Proctology Surgery in Gandhinagar & Ahmedabad | Niraaya Hospital

Anal fistula surgery aims to eradicate the fistulous tract while preserving the sphincter mechanism - maintaining faecal continence, which is the paramount functional concern in anorectal surgery.

Fistulotomy (Laying Open):

For simple, low intersphincteric fistulas where the tract does not involve a significant amount of sphincter muscle - the tract is probed, and the tissue overlying the probe (between the probe and the skin surface) is divided with diathermy or scissors, converting the tube into an open trough that heals from the base. The exposed fistula lining is curetted. Primary healing at 4-6 weeks. Success rate exceeding 95%. Risk of incontinence: very low for truly low fistulas (the divided muscle is minimal).

Seton Placement:

For high or complex fistulas where laying-open would divide too much sphincter muscle, a seton (a surgical thread - silk, Silastic, or cable tie) is threaded through the fistula tract and secured loosely. A loose seton allows: drainage of sepsis and resolution of acute infection, stimulation of fibrosis along the tract, assessment of the amount of sphincter above the tract (allowing time for clinical assessment before definitive repair), and in some cases, treatment itself (for very high fistulas where the seton is slowly tightened - cutting seton - over 6-8 weeks, allowing gradual, fibrotic division of the muscle with minimal continence risk). After loose seton placement, definitive repair is planned.

LIFT Procedure (Ligation of Intersphincteric Fistula Tract):

A modern sphincter-preserving technique for transsphincteric fistulas - the fistula tract is identified in the intersphincteric plane (through a small curved incision in the intersphincteric groove), isolated, ligated with an absorbable suture, divided, and the intersphincteric space is curetted. No sphincter muscle is divided. The skin-side opening is curetted and the intersphincteric wound is closed. Success rate: 60-80% in well-selected patients. No continence risk. Can be repeated if the first LIFT fails.

VAAFT (Video-Assisted Anal Fistula Treatment):

A fully minimally invasive technique - a fistuloscope (a small rigid telescope, 3.3 mm in diameter) is introduced through the external opening of the fistula under direct vision, allowing visualisation of the internal fistula anatomy, identification of secondary tracts, and treatment of the internal opening using electrode or laser under direct vision. The fistula tract is sealed from within. No sphincter muscle is divided.

Advancement Flap:

A mucosal or mucomuscular flap of rectal wall is raised from above the internal opening, the internal opening is cored out and closed, and the flap is advanced and sutured over the closed internal opening - effectively eliminating it. Used for selected complex high fistulas. Success rate: 60-75%. Requires careful patient selection and meticulous technique.

Lateral internal sphincterotomy (LIS) is the definitive surgical treatment for chronic anal fissure that has failed medical management (topical nitrates, diltiazem, or botulinum toxin injection). The principle is straightforward: chronic anal fissure is perpetuated by internal anal sphincter hypertonia (persistently high resting pressure) - which reduces blood flow to the posterior anal commissure and prevents healing. LIS directly addresses this by dividing the lower third of the internal anal sphincter, reducing resting pressure and restoring blood supply to the fissure site.

Technique: Under general or spinal anaesthesia (or local with sedation for short procedures), a small lateral radial incision is made in the anoderm at the 3 o'clock position (in the lateral anal wall, where there are no major vessels). The lower portion of the internal anal sphincter (a smooth, white, involuntary muscle) is identified through this incision and divided precisely - the fistulotomy is limited to the distance from the base of the fissure to the dentate line (to minimise continence risk). The incision is closed or left open. The entire procedure takes 10-15 minutes.

Outcomes: LIS achieves healing of the chronic fissure in over 95% of patients within 6-8 weeks. Post-operative pain is significantly less than from the fissure itself - most patients note improvement from the first post-operative day. The small but real risk of minor incontinence (flatus incontinence in 5-10%, faecal soiling in less than 2%) is discussed with every patient at consultation.

Botulinum toxin (Botox) injection: An alternative to surgery - Botox injected into the internal sphincter causes temporary muscle paralysis (3-6 months), allowing the fissure to heal. Success rate: 60-80%. Lower risk of incontinence than LIS. Used in patients unwilling to accept the small incontinence risk of LIS, or as a bridge before surgical decision.

Excision and Primary Closure:

Complete excision of the pilonidal sinus and its associated secondary tracts, with primary wound closure in a single layer or two layers. Fastest recovery when successful. Recurrence rate: approximately 10-20% at 5 years, rising with midline closure (where the suture line lies in the natal cleft - a position subject to shear forces, maceration, and hair re-entry).

Off-Midline Closure Techniques:

The key principle in reducing pilonidal sinus recurrence is off-midline closure - ensuring the suture line does not lie in the moist, hair-bearing natal cleft. Techniques include:

Bascom cleft lift: The natal cleft is asymmetrically flattened by excising the sinus and closing the wound with the scar positioned off the midline, laterally.

Limberg Flap (Rhomboid Flap): The pilonidal sinus and surrounding affected skin are excised as a rhombus (diamond shape). A rhomboid-shaped flap of adjacent skin and subcutaneous tissue is rotated into the defect - moving the scar laterally, flattening the natal cleft, and providing well-vascularised coverage of the excision site. The most commonly performed and best-studied technique for recurrent or complex pilonidal disease - recurrence rate below 2-5% at 5 years. Dr. Patel performs the Limberg flap as the preferred technique for complex and recurrent pilonidal sinus at Niraaya Hospital.

Karydakis flap: An asymmetric advancement flap moving the scar away from the midline - another well-validated off-midline technique.

Open healing (excision, healing by secondary intention):

The sinus and tracts are excised completely and the wound is packed open - healing by granulation tissue growing from the base of the wound over 6-12 weeks. Very low recurrence rate (2-3%) but significantly prolonged healing time and intensive wound care. Used when infection makes primary closure inappropriate.

Post-operative care and hair removal:

Regardless of technique, post-operative depilation of the natal cleft area (shaving, laser hair removal) significantly reduces recurrence by eliminating the mechanism of new hair penetration. Patients are counselled on this at Niraaya Hospital, Gandhinagar.