FISTULA IN ANO

ANATOMY
DEFINITION
AETIOLOGY
CLASSIFICATION
TYPES
CLINICAL FEATURES
INVESTIGATIONS
TREATMENT

ANATOMY
The anal canal commences at the level
where the rectum passes through the pelvic
diaphragm and ends at the anal verge.
It comprises:

Anorectal ring
Puborectalis muscle
External sphincter muscle
Intersphincteric plane
Longitudinal muscle
Internal sphincter

 Anorectal ring marks the junction between rectum

and anal canal and is formed by joining of
puborectalis muscle, deep external sphincter,
conjoined longitudinal muscle and highest part of
internal sphincter.
Puborctalis muscle: is part of pelvic diaphragm
which maintains the angle between anal canal and
rectum and plays important role in continence.
External sphincter: forms the bulk of anal
sphincter complex and has been subdivided into
superficial, deep and subcutaneous portion but it
occurs as single muscle called Goligher.

 Intersphincteric plane is a potential space

between external sphincter and longitudinal
muscle
which
contains
intersphincteric
glands.
Longitudinal muscle: is a direct continuation
of the smooth muscle of the outer coat of the
rectum.
Internal sphincter: It is thickened distal
continuation of the circular muscle coat of the
rectum. It maintains the tonic state of
contraction.

DEFINITION
It is a sinus tract lined by granulation
tissue which connects perianal skin
superficially to anal canal, anorectum
or rectum deeply.
It usually occurs in a pre existing
anorectal abscess which bursts
spontaneously.

AETIOLOGY

Cryptoglandular
Tuberculosis
Carcinoma
Crohns disease
Ulcerative colitis
Lymphogranuloma venerum
Hydradenitis suppurativa
Traumatic

Cryptoglandular
The
infection of
the
intersphinct
eric glands
initiates the
fistula
in
ano.

Classification
Parks
Intersphincteric - commonest
Transphincteric
Supralevator/Suprasphincteric
Extrasphincteric

TYPES
Low level fistulas
High level fistulas
Single external opening
Multiple external opening

Clinical features
Severe pain in the perianal region
Seropurulent discharge
Skin irritation
Induration of the surrounding skin

INVESTIGATIONS
CLINICAL EXAMINATION
Goodsalls rule
Digital rectal examination
Proctoscopy
MRI
Theindication for imaging:
follow-up of fistulas treated with nonsurgical
methods, especially in Crohns disease
surgical planning

GOODSALLS RULE
Fistulas with an external opening in relation to
the anterior half of the anus is of direct type.
Fistulas with an external opening in relation to
posterior half of the anus, has a curved track
may be of horse shoe type, opens in the midline
posteriorly and may present with multiple
opening all connected to single internal opening.
Fistulas are mostly on the posterior half of the
anus.

TREATMENT
The primary objective are to
eradicate the tract and drain all
associated site of the infection with
simultaneous
preserving
anal
continence.

FISTULA IN ANO
Operative treatment
Fistulotomy (Lay open fistula)
Advancement flap closure of internal
opening
Seton insertion
Fistulectomy
Glue
Plug

 The
laying-open
technique
(fistulotomy) is useful for 85-95% of
primary fistulas (ie, submucosal,
intersphincteric, low transsphincteric

 A probe is passed into the tract

through the external and internal
openings.
The overlying skin, subcutaneous
tissue, and internal sphincter muscle
are divided to open the entire fibrous
tract.
Opening the wound out on the
perianal skin for 1-2cm adjacent to
the external opening promotes

 The granulation tissue present in the

tract is removed for
Histopathology
Bacteriological
Culture
MTB
PCR

A seton can be
placed alone
Combined with fistulotomy,
USES
Visual identification of the amount of
sphincter muscle involved,
Drain.
Fibrosis.
Cut through the fistula.

Indications for seton

insertion
Complex
fistulas
(i.e.,
high
transsphincteric,
suprasphincteric,
extrasphincteric) or multiple fistulas
Recurrent fistulas after previous
fistulotomy
Anterior fistulas in female patients
Poor
preoperative
sphincter
pressures
Patients with Crohn disease or
patients who are immunosuppressed

Procedure for single stage

seton
The seton passes through the fistula
tract around the
Skin, subcutaneous tissue.
Deep external sphincter
Internal sphincter muscle
Subcutaneous
external
sphincter
muscle.
It is tightened down and secured with a
separate silk tie.

Mechanism
Fibrosis occurs above the seton as it
gradually cuts through the sphincter
muscles and essentially exteriorizes
the tract.
The seton is tightened on subsequent
visits until it is pulled through over 68 weeks.
The seton is removed later

Two-stage seton(draining/fibrosing)
Unlike the cutting seton, the seton is
left loose to drain the intersphincteric
space and to promote fibrosis in the
deep sphincter muscle.
After the superficial wound is healed
completely (2-3months later).
The seton-bound sphincter muscle is
divided.

Fisulectomy
It involves coring out of fistula by
diathermy cautery which allows better
definition of fistula anatomy especially at
the level at which the track crosses the
spincteric component and presence of
secondary extensions.

Mucosal advancement flap

If sphincteric complex is not too indurated and
adequate intra anal access can be obtained.
It includes coring out of entire track , closure
of communication with the anal lumen with
adequately
vascularized
flap
consisting
mucosa and int. sphincter, without tension to
anoderm, well distant from site of excised
internal opening.
Principles:
prior elimination of sepsis
Elimination of secondary track
Direct track

Biological agents
Fibrin glue
Porcine intestinal submucosa
Porcine dermal collagen

REFERENCES
Bailey and love