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Published byJamel Sturtevant
Modified about 1 year ago
Advancement flaps for fistula in ano SR Brown Sheffield teaching hospitals
Perfect operation Easy to perform No risk of incontinence Effective
History First proposed 1902 (Noble) for rectovaginal fistulae Anal fistulae 1912 (Elting)
Objectives Indications Types and Techniques Results
Indications High trans-sphincteric/supra-sphincteric fistulae Anterior fistulae in women Rectovaginal fistulae (Crohn’s)
Contraindications Acute presentation Large opening Rectal disease –Neoplasia –Crohn’s –Radiation
Types of advancement flap Endorectal –Full thickness –Partial thickness –mucosal Anocutaneous –V-Y,Y-V –Rhomboid, House
Method Bowel preparation Antibiotics Position
Essential steps Excision of internal opening Excision primary tract Formation flap Attention to external component
Excision fistula tract Sharp dissection core out/curettage Excise secondary tracts Continue to internal sphincter/complete tract
Mobilisation rectal flap Adrenaline (1:300,000) Partial/full thickness internal sphincter flap (based proximally) Divergent lateral incisions Meticulous haemostasis Excise internal opening +/- closure internal tract
Suturing flap Suture with absorbable Vicryl 2/0 Tension free Leave external opening to drain/Malecot catheter/glue No indication for bowel confinement/stoma
Principles for success Stagger the mucosal and muscular suture line Width of base of flap > twice the apex No sepsis
Results Difficulties Due to –Population Inflammatory/Non inflammatory High/low fistulae Recurrent –Surgeon –Follow up –Thoroughness of reporting
Results Endorectal Technique StudyYearNo. pts.Recurrence (%) Incontinence (%) Oh Aguilar Athanasiadas Schouten Ortiz Mizrahi Sonoda Dixon
Reasons for Incontinence Direct damage to sphincter Stretching Scarring Decreased sensation
The anocutaneous flap
Results Anocutaneous technique StudyYearNo PatientsRecurrence (%) Incontinence (%) Del Pino Nelson Zimmerman Amin Sungertekin
Factors that influence healing Redo procedures Crohn’s Rectovaginal fistulas Smoking
Summary Advancement flaps useful part of armamentarium for fistulas Techniques equally effective Consent for recurrences/incontinence particularly certain groups
Rectovaginal fistulae causes Inflammatory –Crohn’s –Neoplastic –Post-radiotherapy Non inflammatory –obstetric
Rectovaginal fistulae types
Types of repair Transanal advancement flap Lay open and primary repair (perineoproctotomy) Transperineal repair (+/- transposition) Transvaginal repair
Fistula-in-ano: a probing of the treatment options John Goligher Colorectal Unit David Jayne Professor of Surgery University of Leeds & Leeds Teaching.
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