Rectal Advancement Flap

The integrity of the anal sphincter is probably one of the most important aspects to consider when contemplating the choice of surgical repair. If the sphincter is intact and the fistula is above the dentate line, an advancement rectal flap procedure can be peformed. Although this repair can be performed in any position, the prone jackknife position provides optimal exposure. I prefer full bowel preparation, use of intravenous (IV) antibiotics, and having a Foley catheter in place during the procedure. Unless the tract is completely dry and epithelialized, I also prefer that a draining seton be in place for a month prior to closure, which facilitates elimination of any sepsis or entrapped fluid in the tract and improves the pliability of the tissues.

The flap starts a few millimeters distal to the internal opening, and the arc for the flap is about 180 degrees. The anal canal mucosa is carefully removed, avoiding injury to the internal anal sphincter. The flap then becomes full thickness of rectum cephalad to the anal sphincter complex. Mobilization of the rectum from the rectovaginal septum continues until the distal end can be advanced without tension to the opposite cut edge on the distal anal canal. The fistula is cored out and closed in layers with figure-of-8, 3-0 polyglycolic acid sutures. The internal opening is closed from the anal side only. The use of a UR 5–type needle facilitates the ability to obtain a deep suture in the confined space of the anal canal to close the opening. Usually the closure is performed from cephalad to caudad in several layers using figure-of-8 sutures. The vaginal or perineal side will be left open, and sometimes the external opening is enlarged to ensure adequate drainage. The distal tip of the flap, which includes the area of the internal opening, is trimmed. The goal is to advance full-thickness rectum distally. To reduce tension at the suture line, one or two simple sutures may be incorporated beneath the flap. One bite (not full thickness) is placed through the tissue on the undersurface and the other is placed through the distal cut edge in the anal canal. Then, after ensuring hemostasis, the flap is advanced to the distal cut edge and sewn in place with 3-0 polyglycolic acid sutures. The middle sutures are placed first with deep, simple, full-thickness bites. Sewing is then carried laterally on each side to complete the suture line. Some variations in flap construction include short bursts of running suture to close the two edges, minimal mobilization of the flap with more of a layered closure, and orientation of the flap longitudinally (instead of the semicircle).

Postoperatively, in patients without a diverting stoma, restricting oral intake for 2 to 3 days may delay passage of stool over the fresh sutures. The perineal area is examined on postoperative day 1 to assess for swelling and bruising. If significant swelling or bruising is present, a delay in the removal of the Foley catheter until postoperative day 2 is considered. Although preoperative administration of antibiotics is universal, considerable variation exists regarding the postoperative use of antibiotics, from none to 7 days. I favor administration of IV antibiotics while the patient is in the hospital and then completion of a total 5- to 7-day course of oral antibiotics. There is also no consensus regarding activity limitations. Although some surgeons curtail activity and prescribe bed rest for postoperative days 1 to 2 in order to avoid pulling on the suture line, I allow patients to be out of bed but ask them to avoid sitting as much as possible. No scientific evidence exists for any of these activity restrictions.

Care after hospital discharge sometimes can be more important than the postoperative care provided in the hospital in facilitating success. Patients are encouraged to walk and go up steps but to lift no more than the weight of a gallon of milk. They can sit on a pillow but not on a doughnut, which spreads the buttocks and pulls on the perineal skin. If they do not have a proximal stoma, I ask them to ingest an ounce of mineral oil daily along with insoluble fiber. While they are in the hospital, I do not allow them to eat until the day of discharge. On the day of their discharge they are given a solid diet, their first dose of mineral oil, and the oral antibiotic. If they do not have a stool by 2 to 3 days after discharge from the hospital, I ask them to ingest an ounce of milk of magnesia daily until they have a bowel movement. Patients are in regular phone contact with my nurse to ensure that constipation is avoided. I also allow patients to take showers but instruct them to avoid taking baths for 2 to 3 weeks because a bath seems to make the anal skin waterlogged.

The nurse continues to be in regular phone contact with the patient, and any concerns regarding pain or pressure are immediately addressed, usually at an office visit. At times, performing an examination with use of an anesthetic is necessary to investigate the source of the pain and verify the absence of trapped fluid. On several occasions, making a counter incision to allow drainage lateral to the flap has prevented the flap from being lifted off when patients presented with new pain or pressure.

