Chapter 29 Anal Fistulotomy
INTRODUCTION
The surgical treatment of perianal fistulous disease is one of the most common, minor, benign anorectal procedures performed by the general surgeon. Despite its frequency and “size,” the appropriate balance between resolution of the troubling symptoms of persistent fistulas and the potential for devastating functional consequences with overly aggressive surgical treatment of fistulas can be very challenging. The major elements of successful anal fistulotomy surgery are described later, with emphasis on the reduction of specific complications.
INDICATIONS
Although not all surgically drained perianal or perirectal abscesses will result in a chronic fistula-in-ano, it is estimated that as many as 50% will.1 The symptoms of a persistent fistula include recurrent abscess formation, chronic perianal drainage, and pain. The diagnosis of a persistent fistula-in-ano in most patients is an indication for consideration of fistulotomy to reduce or eliminate these chronic symptoms and the frequency of recurrent abscess formation. Notable exceptions would include patients with complex fistulas due to Crohn’s disease, perineal radiation, or uncontrolled distal gastrointestinal tract or gynecologic malignancy.
OPERATIVE PROCEDURE
Anesthetic Considerations
Urinary Retention
Urinary retention is one of the most common complications of all anorectal surgery. The extent and complexity of surgery correlates with the incidence of this complication. A large institutional study has reported the incidence of urinary retention after fistula surgery as 5%.2
• Consequences
• Repair
• Prevention
Examination under Anesthesia and Identification of the Internal Opening
Failure to Identify the Internal Opening
Finding the internal opening of the fistula-in-ano is the first of two critical steps in the successful surgical treatment of a fistula. Benign fistulas are the result of crypt-glandular infection at the dentate line and are perpetuated by a persistent internal opening at the inciting gland at the dentate line.
• Consequence
• Repair

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