Advancement flaps for fistula in ano

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Advancement flaps for fistula in ano

• SR Brown
• Sheffield teaching hospitals

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Perfect operation

• Easy to perform
• No risk of incontinence
• Effective

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History

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

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Objectives

• Indications
• Types and Techniques
• Results

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Indications

• High trans-sphincteric/supra-sphincteric fistulae
• Anterior fistulae in women
• Rectovaginal fistulae
• (Crohns)

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Contraindications

• Acute presentation
• Large opening
• Rectal disease
• Neoplasia
• Crohns
• Radiation

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Types of advancement flap

• Endorectal
• Full thickness
• Partial thickness
• mucosal
• Anocutaneous
• V-Y,Y-V
• Rhomboid, House

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Method

• Bowel preparation
• Antibiotics
• Position

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Essential steps

• Excision of internal opening
• Excision primary tract
• Formation flap
• Attention to external component

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Excision fistula tract

• Sharp dissection core out/curettage
• Excise secondary tracts
• Continue to internal sphincter/complete tract

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Mobilisation rectal flap

• Adrenaline (1300,000)
• Partial/full thickness internal sphincter flap
  (based proximally)
• Divergent lateral incisions
• Meticulous haemostasis
• Excise internal opening /- closure internal tract

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Suturing flap

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

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Principles for success

• Stagger the mucosal and muscular suture line
• Width of base of flap gt twice the apex
• No sepsis

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ResultsDifficulties

• Due to
• Population
• Inflammatory/Non inflammatory
• High/low fistulae
• Recurrent
• Surgeon
• Follow up
• Thoroughness of reporting

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ResultsEndorectal Technique
Study Year No. pts. Recurrence () Incontinence ()
Oh 1983 15 13 -
Aguilar 1985 151 2 10
Athanasiadas 1994 169 20 21
Schouten 1999 44 25 35
Ortiz 2000 91 7 8
Mizrahi 2002 66 33 9
Sonoda 2002 55 25 -
Dixon 2004 29 17 -
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Reasons for Incontinence

• Direct damage to sphincter
• Stretching
• Scarring
• Decreased sensation

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The anocutaneous flap
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ResultsAnocutaneous technique
Study Year No Patients Recurrence () Incontinence ()
Del Pino 1996 11 27 -
Nelson 2000 73 23 16
Zimmerman 2001 26 54 30
Amin 2003 18 17 -
Sungertekin 2004 65 9 0
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Factors that influence healing

• Redo procedures
• Crohns
• Rectovaginal fistulas
• Smoking

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Summary

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

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Rectovaginal fistulaecauses

• Inflammatory
• Crohns
• Neoplastic
• Post-radiotherapy
• Non inflammatory
• obstetric

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Rectovaginal fistulaetypes
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Types of repair

• Transanal advancement flap
• Lay open and primary repair (perineoproctotomy)
• Transperineal repair (/- transposition)
• Transvaginal repair