VM49 - A Novel Technique for Treating High Transphincteric Fistula: The Internal Fistulotomy with Opening Closure (IFOC)

Purpose/Background: Complex anal fistulas, particularly with intersphincteric extensions, pose significant challenges in medical interventions due to their high recurrence rates. Often, recurrence is attributed to surgeons' inability to precisely identify the fistula tract in the intersphincteric plane and to achieve secure ligation. This study aims to present a novel surgical technique derived from our experience to address the challenges and reduce recurrences in treating complex fistulas, especially those with intersphincteric extensions.

Methods/Interventions: A patient with a posterior complex anal fistula was examined. The external opening was situated at the 9 o'clock position, while proctoscopy revealed the internal opening at 6 o'clock. Our surgical strategy entailed the utilization of an arterial clamp to determine the fistula tract's orientation. Verification of the tract's connection was achieved by injecting water through the external opening. Subsequently, an intra-anal fistulotomy was executed using electrocauterization. A key aspect of this procedure was the continuous observation of the fistula tract's granulation tissue to prevent inaccurate dissection. This tissue was later eradicated with a curette. To further ascertain the internal opening's location at the external sphincter, another water injection was administered. The internal opening was then securely sealed using absorbable sutures employing the horizontal mattress technique. The success of this procedure was confirmed with a water injection post-tract ligation, which displayed no seepage. Additional curettage was conducted to eliminate granulation at the external tract, succeeded by the placement of a tube drain. Finally, sutures were used to overlay the internal opening, promoting optimal healing.

Results/Outcomes: The patient did not face any post-operative complications. The healing process of the wound was satisfactory, with no observed recurrence three months subsequent to the operation.

Conclusion/Discussion: Our innovative surgical method demonstrates a hopeful alternative to conventional techniques. It bears significant potential in diminishing recurrence rates in intricate fistula situations that encompass intersphincteric extensions.