VAAFT Anal Fistula Surgery

Anal Fistula Surgery: 

Anal Fistula Surgery Dr Kushal Mital MS, FACRSI, Sex Educator

Slide 2: 

Multiple Abscesses in Perineal Region

Slide 3: 

Horseshoe Abscess

Slide 4: 

Multiple Fistula in Ano

Slide 8: 

Excision of tract leaving skin bridge in between

Slide 10: 

Coring out the tract, through sphincteric muscle

Slide 11: 

Closure leaving smaller wound area

VAAFT: 

VAAFT Video Assisted Anal Fistula Treatment Dr Kushal Mital MS, FACRSI, Sex Educator

VAAFT: AIM: 

VAAFT: AIM correct localization of internal fistula opening under vision fistula treatment from inside hermetic closure of the internal opening technique comprises two phases: a. diagnostic b. operative one

VAAFT: Advantages: 

VAAFT: Advantages surgical wounds in perianal region are prevented risk of faecal incontinence is avoided because no sphincter damages are provoked

VAAFT: MATERIAL: 

VAAFT: MATERIAL KARL STORZ Equipment MEINERO Fistuloscope unipolar electrode connected cautery fistula brush Forceps Semicircular or linear stapler (Optinal) 0.5 ml of synthetic cyanoacrylate (Histacryl B Braun) with a nasogastric tube

VAAFT:Meinero's fistuloscope : 

VAAFT: Meinero's fistuloscope fistuloscope is equipped with an optical channel, a working channel and an irrigation channel working length adds up to 18 cm; use of a handle reduces it to an effective length of 14 cm

VAAFT: Operative Steps: 

VAAFT: Operative Steps Spinal anaesthesia Lithotomy position Fistuloscope is connected to the KARL STORZ equipment and to washing solution bag, 5000 cc glycine & mannitol 1% solution Technique comprises a diagnostic phase operative phase

VAAFT:The diagnostic phase : 

VAAFT: The diagnostic phase AIM: correct location of the internal fistula opening Fistuloscope is inserted in ext fistula opening with running washing solution (glycine 1% & mannitol 1%) ; Blocking tissue removed with 2 mm forceps Direction correct when obturator is at lower screen Follow fistula path: move left-right & up-down Guide transanally with inserted finger

VAAFT:The diagnostic phase : 

Continous glycine-mannitol soln flow allows view of fistula's tract to internal opening Insert anal retractor to localize int fistula opening by telescope light in rectum or anal canal VAAFT: The diagnostic phase

VAAFT:The diagnostic phase : 

On exit via internal opening rectal mucosa seen Internal opening may be very narrow; then its location is suspected by viewing fistuloscope light behind rectal mucosa Now, take 2-3 Vicryl 3-0 sutures in two opposite points of internal opening margin to isolate, and keep track of it VAAFT: The diagnostic phase

VAAFT: Operative phase : 

VAAFT: O perative phase AIM: destroy fistula from the inside fistula canal is cleaned / the waste material removed and its internal opening is then closed Burn tract under vision with unipolar electrode passed in operative channel Start at internal fistula opening, all fragments of the whitish material adhering to the fistula wall and all granulation tissue are coagulated

VAAFT: Operative phase : 

complete this phase , cm by cm, from internal opening to ext opening & any abscess cavity Necrotic material is removed under vision with fistula brush The isolated int fistula opening remains open to allow leakage of waste & washing material Remove fistuloscope Pull stay sutures towards anal canal to lift internal fistula opening at least 2 cm like a volcano VAAFT: O perative phase

VAAFT: Operative phase : 

Insert a stapler (e.g. CCS30 Transtar Contour from ETHICON EndoSurgery) at volcano's base & complete mechanical cutting and suturing can also be done by using a linear stapler If tissue in area of internal opening is not sclerotic and allows to form a good "volcano", the stapler can be used If tissue is too rigid and sclerotic, anal advancement flap preferred VAAFT: O perative phase

VAAFT: Operative phase : 

Lastly insert 0,5 ml of synthetic cyanoacrylate right after suture / staple line via the fistula pathway to reinforce the suture Do not fill the whole fistula tract ; only a few drops below the suture line As fistula pathway needs to stay open to allow the passage of secretions This procedure assures a perfect excision and a hermetic closure of the internal fistula opening, excludes risk of stool passage VAAFT: O perative phase

Advantages of the VAAFT : 

Advantages of the VAAFT no surgical wounds in buttocks/ perianal region certainty in localization of int fistula opening fistula can be destroyed from inside no need to know if fistula is transphincteric, extrasphincteric or above sphincteric, as operating from inside there is no sphincter damage no preoperative examination is necessary no risk of postoperative faecal incontinence minimum medications

VAAFT: Advantages: 

VAAFT: Advantages Under vision, all tracts can be identified Minimal scar wound Accurate closure of internal opening No sphincter damage Fistula classification not required Correct location of primary & secondary tracts Early return to work

Treating Anal Fistula Endoscopically : 

Treating Anal Fistula Endoscopically Diagnostic endoscopy thru external opening Internal opening : stay sutures Cauterization of fistula tract Grasper forcep of removal of necrotic tissue Endoscopic brush cleaning Irrigation of tract Anal advancement flap on internal opening Cynoacrylate glue near internal opening

Slide 31: 

Under spinal anesthesia in lithotomy, fistuloscope is passed from external opening

Slide 32: 

Diagnostic phase Aim: localize internal fistula opening Fistuloscope via ext opening, Washing solution of glycine 1% with 1% mannitol Blocking tissue removed with 2 mm forcep

Slide 33: 

Localizing internal fistula opening

Slide 34: 

Suture & tenting of internal opening

Slide 35: 

Cautery fistula tract

Slide 36: 

Fistula tract brushed out

Slide 37: 

Stapler used for affording or

Slide 38: 

2. Anal advancement flap

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VAAFT PROCEDURE

What you do not need: 

What you do not need Methylene blue injection Endo anal USG Fistulography MRI

Fistula operated 3 times, scrotal base opening: 

Fistula operated 3 times, scrotal base opening

Scope Introduced: 

Scope Introduced

Light shows the way: 

Light shows the way

VAAFT in Progress: 

VAAFT in Progress

VAAFT In Progress: 

VAAFT In Progress

Fistulotomy to see depth of cautery: 

Fistulotomy to see depth of cautery

Change for Our Conditions: 

Change for Our Conditions Depth of burn cautery remove debris with forcep & brush recautery repeat till base white after debris removal Managing Internal opening internal opening closed with 3-0 vicryl anal advancement flap, a cheaper option

Lesson Learnt: 

Lesson Learnt Increase depth of burn How: cauterize first layer, curettage, recauterize, repeat till no material on curette Important to leave ext opening to drain Daily irrigation with normal saline If recurrence can be repeated as minimal damage to sphincters

Slide 53: 

Is it Time to Change? Only Time will tell! Thank You