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ANAL FISTULA

A PANTOGEN OPERATION SCRIPT

MICHAEL EDWARDS

NO INFORMATION IN THIS SCRIPT SHOULD BE USED WITHOUT THE APPROVAL OF A FULLY TRAINED PRACTISING SURGEON

THIS SCRIPT COVERS:

SURGICAL ASSESSMENT OF ANAL FISTULA

LAYING OPEN OF A LOW ANAL FISTULA

i.e. A subcutaneous anal fistula

Or a fistula running through less than the lower half of the internal sphincter.

LAYING OPEN OF A RECURRENT LOW ANAL FISTULA

LAYING OPEN OF MULTIPLE LOW ANAL FISTULAS

THIS SCRIPT DOES NOT COVER:

TREATMENT OF A HIGH ANAL FISTULA

i.e. Running through half or more of the sphincter muscle.

LAY OUT OF OPERATION SECTIONS AND STEPS

The operation is divided into SECTIONS.

The SECTIONS are displayed in sequence in the following paragraphs.

Each SECTION is divided into an unlimited number of very small STEPS.

Each STEP contains an unlimited amount of supporting information (PANTINOS)

SECTION 1.00 PRELIMINARIES AND WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT

STEP 1.01 CHECK YOU HAVE THE CORRECT PATIENT

STEP 1.02 CHECK YOU HAVE THE CORRECT SIDE.

STEP 1.03 CHECK THERE IS NO OTHER PROCEDURE TO DO

STEP 1.04 CHECK THERE IS A DIATHERMY PAD

STEP 1.05 CHECK THE PATIENT IS SHAVED

Check the perianal skin is shaved for 10cm. around the anal orifice.

Check the skin is shaved for 5cm. around any fistula opening.

WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT

SECTION 2.00 ANAESTHESIA

GENERAL ANAESTHESIA

Epidural, spinal and caudal anaesthesia are acceptable alternatives.

SECTION 3.00 POSITION

LITHOTOMY

Make sure that the coccyx is visible.

You need access from the back of the genitalia to the coccyx and from one groin

fold to the other.

Use the Lloyd-Davis position if the patient has stiff hips, hip prostheses, or spine

pathology.

Check the male genitalia are held out of the way with a sling of 4" elastoplast across the ::thighs.

SECTION 4.00 STANCE

Stand facing the perineum with the scrubbed nurse on your right and an assistant on your

left.

SECTION 5.00 SKIN PREPARATION

Clean the skin from the back of the genitalia to the coccyx and from one groin fold to the ::other.

Use 2 swabs on sticks with 0.5% Chlorhexidine in 70% Propanol and 1 to dry

off.

SECTION 6.00 TOWELLING UP

STEP 6.01 PLACE AN OPERATING TABLE TOWEL

Tuck a dressing towel firmly under the sacrum.

STEP 6.02 PLACE THE LEFT LEGGING

STEP 6.03 PLACE THE RIGHT LEGGING

STEP 6.04 PLACE AN ANTERIOR SHEET DOWN TO THE BACK OF THE GENITALIA

STEP 6.05 FASTEN THE TOWELS

Use 4 towel clips to fasten the towels to the skin.

STEP 6.06 ATTACH THE DIATHERMY QUIVER

Clip the quiver to the left thigh.

STEP 6.07 CHECK THE DIATHERMY IS WORKING

STEP 6.08 SHAVE ANY RESIDUAL HAIRS

Use a no.22 scalpel.

SECTION 7.00 LOOKING FOR THE FISTULA OPENING(S) IN THE SKIN

STEP 7.01 SIGNS OF THE OPENINGS

Use a probe.

Usually the openings are obvious holes 1-2mm. in diameter.

Sometimes the openings are on the summits of 5mm. mounds of purplish granulation ::tissue.

Gentle pressure on the mounds with the probe will show the opening.

Probe for openings in the scars of earlier perianal abscesses or drainage wounds.

Look very carefully for other openings.

Finger pressure on the perianal tissues may cause pus to ooze out of a hidden opening.

Look for signs of Crohn's disease:

Complex, multiple openings.

Bluish, oedematous perianal skin, and skin tags.

Multiple previous operations.

Look for signs of malignancy:

Excessive hardness of the tissues.

Irregular overgrowths of tissue.

STEP 7.02 TAKE A PUS SWAB

SECTION 8.00 PROBING THE FISTULA TRACK(S)

STEP 8.01 TRACE THE FISTULA TRACKS

Tracks anterior to the middle of the anal canal should run directly towards the canal.

Tracks posterior to the middle of the anal canal should run posteriorly and then hook

forwards in the mid-line into the anal canal.

Be prepared for variants to this rule.

The tracks may follow other routes and be double or triple.

Sometimes the opening only admits the probe with some pressure.

Beware of making false tracks or losing the path of a tortuous track due to excessive

pressure on probing.

An anterior track may be a urethro-cutaneous fistula.

A posterior track may be coming from a pilonidal sinus.

SECTION 9.00 FINDING THE INTERNAL OPENING(S)

STEP 9.01 EXPOSE THE ANAL CANAL

Pass the blades of a 2 bladed St Marks anal retractor fully into the anal canal .

Gently dilate the anal canal digitally to overcome any resistance to passing the

retractor.

Openout the blades of the retractor.

Swivel the retractor around to explore the whole circumference of the anal canal.

The internal openings of the tracks may show up as 2-3mm. elevated patches of ::granulation tissue.

The internal openings are often deeper than expected.

Check the retractor blades are pressed deeply into the anal canal.

Look out for the superficial opening of a subcutaneous fistula.

If no internal opening is obvious:

Continue to the next step.

SECTION 10.00 IDENTIFYING THE TRACK(S)

Pass the probe from the external opening towards any likely internal opening.