Successful closure of an RVF with a rectal advancement flap can be expected in about 65% of women. Smoking and Crohn disease have been associated with failure of this procedure.

Advancement Sleeve Flap

In some women, significant scarring in the anal canal or anal canal stenosis precludes use of an advancement rectal flap. In these situations, use of an advancement sleeve flap is considered. The perioperative preparation is the same as for the advancement rectal flap. The procedure differs in that a full circle of anal canal mucosa is excised, starting anteriorly a few millimeters distal to the internal opening. The incisional line for the posterior half of the sleeve is the dentate line. The mucosectomy is continued cephalad to the top of the anal sphincter; the dissection is then carried laterally so that a full thickness of rectum is mobilized. The plane that is entered is the same one utilized when performing an Altemeier procedure (i.e., a perineal proctosigmoidectomy). However, when performing the Altemeier procedure, the plane is typically a little more redundant and stretched out from the prolapse. Mobilization continues cephalad until the sleeve will advance to the neodentate line without tension. Closure of the internal opening is performed in the same manner as for the rectal advancement flap. Because of the possibility that fluid may become trapped beneath the flap, I insert a 10-mm drain that lies beneath the flap, comes out the buttock laterally (inserted using a trocar), and connects to a red-top test tube or bulb to exert negative pressure. I am amazed at the amount of serous fluid that is collected during the first 2 to 3 days—sometimes as much as 20 mL daily. I remove the drain when the output is about 5 mL in a 24-hour period. The anterior proximal edge of the flap is trimmed and the flap is advanced down and sewn to the neodentate line as outlined for the advancement rectal flap. Because mobilization for a sleeve flap is more extensive, a diverting stoma is typically placed. Otherwise, the postoperative care is the same as that previously outlined for the advancement rectal flap.

A sleeve is useful in persons with Crohn disease because significant anal canal scarring and tissue fixation may be present. The mucosectomy removes the scarred anal canal tissue, and provided the rectum has little to no inflammation, healthy tissue can be brought into the area. The success rate of the sleeve is about 65%, with similar results for Crohn and non-Crohn etiologies.

In some cases the circumferential rectal flap will not reach the neodentate line. When this situation is encountered, the patient will need to be turned onto her back and placed in stirrups, and an abdominal approach is added to gain sufficient length. This procedure entails mobilizing the rectum circumferentially. I try to avoid dividing the inferior mesentery artery and vein until I am sure it is needed for sufficient mobilization and reach. However, I do not hesitate to divide the artery and vein or mobilize the splenic flexure to augment length and avoid tension on the anastomosis. When the abdominal approach is added, an ileostomy is almost always performed.

Turnbull-Cutait Anastomosis

A Turnbull-Cutait staged colo-anal anastomosis, which is a variation of the abdominal mobilization of the rectum, may improve chances of successful closure of the fistula. The difference is that maturation of the anastomosis is delayed for 5 to 7 days as opposed to suturing it at the initial operation. This approach allows two raw surfaces to seal before sutures are placed through the bowel. This approach may be favored when the internal os will be close to the suture line.

After the mucosectomy, abdominal rectal mobilization, and closure of internal os are performed, eight sutures of 3-0 polyglycolic acid are placed in the cardinal positions around the anus. These sutures are placed with deep bites from the outside of the anoderm to the inside of the raw cut surface and pinned out radially to avoid tangling. The healthy bleeding cut edge of the distal bowel (usually rectum) is then brought out the anus and positioned so the bowel is extruded 5 to 10 cm from the anal verge. The bowel is wrapped with petroleum jelly (e.g., Vaseline)-impregnated gauze. Next, the sutures are unpinned and wrapped around the (now Vaseline covered) extruded bowel, and all is held in place via wrapping with Kerlix gauze, which is stabilized with clips or simple sutures. When this approach is used, an ileostomy is always performed.

