
 Nearly always caused by previous perianal
  abscess formation
 Crohn's disease
 Diabetes Mellitus
 Tuberculosis
 Lymphogranuloma venerum
 Actinomycosis
 Rectal duplication
 Trauma
 Radiotherapy
 patients  who are immunocompromised for
    any reason (HIV infection, malignancy)
A fistula-in-ano complicates 30-50% of perianal abscesses.
Park’s Classification
  (according to the relationship of primary tract to the anal sphincters)

    Intersphincteric (45%)
      Simple low tract
      High tract
      High tract with rectal opening
      Extra rectal extention
    Trans-sphincteric (40%)
      Uncomplicated
      High tract
    Suprasphincteric
      Uncomplicated
      High tract
    Extrasphincteric
      Secondary to trauma
      Secondary to anorectal disease
      Secondary to pelvic inflammation


Ref: The ASCRS textbook of colon and rectal surgery
By Bruce G. Wolff, James W. Fleshman, David E. Beck
Based on level of internal opening related to anal sphincters




 Low    variety

 High   variety
 If the internal opening
 begins above the anal
 sphincter then the fistula
 is described as 'high'.
 Usually rare.
 Intermittent     discharge
 (purulent or bloody)

 Pain
 (which increases until temporary
 relief occurs when pus discharges)


 Pruritis   ani

 Perviousepisode of
 anorectal sepsis
 History : Full medical history including
  obstetric, gastrointestinal, anal surgical and
  continence are necessary.

  Before any surgical procedure is carried out
  an EUA should be performed.

 EUA: A full examination/inspection of the perineum
  followed by DRE & Proctosigmoidoscopy.
   DRE examination - area of induration, fibrous tract and
      internal opening may be felt.
     Proctosigmoidoscopic inspection - to evaluate the
      rectal mucosa for any underlying disease process.
 Site of internal opening.
 Site of external opening.
 The course of primary tract
 Presence of secondary extention.
 Sphincter strength.
 The presence of other condition complicating
  the fistula.
   If the external opening
    is anterior to the line,
    the fistula usually runs
    directly into the anal
    canal.

   If the external opening
    is posterior to the line,
    the fistula usually curves
    to the posterior midline
    of the anal canal.
 Fistulography


 Endoanal   ultrasound

 MRI
 Reveal  primary
  and secondary
  tract.
 Useful if an
  extrasphincteric
  fistula suspected
 Determine sphincter
  integrity
 Complexity of the
  fistula




                        Horse shoe fistula
Considered „gold standard‟ for fistula-in-ano imaging




High variety supra-sphicteric fistula      Horse shoe fistula
 Fistulotomy (The laying open technique)
 Fistulectomy
 Setons
 Fibrin Glue            Sphincter preserving techniques
 Anal fistula plug
 Advancement Flap
   It involves division of
    all structures lying
    between internal and
    external openings.

   Applied mainly to low
    variety
    intersphincteric and
    trans-sphinceric
    fistula
 The traditional fistulotomy surgery usually
  results in large and deep wounds which can
  take months to heal.
 “High” often indicates – high risk of faecal
  incontinence if laid open.
 Sphincter preserving techniques are
  preferable than laid open techniques.
 Preferable  surgical option for high variety.
 Setons are usually made from rubber slings
 2 types of seton suture can be placed


 Draining     Seton
     Facilitates draining of sepsis
     Left loose and allows fistula to heal by fibrosis
 Cutting    Seton
     Slowly "cheese-wires" though the sphincter
      muscle
     Allows fibrosis to take place behind as it
      gradually cuts through
Fistula in ano
 The  Anal fistula plug is a minimally invasive
  and sphincter-preserving alternative to
  traditional fistula surgery.
 The plug is a conical device and is placed by
  drawing it through the fistula tract and
  suturing it in place.
 the plug, once implanted, incorporates
  naturally over time into the human tissue
  (human cells and tissues will 'grow' into the
  plug), thus facilitating the closure of the
  fistula.
As with most anorectal disorders, follow-up
  care includes:
 Perianal baths,
 analgesics for pain,
 stool bulking agents, and
 good perianal hygiene.
Fistula in ano

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Fistula in ano

  • 1. Dr. Shamim Khan HMO, Surgery Unit – 1, Ward - 24
  • 2. A fistula-in-ano, or anal fistula, is a chronic abnormal communication, usually lined to some degree by granulation tissue, which runs outwards from the anorectal lumen (the internal opening) to an external opening on the skin of the perineum or buttock. Ref: Bailey & Love’s Short Practice of Surgery 25th edition.
  • 3. A doctor and a patient with fistula in ano. Sketch from a 15th-century Flemish copy of Jan Yperman's Cyrurgie. External opening of a fistula-in-ano
  • 4.  Nearly always caused by previous perianal abscess formation  Crohn's disease  Diabetes Mellitus  Tuberculosis  Lymphogranuloma venerum  Actinomycosis  Rectal duplication  Trauma  Radiotherapy  patients who are immunocompromised for any reason (HIV infection, malignancy)
  • 5. A fistula-in-ano complicates 30-50% of perianal abscesses.
  • 6. Park’s Classification (according to the relationship of primary tract to the anal sphincters)  Intersphincteric (45%)  Simple low tract  High tract  High tract with rectal opening  Extra rectal extention  Trans-sphincteric (40%)  Uncomplicated  High tract  Suprasphincteric  Uncomplicated  High tract  Extrasphincteric  Secondary to trauma  Secondary to anorectal disease  Secondary to pelvic inflammation Ref: The ASCRS textbook of colon and rectal surgery By Bruce G. Wolff, James W. Fleshman, David E. Beck
  • 7. Based on level of internal opening related to anal sphincters  Low variety  High variety If the internal opening begins above the anal sphincter then the fistula is described as 'high'. Usually rare.
  • 8.  Intermittent discharge (purulent or bloody)  Pain (which increases until temporary relief occurs when pus discharges)  Pruritis ani  Perviousepisode of anorectal sepsis
  • 9.  History : Full medical history including obstetric, gastrointestinal, anal surgical and continence are necessary. Before any surgical procedure is carried out an EUA should be performed.  EUA: A full examination/inspection of the perineum followed by DRE & Proctosigmoidoscopy.  DRE examination - area of induration, fibrous tract and internal opening may be felt.  Proctosigmoidoscopic inspection - to evaluate the rectal mucosa for any underlying disease process.
  • 10.  Site of internal opening.  Site of external opening.  The course of primary tract  Presence of secondary extention.  Sphincter strength.  The presence of other condition complicating the fistula.
  • 11. If the external opening is anterior to the line, the fistula usually runs directly into the anal canal.  If the external opening is posterior to the line, the fistula usually curves to the posterior midline of the anal canal.
  • 12.  Fistulography  Endoanal ultrasound  MRI
  • 13.  Reveal primary and secondary tract.  Useful if an extrasphincteric fistula suspected
  • 14.  Determine sphincter integrity  Complexity of the fistula Horse shoe fistula
  • 15. Considered „gold standard‟ for fistula-in-ano imaging High variety supra-sphicteric fistula Horse shoe fistula
  • 16.  Fistulotomy (The laying open technique)  Fistulectomy  Setons  Fibrin Glue Sphincter preserving techniques  Anal fistula plug  Advancement Flap
  • 17. It involves division of all structures lying between internal and external openings.  Applied mainly to low variety intersphincteric and trans-sphinceric fistula
  • 18.  The traditional fistulotomy surgery usually results in large and deep wounds which can take months to heal.  “High” often indicates – high risk of faecal incontinence if laid open.  Sphincter preserving techniques are preferable than laid open techniques.
  • 19.  Preferable surgical option for high variety.  Setons are usually made from rubber slings  2 types of seton suture can be placed  Draining Seton  Facilitates draining of sepsis  Left loose and allows fistula to heal by fibrosis  Cutting Seton  Slowly "cheese-wires" though the sphincter muscle  Allows fibrosis to take place behind as it gradually cuts through
  • 21.  The Anal fistula plug is a minimally invasive and sphincter-preserving alternative to traditional fistula surgery.  The plug is a conical device and is placed by drawing it through the fistula tract and suturing it in place.  the plug, once implanted, incorporates naturally over time into the human tissue (human cells and tissues will 'grow' into the plug), thus facilitating the closure of the fistula.
  • 22. As with most anorectal disorders, follow-up care includes:  Perianal baths,  analgesics for pain,  stool bulking agents, and  good perianal hygiene.