Peri anal surgeries

1. Neoadvancements in Perianal surgeries
Dr. Muhammad Zain Ul Abid
TR SURGICAL Unit-2

2. Introduction:
• A track that is lined by granulation tissue connecting perianal skin superficially to anal
canal or rectum.
• Broadly classified into two types on basis of histology:
1. Crypto glandular (90%)
2. Other causes ( T.B, Crohns disease, Malignancy, UC , Hidradenitis supperativa)

3. Types
• Simple with no extensions
( single external opening)
• Complex with extensions.
(multiple external openings)
• Low level fistulas
(below the internal ring)
• High level fistulas
(above the internal ring)
Standard classification

4. TYPES
• Inter-sphincteric (70%)
• Trans-sphincteric (25%)
• Supralevator/Suprasphincteric (4%)
• Extrasphincteric (1%)

5. Goodsall’s rule
1.Fistulas with an external opening in
relation to the anterior half of the anus
are of direct type.
2.Fistulas with openings in relation to
posterior half of the anus, has a curved
track opens in the midline posteriorly
and may present with multiple external
openings

6. CLASSIFICATION ON BASIS OF MRI

7. Treatment
1. Fistulotomy
(Lay open)

8. Treatment
2.Fistulectomy
3.Fistulectomy
with seton.

9. Neoadvancements in Perianal Surgeries
1. VAAFT
2. PERFACT
3. TROPIS
4. FIPS
5. TFSIA
6. LIFT PROCEDURE and MODIFIED LIFT PROCEDURE
7. FILLING THERAPY
8. PDT ( photodynamic therapy)

10. VAAFT (Video-Assisted Anal Fistula Treatment)
• A video telescope (fistuloscope) to see
inside the fistula tract.
• A fistula brush and forceps for cleaning
the tract and clearing any granulation
tissue.
• A diathermy.

11. • Inner opening is ligated through vicryl from luminal side.
• It is considered to be the only technique with which whole tract can be visualized.
• VAAFT can be considered an effective and a safe method for the treatment of complex
and high FIA with satisfactory outcome and acceptably low complications. Recurrence
after VAAFT may be related to previous fistula surgery and the method of closure of the
internal opening.
(A Systematic review and meta-analysis of the efficacy and safety of video-assisted anal fistula treatment)

12. Modified seton technique
• After excising the entire fistula tract
as much as possible from the
secondary opening to the internal
sphincter muscle
• a seton rubber band is placed
between the primary opening and
the nearest point of skin incision.

13. LIFT Procedure (Ligation of inter-sphincteric
fistulous tract)
• Inter-sphincteric space is reached
through a transverse incision.
• Fistula running across is identified
and ligated using vicryl on either
side.
• Part is excised; outer part is
curetted through external
opening.

14. MODIFIED LIFT PROCEDURE
• Fistula is ligated at high level after
dissection from the external opening
toward the internal opening until internal
anal sphincter is reached and the
sphincter space is exposed
• Where fistula is ligated followed by the
removal of the ligated distal part.
• This reduces the chance of inter-
sphincteric fistula formation.

15. ADVANTAGES OF MODIFIED OVER LIFT
• LIFT is associated with higher recurrence
in the form of an inter-sphincteric fistula
formation.
• It is difficult to perform due to narrow
inter-sphincteric space.
• In modified LIFT, fistula is ligated at high
level after dissection from the external
opening.
• This reduces the chance of inter-
sphincteric fistula formation. That’s why
modified LIFT has advantage over Simple
LIFT procedure.

16. PERFACT PROCEDURE

17. INDICATIONS
• Fistula associated with multiple tracts
• Horse shoe fistulas
• Recurrent fistulas
• Anterior fistula in females
• Fistula with long tracts (any tract length >
10 cm)
CONTRAINIDICATIONS
• Simple low fistula
• Fistula with supra-levator rectal opening
(on MRI and/or examination on operating
table)

18. PROCEDURE
• Proximal superficial cauterization:
• The area around the internal opening is freshened and de-epithelized by cautery and wound
is encouraged to heal by secondary intention.
• This usually closes the internal opening in about 10-12 days.

19. • All the tracts are thoroughly curetted and debrided of their lining with a curette.
• Emptying regularly of fistula tracts.
• The curetted tracts are kept clean and empty of any serous fluid as to ensure the tracts
are healed by granulation tissue.

20. To ensure proper cleaning of the tracts,
• Multiple holes are made along the straight or the horseshoe tract.
• The external opening is widened. This facilitates cleaning of the tracts for a longer
duration.
• Loose rubber setons are inserted in the holes to prevent their premature closure. These
are removed 10-12 days post-op.

22. OTSC PROCEDURE
• OTSC® (over-the-scope-clip)
proctology device involves
the placement of an elastic
alloy clip called Nitinol on the
internal fistula opening to
achieve fistula healing.

23. TFSIA
• Mostly done in high complex fistulas.
• Tunnel-Like Fistulectomy Plus Draining Seton with Incision of Internal Opening.

26. TROPIS
• Trans-anal opening of inter-sphincteric space (TROPIS)
• Transanal laying open of the intersphincteric space (TROPIS) is done through the
internal opening.
• The external sphincter is not cut. The tracts in the ischiorectal fossa are curetted
and cleaned.

27. The intersphincteric space and internal opening is laid open into the anal canal while
preserving the external sphincter. The external tracts are thoroughly curetted and cleaned

28. FIBRIN GLUE METHOD
• Fibrin glue is a multicomponent system containing mainly human plasma
fibrinogen and thrombin.
• Once prepared it is injected into the fistula track which hardens in few minutes
and fills the entire track.
• Success rate is not good

30. ANAL FISTULA PLUG
• anal fistula plug (porcine small intestine submucosa, SIS) is used
• 85% success rate is noted in simple fistula.
• It contains naturally derived extracellular matrix which acts to cause,
2. Ingrowth of tissue.
3. Remodeling.

31. • the fistula tract is repaired without cutting the sphincter muscle.
• The risk of incontinence is minimized.

33. Advancement flap procedure
• An advancement flap procedure is considered if fistula passes through the anal
sphincter.
• It involves cutting or scraping out the fistula and covering the hole where it entered the
bowel with a flap of tissue taken from inside the rectum.
• This has a lower success rate than a fistulotomy.
• But avoids the need to cut the anal sphincter muscles.

35. Photodynamic Therapy for the Treatment of
Complex Anal Fistula
• Intralesional 5-aminolevulinic acid (ALA) gel (2%) is injected directly into the fistula.
• The internal and external orifices are closed.
• After an incubation period of 2 hours, the fistula is irradiated using an optical fiber
connected to a red laser.

37. Fistulectomy and primary sphincteroplasty (FIPS)

38. References
• Emile SH, Elfeki H, Shalaby M, Sakr A. A Systematic review and meta-analysis of the
efficacy and safety of video-assisted anal fistula treatment (VAAFT). Surg Endosc. 2018
Apr;32(4):2084-2093. doi: 10.1007/s00464-017-5905-2. Epub 2017 Oct 19. PMID:
29052068.
• https://asiindia.org/2014/10/25/perfact-procedure-by-dr-pankaj-garg/
• SRB

39. •Thank You 