The patient recovers on the nursing floor and is able to walk and sit. The only caveat is that most women retain their Foley catheter until after stage 2. After 5 to 7 days, the patient is returned to the operating room and placed in the lithotomy position, the gauze is carefully unwrapped, and the sutures are pinned out radially around the anus. By this time the serosa of the bowel has adhered to the raw surface created in the anal canal. Great care is taken to avoid disrupting this attachment. The bowel is amputated at least 1 cm distal to the anal opening, and the sutures are placed through the cut edge of the bowel and tied. I prefer to add short bursts of running suture to further stabilize and seal the anastomosis. When the anastomosis is completed, a small amount of ectropion exists that typically will retract into the anal canal within 6 months. Amputating the bowel more proximally increases the risk of disrupting the seal between the bowel and the anal canal.

Before closing the stoma, I routinely examine the anesthetized patient to ensure the fistula is closed and everything has healed.

Ligation of the Intersphincteric Fistula Tract

If the tract is in the upper anal sphincter region, then a ligation of the intersphincteric fistula tract can be performed. This technique does not divide any anal muscle, and data are accumulating regarding the results for closure with this approach. (A more detailed description of this approach for non-RVF anal fistula can be found in Chapter 5 ).

Episioproctotomy

When a woman who had a previous vaginal delivery has an anterior sphincter defect (no matter the cause of the RVF), an episioproctotomy is recommended. It is important to remember that the patient can have a wide intact perineal body but a weak, deficient, or scarred sphincter. Therefore, unless the sphincter is clearly defective, an anal ultrasound is invaluable in detecting an anal sphincter defect.

The preparation is the same as for the advancement rectal flap. With the patient in the prone position, a probe is placed through the fistula tract and an incision is made over the probe. Sometimes the length of skin that will be divided is daunting, but remembering that no or minimal muscle will be divided is key. The muscle ends are dissected out and the internal and external sphincter muscles that have been joined by scarring are left in place. Some dissection is required in the rectovaginal septum to debride the epithelialized fistula tract and allow the sphincter repair space to lie flat after sutures are tied. The sphincter is totally debrided, and hemostasis is ensured. Crossing the sphincter over in a vest-over-pants type fashion (i.e., left over right versus right over left) will allow visualization of the optimal setup for repair. The goals are for the overlapped muscle repair to lie flat and as much dead space as possible to be obliterated. After determination of the optimal overlap, attention is turned to the rectal mucosa, which is closed first. Starting at the cephalad aspect, far-far-near-near 2-0 or 3-0 polyglycolic acid sutures are placed in the rectal mucosa. The aim is precise approximation of the mucosa. These sutures are placed until about the level of the dentate line and tied down. It is important to place these sutures first because visualization will be decreased after the muscle overlap, making precise placement impossible. Next, using 2-0 polydioxanone sutures, a vest-over-pants type repair is performed to overlap the muscle; then the free edge of muscle from the overlap can be tacked down with 2-0 polydioxanone suture. The rectal mucosa is then closed to the level of the perineal skin, stopping at about the anal verge. Next, the apex of the vaginal defect is closed with mattress sutures of 2-0 polyglycolic acid. Depending on the amount of dead space, I will loosely approximate the vaginal closure, because if fluid has accumulated, I want it to drain out the vaginal side rather than the anal side. Care is taken to line up the hymenal ring during the vaginal closure. The perineal skin from the introitus to the anal verge is also usually (but not always, depending on the amount of dead space) left open for drainage.

Postoperative care is similar to that for the rectal sleeve flap. This approach does not require a diverting stoma, although if the repair is a repeat procedure or if it is unusually complex, use of a stoma may be considered. Careful postoperative monitoring is key to improving success. Any reports of pressure or increased pain or concerns about fluid accumulation require an examination after induction of anesthesia to drain trapped fluid and prevent it from coming out the anorectal suture line. On many occasions, a local physician has prescribed antibiotics for these symptoms, and when I finally see the patient, she will report that fluid or drainage came from the anus, which relieved her symptoms but was associated with recurrent RVF symptoms. Preventing drainage of this fluid from the anorectal suture line may help avoid a recurrence.

If a stoma has been placed, about 2 to 3 months later I examine the anesthetized patient prior to closing the stoma. Any granulation tissue found along any suture line raises suspicion for a persistent fistula and mandates a very careful examination.

With this approach, closure of the fistula has been reported in nearly 80% of cases when the cause was obstetrical or cryptoglandular.

Tissue Interposition