Minimally Invasive Anal Fistula Treatment—a True Minimal Invasive Surgical Procedure

Abstract

A surgical procedure comprises of two aspects—the surgical access and surgery on the target organ. For decades, general surgeons focussed their minds to propel development in the latter, i.e., surgery on the target organ. Trauma due to surgical access was considered inevitable. Patient discomfort, debility, and disfigurement were considered to be a small price the patients were paying in the larger interest of surgical cure. The advent of minimal access surgery revolutionized the concept of surgical practice. The approach placed the patient at the center of all surgical decisions. It was for the first time that the comfort and needs of the patient were given paramount importance. Through minimal access surgery, the trauma of surgical access has been dramatically minimized, with shorter hospital stay and greater patient satisfaction. Today, minimal access surgery is firmly established in the armamentarium of surgeons worldwide. The early postoperative sequelae following management of anal fistulae in terms of postoperative pain, need for dressings, and time taken off work has not been reported much in literature. Mostly, long-term outcomes in terms of recurrence and incontinence have been addressed in studies reported so far. Traditional techniques including fistulectomy and use of cutting seton have been associated with incontinence, especially in patients who have had previous surgery. Mucosal advancement flaps are technically challenging and are associated with high recurrence rates and high rates of incontinence postoperatively. Although surgical field has undergone significant evolution over the past few decades, the surgical management of the perianal anomalies is yet to witness a technological breakthrough. Apart from treatment of hemorrhoids, there have not been many surgical innovations for perianal infective pathologies. The newer treatment options include use of fibrin glue, bio-prosthetic plugs, and ligation of intersphincteric fistula tract (LIFT) and video-assisted anal fistula treatment (VAAFT). LIFT procedure has been associated with good healing rates. The early results with the use of VAAFT have been encouraging so far. The video-assisted anal fistula treatment (VAAFT) was developed by Professor P. Meinero in 2006 [1]. However, we strongly feel and advocate the terminology of minimally invasive anal fistula treatment (MAFT), which is much more appropriate and is the correct description of the procedure. MAFT qualifies as a trueminimal invasive surgical procedure. There are no iatrogenic incisions for access on the patient. Surgical access is obtained from a pre-existing pathological opening of the fistula. The technique comprises identification and secure internal closure of the internal fistula opening and visualization with cauterization of the fistulous tract using a specially designed fistuloscope. The MAFT is based on the same principles as other procedures for closing the internal opening and obliterating the tract with the innovation that allows precise identification of the fistula anatomy and the internal opening by fistuloscopy and fulguration of the tract walls under direct vision. This approach allows the identification and treatment of all the secondary tracts and the abscess cavities connected to the main track. In our opinion, the adoption of fistuloscope-aided exploration along with effective closure of the internal opening and reinforcing the closure of the opening from the inner side of the staple/suture line is the most effective way of achieving a high healing rate for complex anal fistulas with preservation of the anal sphincter. We adopted the MAFT technique in April 2011 in an effort to reduce early postoperative morbidity and offer patients * P. K. Chowbey pradeepchowbey@gmail.com