Prof. Dr. R. K. Mishra. MRCS,M.MAS (U.K).
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The Video assisted anal fistula treeatment (VAAFT) way is performed for that surgical procedure of complex anal fistulas and their recurrences. Key points are the correct localization of the internal fistula opening under vision, the fistula treatment from the inside, and also the hermetic closure from the internal opening. This technique comprises two phases: a diagnostic one as well as an operative one. There is no need to know the fistula classification which obviously saves time and money. Moreover, surgical wounds in the perianal region are prevented and the chance of faecal incontinence is avoided because no sphincter damages are provoked.
The technique comprises a diagnostic phase and an operative phase.
(1) THE DIAGNOSTIC PHASE
The objective of diagnostic phase is the correct location of the internal fistula opening. The fistuloscope is inserted with the external fistula opening using the washing solution (glycine 1% and mannitol 1%) already running; providing a definite look at the fistula pathway which appears on screen. Blocking tissue can be taken off while using 2 mm forceps to facilitate the insertion of the fistuloscope.
The direction of the telescope is correct once the obturator appears within the lower area of the screen. The surgeon follows the fistula pathway using slow left-right and up-down movements. Since the fistuloscope is rigid it helps to guide it using a transanally inserted finger. These diagnostic phase maneuvers are favored by the complete relaxation of the surrounding tissue induced through the spinal anesthesia. The continous flow from the glycine-mannitol solution in diagnostic phase of video assisted anal fistula treatment allows for an optimal look at the fistula's inside as much as the interior opening. The assistant can insert an anal retractor in order to localize the interior fistula opening by looking for the light of the telescope within the rectum or anal canal. Dimming the lights within the operating theatre during diagnostic phase enables a simple localization of the fistuloscope light within the rectum.
Once the fistuloscope exits through the internal opening the rectal mucosa clearly appears on screen. In diagnostic phase some instances the interior opening might be very narrow; in this case, its location is suspected viewing the fistuloscope light behind the rectal mucosa. At this point, we put two or three stitches in 2 opposite points of the internal opening margin to be able to isolate and, above all, not to loose it. We should make sure to capture sufficient tissue thickness.
(2) THE OPERATIVE PHASE
Purpose of operative phase of video assisted anal fistula treatment phase is the destruction of the fistula from inside. Like a next thing, the fistula canal is cleaned and the waste material removed and its internal opening will be closed hermetically. Surgeon start destroying the fistula under vision using a unipolar electrode which may be passed with the operative channel of the fistuloscope and is attached to the electrosurgical power unit. Starting at the internal fistula opening, all fragments of the whitish material sticking with the fistula wall and all granulation tissue are coagulated. We complete this phase from the operation, centimeter by centimeter, from the internal opening towards the external opening keeping in mind any abscessual cavity.
In video assisted anal fistula treatment the necrotic material is taken away under vision using the fistula brush. Until that time, the isolated internal fistula opening remains available to allow the leakage of waste and washing material in to the rectum. At this time surgeon completely take away the fistuloscope. The assistant stretches the threads for the internal rectal space or rather the anal canal using a straight forceps in order to lift the internal fistula opening at least 2 cm in to the form of a volcano. Subsequently, we insert a stapler in the volcano's base and complete the mechanical cutting and suturing. The hermetic closure of the internal fistula opening can also be accomplished by using a linear stapler This also depends on the internal opening position. Utilizing a semicircular stapler, the suture is going to be horizontal. Using a linear stapler, the suture is going to be vertical.
In video assisted anal fistula treatment when the tissue in the region of the internal opening isn't sclerotic and allows to form a good "volcano", the stapler may be used, however if the tissue round the internal opening is simply too rigid and sclerotic, using the stapler may be difficult. In this instance a cutaneous mucosal flap could be preferred.
As a last step is that to insert fibrin glue right after the suture and staple line via the fistula pathway to help reinforce the suture. Therefore in video assisted anal fistula treatment the use of the synthetic cyanoacrylate behind the suture line or behind the flap assures the perfect opening closure. It is important to keep in mind that not the entire fistula tract is filled up with the synthetic cyanoacrylate; merely a small amount is inserted directly below the suture line. That's why the fistula pathway needs to stay open to allow the passage of secretions. This process assures an ideal excision along with a hermetic closure of the internal fistula opening, excluding the chance of stool passage. Since the suture can be found tangential to the sphincter, the postoperative pain is low even if the suture falls both in the anal canal and the rectum.
The advantages of the video assisted anal fistula treatment (VAAFT) technique are evident: no surgical wounds around the buttocks or in the perianal region are provoked, there's complete certainty within the localization of the internal fistula opening, and the fistula can be completely destroyed from the inside. There is no requirement to understand when the fistula is transphincteric, extrasphincteric or over sphincteric because operating from inside no damage is caused towards the anal sphincters. Therefore, no preoperative examination is essential. The chance of postoperative faecal incontinence is excluded. Moreover, the patient doesn't have any medications and he can start working again after a couple of days because the VAAFT technique can be performed in day surgery.