Hanley procedure and TROPIS method – modern therapeutic approaches in complicated anal fistulae

Abstract

High recurrence rates after surgical management of complicated anal fistulae and concerns over postoperative incontinence encourage surgeons to look for new surgical solutions. Fistulas with high purulent reservoirs in diagnostic imaging are particularly challenging. Surgical opening of high branches and purulent reservoirs is a key therapeutic element in the management of complex fistulas. Access to these reservoirs should be established via the simplest route, hence for example, the deep postanal space should be reached from the outside by separating the external sphincter fibers, while the shortest access to high intersphincteric reservoirs is through the anal canal. The paper discusses two surgical approaches: a historical method proposed many years ago by Hanley and involving a wide opening of the deep postanal space, and TROPIS, which is a new, recently published method for accessing high intersphincteric fistulas. We describe the techniques, indications and contraindications for these two approaches. We concluded that proper patient qualification for the above therapeutic approaches is crucial. Pre-operative MRI or transrectal ultrasound imaging of the fistulous tract and determining the shortest drainage route are important.