Subtle variations of the original technique are described. We prefer to remove a portion of the tract if the length allows it [3]. The closure of the tract after suture ligation may be tested, either with direct probing or with injection of hydrogen peroxide or saline [2, 4, 5]. Postoperative admission for observation is not necessary. Several series report discharging patients with a week of oral antibiotics [2, 4, 5]. There is no consensus on the use of seton preoperatively. As a standard, at our institution, setons are used to drain all infection prior to undertaking definitive surgical repair of the fistula and many of the other series do so as well. There is anecdotal evidence that when the seton is left in place 8–12 weeks prior to LIFT, the tract fibroses nicely, making it easily identifiable and, in many cases, easier to dissect free from the surrounding tissues ensuring a successful ligation [3, 6]. Routine diagnostic imaging preoperatively or postoperatively with either MRI or endorectal ultrasound is not necessary. Diagnosis of fistula and treatment failures can be decided clinically.

This operation may be performed in prone jackknife or lithotomy position, under either regional or general anesthesia. Some surgeons use lithotomy or prone jackknife position depending on the location of the fistula [7]. Bowel preparation consists of two phospho soda enemas the day before surgery. Patients are administered only a single dose of appropriate peri-operative antibiotics intravenously, usually cefoxitin, or ciprofloxacin/metronidazole if the patient is penicillin-allergic. At the end of the procedure, a dibucaine-coated piece of gelfoam is rolled and gently inserted into the anal canal for analgesia. The patients are not admitted for observation and are sent home directly from the recovery unit on oral analgesics and stool softeners [3].