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| Name | HORSE SHOE FISTULA SURGERY USING TWO DIFFERENT KIND OF SETONS |
| Video Uploader | Video From Dr Pravin J Gupta, MBBS MS Laxmi Nagar, NAGPUR, IN |
| Upload Date | This Video Uploaded At 20-07-2023 13:22:26 |
| Video Discription | DISCLAIMER- Medical Educational Video. Not to promote sexuality or Nudity. A HORSE SHOE FISTULA The natural history and the developmental steps of anorectal abscess fistula disease are well known. At first, a cryptoglandular abscess develops in the intersphincteric space which contains the anal glands. Infection may spread via vertical, horizontal or circumferential routes, and this determines the site of the abscess. Circumferential spread may occur in the intersphincteric, ischiorectal or supralevator compartments to form horseshoe fistulas. On the other hand, abscesses perforating the external anal sphincter anteriorly or posteriorly enter the preanal or postanal spaces in which situation the internal opening may be identified on the anterior or posterior midline at the level of dentate line. If the abscesses are not drained either surgically or spontaneously at this stage, they spread extensively into the ischiorectal spaces. This pattern of spread results in anterior and posterior horseshoe abscesses. Incomplete or semi-horseshoe fistula develops when one arm of horseshoe abscess spontaneously drains into the skin, while drainage of both arms results in a complete horseshoe fistula. On the other hand, there may be associated fistulas which are usually transsphincteric. Simple anorectal fistulas are usually diagnosed by physical examination only, in patients suffering intermittent pain and purulent, often bloodstained, perianal discharge with a common history of anorectal abscess drainage. While physical examination is usually sufficient for assessment in uncomplicated abscess fistula disease, imaging studies such as contrast fistulography, US or MRI may be useful in the evaluation of complex or recurrent disease . We do not perform routine radiologic studies in patients with anorectal abscess fistula disease, since the diagnosis can be established preoperatively by physical examination and intraoperative findings and the course of fistula tracts direct surgeons to choose the appropriate type of operative procedure. However, if patients describe rectal discomfort, fullness or deep pelvic pain which may indicate the presence of an associated condition, we prefer MRI for diagnosis as well as demonstration of the extent of the abscess fistula. Several methods can be employed to identify fistula tracts intraoperatively. Passage of a probe from both the external and the internal aspects is the most reliable technique to demonstrate the course of the fistulous tract. However, injection of various substances such as methylene blue, indigo carmine, hydrogen peroxide or even milk has been described and widely used. It should be remembered that when stains are injected, the surgeon may have only one opportunity to visualize the internal opening before the surrounding tissue and the operative field are contaminated by the stain. In order to avoid this, milk has been advocated. However, in patients with a stenosis in the fistula tract, these staining techniques may fail. Injecting hydrogen peroxide is probably the best mean for identifying the internal opening, since the pressure created by the bubbles may be sufficient to penetrate even a stenotic tract . We did not encounter this problem during the operations; therefore, we did not need special manoeuvres in any patient. Presence of an anal papilla guarding the internal opening is another way to locate the internal opening. Probing not only provides the identification of the course of the fistula tracts but also facilitates fistulotomy over the probe. However, probing should be gentle, otherwise it easily results in creation of a false route which may further complicates the operative procedure. Both the lower edge of the internal sphincter and the subcutaneous external sphincter should be severed during the drainage of any associated abscess and external sphincter should be divided into two halves. Fistulotomy should also be carried out along the tracts of the fistula. The superficial external sphincter can be divided by either sphincterotomy or seton placement unilaterally or even bilaterally as appropriate. Although good results following the insertion of seton for this step have been reported, we advocate sphincterotomy without reservation because no serious complication such as incontinence has developed during the long-term followup. |
| Category | People & Blogs |
| Tags | #seton | # high fistula | # loose seton in fistula | # incontinence | # cutting seton | # draining seton | # fistula recurrence | # railroad | # false passage | #recurrence | # relapse | # non healing | #fistulotomy or seton placement | # risk of incontinence | # radiofrequency | # continence disturbances | # postoperative scarring | #recurrent fistula in ano | # horseshoe fistula | # multiple anal fistula | # probing of a fistula | # multiple tracts of anal fistula | # cutting rubber seton |
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