Equipment

Equipment required for anal fistulotomy may include the following:

Local anesthetic
Fistula probes
Methylene blue, hydrogen peroxide
Seton (Silastic vessel loop, suture)
Additional equipment, depending on the specific approach employed (fibrin glue or plug, bioprosthetic plug)

Patient Preparation

Local anesthesia (0.25% or 0.5% bupivicaine with 1:200,000 epinephrine injected circumanally and submucosally) with intravenous sedation can be used. General anesthesia may be required for airway control issues.

The patient is placed in a prone jackknife position, with the buttocks gently taped apart to afford better exposure.

Technique

Rakinic J, Poola VP. Hemorrhoids and fistulas: new solutions to old problems. Curr Probl Surg. 2014 Mar. 51 (3):98-137. [QxMD MEDLINE Link].
Cirocco WC, Reilly JC. Challenging the predictive accuracy of Goodsall's rule for anal fistulas. Dis Colon Rectum. 1992 Jun. 35 (6):537-42. [QxMD MEDLINE Link].
Coremans G, Dockx S, Wyndaele J, Hendrickx A. Do anal fistulas in Crohn's disease behave differently and defy Goodsall's rule more frequently than fistulas that are cryptoglandular in origin?. Am J Gastroenterol. 2003 Dec. 98 (12):2732-5. [QxMD MEDLINE Link].
Gunawardhana PA, Deen KI. Comparison of hydrogen peroxide instillation with Goodsall's rule for fistula-in-ano. ANZ J Surg. 2001 Aug. 71 (8):472-4. [QxMD MEDLINE Link].
[Guideline] Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD, Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of perianal abscess and fistula-in-ano. Dis Colon Rectum. 2011 Dec. 54 (12):1465-74. [QxMD MEDLINE Link]. [Full Text].
Geltzeiler CB, Wieghard N, Tsikitis VL. Recent developments in the surgical management of perianal fistula for Crohn's disease. Ann Gastroenterol. 2014. 27 (4):320-330. [QxMD MEDLINE Link]. [Full Text].
Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976 Jan. 63 (1):1-12. [QxMD MEDLINE Link].
Garcia-Olmo D, Herreros D, Pascual I, Pascual JA, Del-Valle E, Zorrilla J, et al. Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial. Dis Colon Rectum. 2009 Jan. 52 (1):79-86. [QxMD MEDLINE Link].
[Guideline] Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL, et al. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2016 Dec. 59 (12):1117-1133. [QxMD MEDLINE Link]. [Full Text].
Dudukgian H, Abcarian H. Why do we have so much trouble treating anal fistula?. World J Gastroenterol. 2011 Jul 28. 17 (28):3292-6. [QxMD MEDLINE Link]. [Full Text].
Ritchie RD, Sackier JM, Hodde JP. Incontinence rates after cutting seton treatment for anal fistula. Colorectal Dis. 2009 Jul. 11 (6):564-71. [QxMD MEDLINE Link].
van Tets WF, Kuijpers HC. Continence disorders after anal fistulotomy. Dis Colon Rectum. 1994 Dec. 37 (12):1194-7. [QxMD MEDLINE Link].
Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM. Seton treatment of high anal fistulae. Br J Surg. 1991 Oct. 78 (10):1159-61. [QxMD MEDLINE Link].
Lindsey I, Smilgin-Humphreys MM, Cunningham C, Mortensen NJ, George BD. A randomized, controlled trial of fibrin glue vs. conventional treatment for anal fistula. Dis Colon Rectum. 2002 Dec. 45 (12):1608-15. [QxMD MEDLINE Link].
de Parades V, Far HS, Etienney I, Zeitoun JD, Atienza P, Bauer P. Seton drainage and fibrin glue injection for complex anal fistulas. Colorectal Dis. 2010 May. 12 (5):459-63. [QxMD MEDLINE Link].
Sentovich SM. Fibrin glue for anal fistulas: long-term results. Dis Colon Rectum. 2003 Apr. 46 (4):498-502. [QxMD MEDLINE Link].
Swinscoe MT, Ventakasubramaniam AK, Jayne DG. Fibrin glue for fistula-in-ano: the evidence reviewed. Tech Coloproctol. 2005 Jul. 9 (2):89-94. [QxMD MEDLINE Link].
Yeung JM, Simpson JA, Tang SW, Armitage NC, Maxwell-Armstrong C. Fibrin glue for the treatment of fistulae in ano--a method worth sticking to?. Colorectal Dis. 2010 Apr. 12 (4):363-6. [QxMD MEDLINE Link].
Ellis CN, Rostas JW, Greiner FG. Long-term outcomes with the use of bioprosthetic plugs for the management of complex anal fistulas. Dis Colon Rectum. 2010 May. 53 (5):798-802. [QxMD MEDLINE Link].
Song WL, Wang ZJ, Zheng Y, Yang XQ, Peng YP. An anorectal fistula treatment with acellular extracellular matrix: a new technique. World J Gastroenterol. 2008 Aug 14. 14 (30):4791-4. [QxMD MEDLINE Link]. [Full Text].
Mushaya C, Bartlett L, Schulze B, Ho YH. Ligation of intersphincteric fistula tract compared with advancement flap for complex anorectal fistulas requiring initial seton drainage. Am J Surg. 2012 Sep. 204 (3):283-9. [QxMD MEDLINE Link].
Sirany AM, Nygaard RM, Morken JJ. The ligation of the intersphincteric fistula tract procedure for anal fistula: a mixed bag of results. Dis Colon Rectum. 2015 Jun. 58 (6):604-12. [QxMD MEDLINE Link].
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Media Gallery

Anorectal spaces.
Intersphincteric fistula.
Transsphincteric fistula.
Suprasphincteric fistula.
Extrasphincteric fistula.
The Goodsall rule.
Seton.
Anorectal advancement flap. A) Transsphincteric fistula-in-ano. B) Enlargement of external opening and curettage of granulation tissue. C) Mobilization of flap and closure of internal opening. D) Suturing of flap covering internal opening.
Fistula plug technique.

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Author

Vassiliki Liana Tsikitis, MD, MCR, MBA, FACS, FASCRS Professor of Surgery, Medical Director of Digestive Health Center, Department of Surgery, Chief of Division of Gastrointestinal and General Surgery, Oregon Health and Science University School of Medicine

Vassiliki Liana Tsikitis, MD, MCR, MBA, FACS, FASCRS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Clinical Oncology, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, European Society of Coloproctology, International Society for Digestive Surgery, International Society of Surgery, Pacific Coast Surgical Association, Society for Surgery of the Alimentary Tract, SWOG

Disclosure: Nothing to disclose.

Coauthor(s)

Ragavan V Siddharthan, MD General Surgery Resident, Department of Surgery, Oregon Health and Science University

Ragavan V Siddharthan, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Associate Professor, Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Yale University School of Medicine; Chair, Department of Surgery, Saint Francis Hospital, Trinity Health of New England Medical Group

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Nicole EK Wieghard, MD Resident Physician, Department of Surgery, Oregon Health and Science University School of Medicine

Nicole EK Wieghard, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, Association of Women Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases thank Francisco Javier Reyes Martin, MD, Resident Physician, Department of Surgery, University of Arizona College of Medicine, for his contributions to an earlier version of this topic.

Anal Fistulotomy Periprocedural Care

Equipment

Patient Preparation

References

Tables

Contributor Information and Disclosures

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