Surgery – The Different Procedures
There are a number of different procedures to combat fistulas. Depending on your particular case and how severe it is, your surgeon, and even the country you live in, will determine which procedure may be recommended to you.
Definitive treatment of a fistula aims to stop it recurring. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.
There are usually several stages to treating a fistula. You may start off with a seton, and then have another procedure such as Advancement Flap surgery.
What follows are brief descriptions of the different surgery procedures associated with fistulas. If you surgeon is recommending any of these procedures to you, make sure you are prepared, research and ask lots of questions!
Doing nothing – A drainage seton can be left in place long-term to prevent problems. This is the safest option although it does not definitively cure the fistula.
Fistulectomy – Excision (removal) of the fistula track, allowing it to heal by granulation, so the tissue fills the space as it grows.
Cutting seton – If the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting seton may be used. This involves inserting a thin tube through the fistula tract and tying the ends together outside of the body. The seton is tightened over time, gradually cutting through the sphincter muscle and healing as it goes. Once the fistula tract is in a low enough position it may be laid open to speed up the process, or the seton can remain in place until the fistula is completely cured and the seton eventually falls out.
Draining Seton – A length of suture material looped through the fistula which keeps it open and allows pus to drain out. In this situation, the seton is referred to as a draining seton. A stitch is placed close to the ano-rectal ring – which encourages healing and makes further surgery easy.
Fibrin glue injection - This is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the risk of incontinence, and creates minimal stress for the patient.
Fistula plug - This surgery involves plugging the fistula with a device made from small intestinal submucosa. The fistula plug is positioned from the inside of the anus with suture. According to some sources, the success rate with this method is as high as 80%. This treatment option does not carry any risk of bowel incontinence.
Advancement flap surgery - This is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place. The external opening is cleaned and sutured. Success rates are variable and high recurrence rates are directly related to previous attempts to correct the fistula.
LIFT Technique – This is a novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (ligation of inter sphincteric fistula tract) procedure. LIFT procedure is based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle.