Ahmed E Lasheen*, Ramadan Mahmoud, Osama abd Elaziz, Mohammed Alkilany, Tamer Alnaimy and Tamer Rushdy
General and Laparoscopic Surgery Department, Faculty of Medicine, Zagazig University, 44519, Egypt
Received: 29 April, 2016; Accepted: 03 June, 2016; Published: 04 June, 2016
Ahmed E Lasheen, MD, General and Laparoscopic Surgery Department, Zagazig University Hospital, Zagazig City, Egypt, Tel: + 20552343035; Fax: +20552307830; E-mail:
Lasheen AE, Mahmoud R, abd Elaziz O, Alkilany M, Alnaimy T, et al. (2016) Skin Sparing Fistulectomy with Primary Sphincters Repair by Special Sutures for Management of High Perianal Fistula. J Surg Surgical Res 2(1): 035-038.10.17352/2455-2968.000028
© 2015 Lasheen AE, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Skin sparing fistulectomy; Special sutures; High perianal fistula
Background: Fistula in ano is a common disease seen in the surgical outpatient department. Many procedures are advocated for the treatment of fistula in ano. However, none of the procedures is considered the gold standard. Aim of this study was to evaluate our procedure in the managing high perianal fistula.
Methods: Between February 2014 and September 2015, 71 patients with high perianal fistula were managed by skin sparing fistulectomy and special sutures for primary repair of anal sphincters. The clinical outcome was assessed in terms of time for healing, continence and recurrence for follow-up period (ranged from 4 to 24 months).
Results: Anorectal wounds were healed within 3 to 4 weeks. Complications included urine retention 9 patients (12.7 %), superficial wound infection 29 patients (40.9 %), and transient incontinence 33 patients (46.5 %) for flatus for period ranged from 2 to 3 weeks. No deep infection, no permanent incontinence were recorded. Recurrence was in one patient (1.4 %).
Conclusion: Our technique is less invasive, rapid healing, maintain on normal configuration of anus, and associated with good results for high perianal fistula management.
Perianal abscess and fistulas represent two stages of same disease. The main etiology is cryptoglandular. Perianal abscess and fistulas are two of the oldest human surgical entities . A fistula in ano is a common perianal condition that is associated with appreciable morbidity and inconvenience to the patient . The objectives of treatment are to achieve fistula healing, prevent recurrences and maintain on anal sphincter function. The risk of incontinence associated with treatment ranged from 10% to 57% . The disease has an incidence of 8.6 per 100 000 people and nearly 20 000 to 25000 fistulas are treated annually in the United States . The incidence of fistula after perianal abscess is 27% to 60% . Conventional classification and treatment depends on the level of the internal opening and extent of involvement of the external sphincter by the fistulous tract [5,6]. Traditionally, a “complex fistula” is defined by a high risk of recurrence or incontinence following treatment. Broadly, complex fistulas are those that are not low trans-sphincteric or inter-sphincteric fistulas. The surgical options for these fistulas include fibrin application, plug placement, endorectal advancement flap, fistulectomy with primary sphincter repair, partial fistulectomy seton placement, ultra-low anterior resection and coloanal anastomosis, the ligation of the inter-sphincteric fistula tract and video assisted fistula tract procedure . In this study, skin sparing fistulectomy and repair of anal sphincters by special sutures in high perianal fistula management, surgical procedure and clinical results were discussed.
Patients and Methods
Between February 2014 and September 2015, seventy one patients (54 males and 17 females) with high perianal fistula were included in this study. This research was discussed and approved from Ethical Committee of Zagazig University in January 2014. All information about this technique was discussed with all patients, and all patients gave writing consent for inclusion of their data in this study. The median age was 43.7 years (range 21 to 63 years). Eleven patients (15.5%) had previously undergone one or more repair attempts before referral for this technique (all patients subjected to core fistulectomy and endorectal advancement flap, and 5 patients trial to use fibrin injection after recurrence). Every patient was subjected to carful digital examination and trans-rectal endosonography to determine the number and site of fistula tract. All patients were continent before our technique. The patients were underwent a mechanical bowel preparation, and received systemic antibiotic preoperative and continue for 7 days postoperative. Under general or spinal anesthesia, the patient was placed in the lithotomy position. The external, internal openings, and fistula tract were located. Injection of colored material (Methylene blue) through the external opening is helping to detect the fistula tract and internal opening. Skin sparing fistulectomy was done through multiple transverse incisions. First incision is around the external opening, the opening and fistula tract were dissected until reaching highest possible point. Then, another transverse incision is made and dissection of fistula tract resumed until reaching the mucocutaneous junction. From the mucocutaneous junction to internal opening, fistulectomy was done through longitudinal incision in anorectal mucosa and anal sphincters close and complete. Then, repair of anal sphincters and wound was done from endoanal by multiple double incomplete circular sutures (buried sutures) by using Vicryl No. 2/0 on round needle. The needle with Vicryl was passed from one edge of wound through the sphincters muscles, under the wound floor, and another edge of sphincters muscles until reaching to other wound edge. Then, returned in opposite direction to starting point by same manner with distance between two sutures limbs about 0.5 cm. Now, one suture becomes complete and two suture limbs were holed by tissue forceps (Figures 1a-c and Figures 2a-e). The distance between each suture and other was about 0.5 cm. to put both edges of sphincters and wound close to each other when ting them. Number of sutures were used according the length of the wound, where were tied them making the wound and muscles edges in contact to each other. So, primary repair of the anal sphincters and wound was achieved by buried sutures without forming closed space, which allows for free drainage of the wound through all length and depth. Local wound care was continuous in form of wound cleaning and application of topical ointment contains local anesthetic and promotes healing agents. The follow up period was ranged from 4 to 24 months (mean was 18 months) for any anal complications.