1. Introduction

2. Palpate for Possible Internal Opening

3. Thread Fistula

4. Fistulotomy vs Fistulectomy Discussion

5. Open Fistulous Tract

6. Closure

7. Post-op Remarks

Fistula-in-ano is a chronic abnormal communication between the anal canal and, usually, the perianal skin. It can be described as a hollow tract that is lined with granulation tissue and connects a primary opening inside the anal canal to a secondary opening in the perianal skin. It usually originates from the anal glands and is frequently the result of a previous anal abscess. Anal fistulae present with pain, swelling, pruritus, skin irritation, and purulent or bloody drainage. Most anal fistulae are diagnosed based on clinical findings, but complex and deep anal fistulae usually require imaging studies such as CT scan or MRI to delineate the tract. Fistulae are categorized based on their relationship to the anal sphincter complex. An intersphincteric fistula tracks through the distal internal sphincter and intersphincteric space to an external opening near the anal verge. A trans-sphincteric fistula extends through both the internal and external sphincters. A suprasphincteric fistula originates in the intersphincteric plane and tracks up and around the entire external sphincter. An extrasphincteric fistula originates in the rectal wall and tracks around both sphincters to exit laterally, usually in the ischiorectal fossa. Currently, there is no medical treatment available and surgery is almost always necessary. A simple intersphincteric fistula can often be treated with fistulotomy or fistulectomy, while trans-sphincteric and suprasphincteric fistulae are treated by placement of a seton to maintain drainage and induce fibrosis. Extrasphincteric fistula treatment depends on the anatomy and etiology of the fistula. We present the case of a 1-year-old male with a history of recurrent perianal infection, which led to the development of an anal fistula. The anal fistula was noted to be superficial and a fistulotomy was performed.

<h4>CHAPTER 1</h4>

<p>This is a case of a 1-year-old male
with a recurrent infection around the anus.
So we've observed this patient for a couple of months,
but it has continuously recurred.
It seems like there's a mature -
external opening here,
which could be the fistula.</p>

<h4>CHAPTER 2</h4>

<p>So I normally palpate the -
the rectum and anus -
to try to feel for a -
notch or an opening here on the side of the fistula.
And it seems like a hard area here.
Some fibrosis, which could be the internal opening.</p>

<h4>CHAPTER 3</h4>

<p>What's important for a fistula-in-ano diagnosis
is to identify the external opening and the internal opening.
So we could do this by using a probe.
This is an anal probe.
I put some lubricating jelly.
I angled it a bit
so it'll be easier to insert.
So what's important is you get the external opening
towards the internal opening.
So we do that slowly.
Try to insert the probe slowly.
Sometimes it will be a little closed with some fibrosis.
So -
Again, what's important is you don't want to -
to make a false tract.
So we don't want to force in the probe
We're hoping that we could identify the -
the tract, if there is a tract.
So it has inserted already.
Now I'm trying to -
feed it inside here.
And you just push a bit.
So you try to just -
push it in slowly.
And here you could see, I have it superficially.
It's important that you check if it's -
if it goes through the sphincters.
This one seems like it's just superficial.
There. So there is a tract
from the internal opening here -
pickup, please -
internal opening, inside the anus, and towards the outside.</p>

<h4>CHAPTER 4</h4>

<p>There are 2 ways to do it.
There's a fistulotomy, which we'll do now,
which is cutting this open, burning the edges,
and probably we will curette the internal area.
And we leave it open, so it will close by secondary healing.
And this tract will be -
will be obliterated or it will close in a better way.
Another way is a fistulectomy, by excising the whole thing.
But for this one, which is superficial
and it doesn't seem like it's really fibrosed or hard,
we could just do a fistulotomy, by just cutting this open.</p>

<h4>CHAPTER 5</h4>

<p>So since we've identified it here clearly,
I'll use a cautery. I'll use the cutting.
I just mark it a bit.
And then that's where I'll make my incision.
So once you start cutting, it normally goes -
if you use the cutting button, it goes a little deeper already.
So it's best that you mark it beforehand.
You can see some of the sphincter muscles contracting.
So there, once you're ready,
go over the skin incision, and then you can use the coag.
While - so the key here is, you're also pulling on this probe
while you're pulling on this -
you're using the coag, so -
you can really burn the tissues.
There you can see we're going through some -
some muscles in this area.
It's just minimal. Nothing much.
So this is called a fistulotomy,
where you just open up the fistulous tract.</p>

<h4>CHAPTER 6</h4>

<p>And then you just leave it open.
So you can see here, there's the tract.
There.
It seems like there really is a true tract, as you can see here.
This is the lining.
So I just burn the area.
Just to control some of the bleeding.
A curette, yeah.
So, as you can see, the anatomy, the dentate line here.
The columns.
So we're pretty superficial.
I'll use a curette to curette the area,
just to try to eliminate a possible recurrence.
So here you can feel, it's a little softer tissue here.
And you can see where the tract is, it's a little firm.
It's a different consistency.
So -
I think this is a true fistula-in-ano.
It's normally for children. It's not that common.
We normally have a recurrent
infection due to diaper rash,
and normally this subsides.</p>

<h4>CHAPTER 7</h4>

<p>So that is fistulotomy.
I think we're done. We're just checking for bleeding.
Normally when the baby cries,
sometimes the bleeding will be evident,
but here you can see it's all dry.
I just feel again.
Put some jelly, try to feel, and it's pretty clear.
I don't think I injured any -
muscles.
So that's the procedure for a fistulotomy.
And then we put ointment, and we put a gauze,
and then instruct the parents for post-op care.
And then we put the ointment - there.
And then put the gauze after.
So what happens is the underlying tissue here would heal secondarily.
It would also be more superficial through the days.
What would help this - what we call a hot sitz -
hot sitz bath, or - you put some warm water in this area.
It's to allow cleansing or cleaning of the wound.
In older patients, they would actually submerge their -
their anus in a -
in a basin of water, hot - warm water.
So this wound would normally heal probably -
after 2 to 3 weeks, completely.
So we just avoid - avoid, um -
sometimes we give some stool softeners.
So that the -
the bowel movement would be with better consistency,
to avoid further injuring the wound.
So we normally give some antibiotics
to cover the infection, and pain reliever.
And you ask - maybe to follow up probably after a week.</p>


Watch full-length, narrated surgical procedure of an anal fistulotomy on a 1-year-old male. Performed on a surgical mission with the World Surgical Foundation.

DOI
Publication Date	2023/07/12
Article ID	278.1
Production ID	0278.1
Volume	2023
Issue	278.1
https://doi.org/10.24296/jomi/278.1

Anal Fistulotomy

Procedure Outline

Table of Contents