In most cases, the fistula is single, with a predictable simple track.

i.e. The probe passes through a solitary external opening, easily along a single track, to  :::emerge through a single internal opening. This will be below or just penetrating the :::lowest fibres of the internal sphincter muscle.

In all cases, however, look out for:

Multiple skin openings.

Tortuous, branching, and multiple tracks.

Blind tracks, high and low.

Multiple and high internal openings.

SECTION 11.00 ASSESSING THE SPHINCTER

STEP 11.01 Use a finger to palpate the tissue lying medial to the probe.

1mm. thickness will be mucosa and submucosa.

The rest will be the internal sphincter muscle.

The external sphincter lies laterally and does not appear in this operation.

Superficial and low fistulas will have less than 2 mm. of sphincter muscle palpable

between the mucosa and the probe.

High fistulas will have more than 4 mm. of muscle between the mucosa and the probe.

This leaves a difficult group of patients where it is not clear whether the fistula is

high or low.

In this group, assume the fistula is a low one, unless there are complicating features.

e.g.

Sphincter damaged by:

Previous fistulectomy.

Episiotomy.

Sphincterotomy.

Haemorrhoidectomy.

Atrophic sphincter.

A degree of Incontinence.

Inflammatory bowel disease.

SECTION 12.00 DECIDING ON TREATMENT

The aims of treatment are to obtain healing of the fistula and to maintain continence.

The fistula will heal if it is laid open like a railway cutting and allowed to fibrose

into a flat scar.

Continence will be maintained if there is a minimum of about 7mm. of functioning internal ::sphincter lateral to the fistula incision.

Estimate the amount of residual functioning sphincter indirectly by assessing the amount

of muscle lying medially.

FOR A DEFINITE HIGH FISTULA:

Refer the patient for specialist advice and treatment.

FOR AN INTERMEDIATE FISTULA WITH COMPLICATING FEATURES

Be conservative.

A permanent minor discharge from a deep fistula may well be acceptable to a patient,

rather than major surgery and possible faecal incontinence.

Refer the patient for specialist advice and treatment.

FOR AN INTERMEDIATE FISTULA WITHOUT COMPLICATING FEATURES:

Treat as a low fistula.

FOR A BLIND TRACK WITH LESS THAN 5MM. COVER:

Treat as a low fistula.

FOR A HIGHER BLIND TRACK:

Treat as a high fistula.

SECTION 13.00 LAYING OPEN A LOW FISTULA

STEP 13.01 REPLACE THE PROBE WITH A GROOVED DIRECTOR

Turn the groove towards the lumen of the anal canal.

STEP 13.02 LAY OPEN THE FISTULA

Cut down onto the probe from internal to external opening using a NO.10 scalpel.

Biopsy the track.

Send the tissue for histology.

STEP 13.03 EXAMINE THE TRACK

Probe for any other tracks opening into the deroofed one.

Deroof secondary tracks as required.

Record, but do not deroof tracks passing deep to the internal sphincter.

You will probably be able to palpate the residual internal sphincter through the wound

at this stage.

IF THERE IS ANOTHER FISTULA

GO BACK TO STEP 13.01 REPLACE THE PROBE WITH A GROOVED DIRECTOR

Beware of sphincter damage and incontinence if you lay open more than 2 fistulas at ::one sitting.

SECTION 14.00 IF THERE ARE NO MORE FISTULAS:

CONTROL BLEEDING

Coagulate superficial bleeders.

Apply pressure with gauzes to deeper bleeders.

SECTION 15.00 DRESSING THE WOUND

Use Paraffin gauzes.

Apply 10 dry gauze dressings.

Apply 2 dry Surgipads.

FIX THE DRESSINGS

Use elasticated net pants.

SECTION 16.00 CHECK THE SWAB, AND INSTRUMENT COUNTS

SECTION 17.00 FINAL TOUCHES AND WHO SAFE SURGERY CHECKLIST SIGN OUT

STEP 17.01 REMOVE THE SLING FROM THE SCROTUM

STEP 17.02 CLEAN THE SKIN

Use a swab with 0.1% Chlorhexidene in 70% Propanol to clean the skin surrounding the ::dressing.

STEP 17.03 FILL IN THE HISTOLOGY AND BACTERIOLOGY FORMS

STEP 17.04 WRITE LEGIBLE OPERATION DETAILS

STEP 17.05 FILL IN THE SURGICAL AUDIT FORM

STEP 17.06 DICTATE AN OPERATION LETTER TO THE GENERAL PRACTITIONER PLUS A COPY TO THE REFERRING PHYSICIAN

END OF OPERATION

WHO SAFE SURGERY CHECKLIST SIGN OUT

SECTION 18.00 EQUIPMENT AND MATERIALS LIST

(FRIARAGE HOSPITAL)

SURGEON MR EDWARDS PROCEDURE LAYING OPEN ANAL FISTULA

GLOVES 7

PREPARATION HIBITANE x 2 WET X 1 DRY

SUTURES 0

BLADES NO.22 , NO.10

DIATHERMY FORCEPS, LEAD, QUIVER

ADDITIONAL INFORMATION

DRESSING GAUZE

KNICKERS

BASIC PACK SMALL LITHOTOMY

INSTRUMENTS 3 SPONGE HOLDERS

4 BACHHAUS

4 TOWEL CLIPS

1 ASSISTANTS SCISSORS

10 CURVED JOLLS FORCEPS

1 NON TOOTHED DISSECTING FORCEPS

1 NEEDLE HOLDER

1 VOLKMANN SPOON

1 PROBE

1 GROOVED DIRECTOR

DRAINS 0

TABLE FITTINGS

SPRAYS 0

CATHETERS 0

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Michael Edwards

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