Fistula in Ano

Our Approach In Managing Fistula in Ano

Map the tract. Treat the source. Protect continence.

Anal fistula surgery is a field where surgical experience matters enormously - because the central challenge is treating a tract that frequently passes through or near the muscles responsible for bowel control. A fistula treated too aggressively risks incontinence; a fistula treated too conservatively risks recurrence. The right approach depends entirely on the fistula's relationship to the sphincter complex - information that must be mapped precisely before any treatment decision is made.

At Shree Hospitals, our approach to complex perianal fistula diagnosis and sphincter sparing care is built around this principle: complete anatomical understanding before any intervention. Our anal fistula specialists combine advanced imaging, careful clinical assessment, and a graduated treatment philosophy - selecting techniques that achieve cure while preserving function for each individual tract anatomy.

1. Comprehensive Fistula Mapping

• Detailed clinical examination - identifying the external opening, palpating the tract, and assessing for induration suggesting the internal opening location
• MRI fistulogram - the gold-standard imaging technique for complex perianal fistula diagnosis, mapping the tract's relationship to the internal and external sphincter with high precision
• Endoanal ultrasound - an alternative or complementary imaging modality, particularly useful for assessing sphincter integrity
• Examination under anaesthesia (EUA) - direct probing of the fistula tract at the time of surgery to confirm imaging findings and identify the precise internal opening
• Goodsall's rule application - predicting internal opening location based on external opening position, refined by direct imaging correlation
• Assessment for underlying causes - particularly Crohn's disease, which significantly alters fistula behaviour and treatment approach

2. Management of Acute Perianal Abscess
    
   Most fistulas originate from a previous abscess - and acute presentations require urgent drainage:

• Perianal abscess drainage - urgent incision and drainage under appropriate anaesthesia, providing immediate symptom relief and infection control
• Identification of an associated fistula tract at the time of abscess drainage where anatomically apparent
• Antibiotic therapy as an adjunct to drainage, particularly for patients with systemic signs of infection or significant cellulitis
• Planned interval assessment for fistula formation - approximately 30 to 50% of drained abscesses develop into a chronic fistula requiring definitive treatment

3. Seton Placement
    
   A cornerstone technique in modern fistula management, particularly for complex tracts:

• Seton placement - a soft surgical thread passed through the fistula tract, allowing continued drainage while preventing abscess recurrence
• Loose (draining) seton - used for high or complex fistulas to control sepsis while definitive treatment is planned, particularly in Crohn's-associated fistulas
• Cutting seton - gradually tightened over weeks to slowly divide the sphincter muscle it passes through, allowing the tissue to heal as it is divided, minimising continence impact
• Staged approach for complex fistulas - seton placement first, followed by definitive sphincter-sparing surgery once acute inflammation has resolved

4. Sphincter-Sparing Surgical Techniques
    
   For complex or high fistulas where sphincter division would risk significant continence impact:

• LIFT procedure (Ligation of Intersphincteric Fistula Tract) - accessing and ligating the fistula tract between the internal and external sphincters, without dividing either muscle
• Fistulotomy - laying open the tract completely; reserved for simple, low fistulas involving minimal sphincter muscle where continence risk is negligible
• Endorectal advancement flap - mobilising healthy rectal tissue to cover the internal opening after tract curettage, preserving the sphincter complex entirely
• Fibrin glue and fistula plug techniques - biological materials used to occlude the tract in selected straightforward cases
• Video-Assisted Anal Fistula Treatment (VAAFT) - endoscopic visualisation and treatment of the tract from within, combining diagnostic and therapeutic precision

5. Management of Complex & Recurrent Fistulas
   

• Multi-stage treatment planning for horseshoe fistulas and those with multiple tracts or branches
• Combined seton and flap procedures for high transsphincteric or suprasphincteric fistulas
• Management of Crohn's-associated fistulas in coordination with gastroenterology - addressing underlying inflammatory bowel disease alongside local fistula control
• Revision surgery for recurrent fistulas following previous treatment elsewhere - careful re-mapping before any further intervention

6. Post-Operative Care & Continence Preservation

• Structured wound care guidance for open fistulotomy wounds - sitz baths and dressing changes during the healing period
• Continence assessment before and after surgery - objective documentation protecting both patient and surgical decision-making
• High-fibre diet and stool softener use to minimise straining during the healing phase
• Regular follow-up to monitor healing progression and detect any early signs of recurrence
• Long-term continence monitoring for patients undergoing sphincter-involving procedures as part of Fistula in Ano treatment in Mumbai, India