COMPLICATED

PERIANAL FISTULA
Syahbudin Harahap
Department of Surgery
Faculty of Medicine
University of North Sumatera
Medan, Indonesia.
Introduction
Complicated Perianal fistula when an perianal
fistula still has not healed after surgical intervention
and include high transsphincteric
fistulas,suprasphincteric and extrasphincteric
fistulas, horseshoe fistulas.
 CLASSIFICATION OF PERIANAL FISTULA
Based on fistula anatomical course relative to the sphincter
complex:
• Park’s classification 1961
Intersphincteric 45%
Transsphincteric 30%
Suprasphincteric 20%
Extrasphincteric 05%

• ASCRS 2011
Simple perianal fistula
Complex perianal fistula
Etiology Perianal Fistula
• Cryptoglandular infection approximately 80%
• Crohn’s disease
• Tuberculosis
• Actinomycosis
• Radiation
• Malignancy
• HIV
• Secondary to trauma

Investigation
• Fistulography
• PELVIC MRI
The goal in the treatment of fistula-in-ano:
• Eliminate the fistula tracks
• Prevent recurrence
• Preserve sphincter function
FISTULA HEALING:
• It is rare for a fistula to heal spontaneously.
• In order to heal, the internal opening must
be obliterated and therefore surgery is
necessary.
• Options to remove the internal opening and
granulation tracks fistulotomy is one of
the best.
 Identification of the Fistula Tract
• Goodsall's rule
• Physical examination /DRE
• Probing of the tract
• Injection hydrogen peroxide/methylene
blue of the external opening

Transverse
Anal line
 Modalities of treatment
No single technique is appropriate
Treatment must be directed by
1.Etiology and anatomy of the
fistula
2.Degree of symptoms
3.Patient comorbidities
4.Surgeon experience.
 Modalities of treatment
• Cutting of the sphincter complex
1.Fistulotomy and marsupialization
2.Seton insertion
3.Fistulectomy
These modalities have an risk of postoperative
incontinence.
• No cutting of the sphincter complex .
1.Fibrin glue
2. Fistula plug
3. Ligation of Intersphincteric tract (LIFT)
4. Video assisted anal fistula treatment (VAAFT)
 General principles cutting of the sphincter
complex management
1. A solid knowledge of the
anatomy consideration of the
anal canal.
2. There should be good local
sepsis control
3. If <30% of the sphincter muscle
length is enveloped by the
fistula tract, it can be safely
cut fistulotomy and
marsupialization without fear
of major incontinence.
4. If >30% of the sphincter muscle
length is enveloped by the
fistula tract , it would be safer
to use a seton.
5. Biopsies should be performed
from the tract to rule out
malignancy, tuberculosis.
ANAL FISTULOTOMY AND MARSUPIALIZATION
Fistulotomy remains the “gold standard.”
Lay-opening of the fistula track from external opening to internal
opening and allowing it to granulate .
Fistulotomy is successful in permanently treating fistulas for more
than 95% of cases simple perianal fistula.
Complicated Perianal fistula low Transsphinctericfistula
Complicated Perianal fistula low Transsphinctericfistula
Simple Intersphincteric fistula
Low Transsphincteric fistula
Trans sphincteric fistula
Low Transsphincteric fistula
 SUPRASPHINCTERIC FISTULA
Tuberculosis
Fistelectomy and marsupialization
 Seton
Still occupy an important position in the treatment of
complicated perianal fistula (high anal fistulas).

Cutting seton
• Used in complicated perianal fistula (high anal fistulas).
• Divide the muscle slowly to produce a gradual fistulotomy

Loose seton
• Achieve drainage of the fistula track
• Allow any secondary track to heal
• Draining pus and controlling sepsis prior to definitive
treatment
 CUTTING SETON

Complicated perianal fistula (high anal fistulas).

Creation of a simple loop within the knot of the seton
suture to allow a new suture to be threaded into the
loop at the time of changing the seton.
Thank you
SYAHARA