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Anal Fistulectomy

Eric de Leon, MD1; Jaymie Ang Henry, MD, MPH2

1Perpetual Help Hospital
2Florida Atlantic University, G4 Alliance

Transcription

CHAPTER 1

This is a case of an 18-year-old male who started complaining of an abscess in the perianal area after which he took antibiotics, and then after a couple more weeks started noticing drainage from his underwear. So, probably as a complication of the fis - of the perianal abscess, probably he has a fistula-in-ano. With regards to fistula-in-ano, the first thing you ask the patient is the history of abscess because that's part of the pathophysiology of having a fistula-in-ano.

In this case, we did a laryngeal mask airway for the patient. Put the patient on stirrups, lithotomy position, so you can examine the patient better. Two days ago, he underwent a bowel preparation, so as to make our field - that's part of the mechanical cleansing for anal surgeries.

As the wor - Rakhi? As the word implies, fistula is a connection between the inside environment and the outside environment. In this case, part of the anal canal has an interior opening. What you can see here is the exterior opening. So my intention for this operation is to look for the - from the external opening, I will look for the internal opening and I will open it up. Theoretically, we can do either fistulotomy - fistulotomy is, you open up the tract - or we can do fistulectomy, when we remove the tract. Studies have shown that there's not much difference between doing any of the 2 procedures, depending on the preference and the expertise of the surgeon.

CHAPTER 2

Now we're injecting local anesthesia to the area. This is for postop management.

CHAPTER 3

This is probably the external opening. Okay. See? I have to thread this - I have to thread this going to the internal opening. Be careful not to make a false tract. Anyway, the tract offers no resistance at all. See? Without much resistance, I'm slowly getting inside the anal canal.

CHAPTER 4

What I plan to do is open up the canal.

There's probably - that's the internal opening. There's the internal opening. There. Without much resistance - I could - There! This is a good, uh - Again - this is the external opening. This is the internal opening. From this opening to this opening, you call it the fistulous tract. What I will do is do a fistulectomy and remove the whole tract.

Can you lower down the cautery, please? It's too high. Okay. Perfect. Here, I'm going to - this is the tract, I'm going posteriorly. And also the other side.

See, this is the fistulous tract. There are 2 ways, again - it's either you do a fistulotomy or you cut this, and then you burn the posterior side of your fistulous tract. What I'm doing is a fistulectomy. So I'm getting the whole of the tract. I'm removing the tract.

So this is the tract - fistulous tract. Now we send this for a pathology for - just to confirm that it's part of the fistulous tract.

CHAPTER 5

If you ask me, no sutures? No, no sutures. Because we let the granulation tissue pop out. I just have to burn this to make sure there's no bleeding.

And we're done.

We’re offering healing of secondary intention. So that skin will grow back from this defect.

CHAPTER 6

So, points to remember: you have to maintain the patient on a high-fiber diet. Increase oral fluid intake so it makes the stools soft. So just to lessen the pain also. Additional management will be - a hot sitz bath, 10 to 15 minutes, 3 times a day. And - that's about it.

This is a non-complicated fistula. Other fistulas would be - multiple lines with connecting branches, which is more complicated and more difficult to do. We are lucky today that we had a simple and very straightforward and properly structured fistula for this case.