Fistulectomy and immediate sphincter reconstruction with fistula bed reinforcement—A video vignette

SCRIPT OF THE VIDEO

This video aims to demonstrate a novel surgical technique for the treatment of anal fistulas.

It is a modification of fistulectomy and immediate sphincter reconstruction.

According to the 2023 ESCP Guidelines for the Diagnosis and Treatment of Cryptoglandular Anal Fistula, FISR may be considered in highly selected patients with high transsphincteric anal fistulas [1]. This recommendation is based on low‐level evidence, as, according to Iqbal et al., many studies evaluating FISR included patients with low anal fistulas. Meta‐analyses report a very high healing rate (90%) but a significant (11%–16%) incontinence rate [2, 3].

The FISR technique involves fistulotomy or fistulectomy, followed by layer‐by‐layer reconstruction. Typically, the mucosa is closed first, followed by suturing of the internal anal sphincter and external anal sphincter. However, there is considerable heterogeneity in the operative techniques [4]. The procedure is similar to obstetric anal sphincter injury (OASIS) reconstruction following obstetric trauma.

Our modification involves reinforcement of the innermost layer using the fistula bed. First, we lay open the fistula tract, then mobilize the fistula bed from the underlying external and internal anal sphincters and use it for mucosal reinforcement. The subsequent muscle reconstruction is identical to that performed in FISR.

It is a method that can be utilized for high transsphincteric anal fistulas that are unsuitable for simple fistulotomy.

The technique should be performed after fistula rationalization popularized by Phil Tozer. There should be no residual collections or extensions, and the procedure should be preceded by at least 6–8 weeks of loose seton drainage. Because this technique carries a high risk of faecal incontinence if the repair is unsuccessful, it should be performed by expert surgeons as a method of last resort, following multiple failures of less invasive treatment options.

CASE

The presented case involves a high anterior transsphincteric fistula in a female patient, making it unsuitable for simple lay‐open. The patient is placed in lithotomy position. We begin the procedure by laying open the fistula tract. We confirm that there are no side extensions arising from the fistula (Video 1).

VIDEO 1.

Download video file ^{(456.1MB, mp4)}

Representative video demonstrating FISR‐FBR technique. Video content can be viewed at https://onlinelibrary.wiley.com/doi/10.1111/codi.70611.

For the next step, a Lone Star retractor is usually used. We meticulously dissect the fistula bed from the underlying external and internal anal sphincters, ensuring that the tissue is fully mobilized. The area of greatest interest is the intersphincteric space, as this is the origin of the cryptoglandular infectious process.

Next, we dissect the anal sphincters. The fat within the ischioanal fossa serves as a useful anatomical landmark. It is helpful to grasp the ends of the external anal sphincter using Babcock forceps. Contraction of the sphincter ends can also be appreciated when the energy device is in close proximity.

After complete mobilization of the fistula bed and external anal sphincter, we assess whether the dissection is satisfactory.

We suture the fistula bed to the adjacent mucosa using 3/0 absorbable sutures in a simple interrupted fashion. The fistula bed flap will likely undergo necrosis and eventually will slough off due to insufficient blood supply; however, it serves as an additional protective layer during the critical early period following repair. Furthermore, it prevents the inadvertent funnel‐shaped deformity of the anal canal by adding an additional layer of tissue within the anal canal below the previous internal opening.

In this case, we plicate the subcutaneous part of the external anal sphincter and approximate the transverse perineal muscles in order to lengthen the perineum, which was shortened at baseline. It is important to always place a finger in the vagina to prevent the creation of a rectovaginal fistula.

The muscles can be approximated using either an end‐to‐end or an overlapping technique. In the presented case, an overlapping sphincteroplasty is performed, similar to the technique used for secondary repair of OASI. The muscles are sutured using 3–4 monofilament sutures, depending on the height of the fistula. Usually, the internal and external anal sphincters cannot be separated due to fibrosis resulting from previous repairs.

We tie the sutures layer by layer. Usually, a small superficial opening is left in the centre of the wound to facilitate drainage of any blood collection. Alternatively, a suction drain may be placed. The operating time was 45 min.

The postoperative course was uneventful. The image demonstrates a fully healed wound. The patient remains fully continent.

Additional measures

• If wound dehiscence occurs, the result can be catastrophic and may inevitably lead to faecal incontinence. Therefore, full bowel preparation is performed prior to surgery. Patients are instructed to follow a liquid diet for 3 days after the procedure. In patients with extremely severe cases with risk factors, particularly those with Crohn's disease and receiving glucocorticoids, a diverting stoma is created 4–6 weeks before surgery;

• Broad‐spectrum antibiotics are administered for 7–10 days following the procedure;

• Prolonged sitting, cycling and any excessive perineal strain are contraindicated for at least 4–6 weeks following repair.

Limitations

• The fistula bed should be mature and soft, without induration and preferably epithelialized. We usually wait approximately 3 months after seton placement during fistula rationalization;

• We reserve this technique exclusively for cases with a wide fistula tract. When the tract is very narrow, there is insufficient fistula bed tissue available to reinforce the mucosal layer;

• Long‐term outcomes of this modification are not yet known.

Thank you for your attention.

AUTHOR CONTRIBUTIONS

Przemyslaw Ciesielski: Conceptualization; writing – review and editing; formal analysis; supervision; investigation; methodology; validation. Stanislaw Rzadkowski: Writing – original draft; project administration; software; writing – review and editing; investigation.

FUNDING INFORMATION

The authors have nothing to report.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

The study was conducted in accordance with applicable ethical standards and institutional requirements. Written informed consent was obtained from the patient for the treatment and publication of the case and associated clinical information.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.