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