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Advancement flaps for fistula in ano SR Brown Sheffield teaching hospitals.

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Presentation on theme: "Advancement flaps for fistula in ano SR Brown Sheffield teaching hospitals."— Presentation transcript:

1 Advancement flaps for fistula in ano SR Brown Sheffield teaching hospitals


3 Perfect operation Easy to perform No risk of incontinence Effective

4 History First proposed 1902 (Noble) for rectovaginal fistulae Anal fistulae 1912 (Elting)

5 Objectives Indications Types and Techniques Results

6 Indications High trans-sphincteric/supra-sphincteric fistulae Anterior fistulae in women Rectovaginal fistulae (Crohn’s)

7 Contraindications Acute presentation Large opening Rectal disease –Neoplasia –Crohn’s –Radiation

8 Types of advancement flap Endorectal –Full thickness –Partial thickness –mucosal Anocutaneous –V-Y,Y-V –Rhomboid, House

9 Method Bowel preparation Antibiotics Position

10 Essential steps Excision of internal opening Excision primary tract Formation flap Attention to external component

11 Excision fistula tract Sharp dissection core out/curettage Excise secondary tracts Continue to internal sphincter/complete tract


13 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



16 Suturing flap Suture with absorbable Vicryl 2/0 Tension free Leave external opening to drain/Malecot catheter/glue No indication for bowel confinement/stoma


18 Principles for success Stagger the mucosal and muscular suture line Width of base of flap > twice the apex No sepsis

19 Results Difficulties Due to –Population Inflammatory/Non inflammatory High/low fistulae Recurrent –Surgeon –Follow up –Thoroughness of reporting

20 Results Endorectal Technique StudyYearNo. pts.Recurrence (%) Incontinence (%) Oh19831513- Aguilar1985151210 Athanasiadas19941692021 Schouten1999442535 Ortiz20009178 Mizrahi200266339 Sonoda20025525- Dixon20042917-

21 Reasons for Incontinence Direct damage to sphincter Stretching Scarring Decreased sensation

22 The anocutaneous flap






28 Results Anocutaneous technique StudyYearNo PatientsRecurrence (%) Incontinence (%) Del Pino19961127- Nelson2000732316 Zimmerman2001265430 Amin20031817- Sungertekin20046590

29 Factors that influence healing Redo procedures Crohn’s Rectovaginal fistulas Smoking

30 Summary Advancement flaps useful part of armamentarium for fistulas Techniques equally effective Consent for recurrences/incontinence particularly certain groups

31 Rectovaginal fistulae causes Inflammatory –Crohn’s –Neoplastic –Post-radiotherapy Non inflammatory –obstetric

32 Rectovaginal fistulae types

33 Types of repair Transanal advancement flap Lay open and primary repair (perineoproctotomy) Transperineal repair (+/- transposition) Transvaginal repair

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