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Advancement flaps for fistula in ano

Advancement flaps for fistula in ano. SR Brown Sheffield teaching hospitals. Perfect operation. Easy to perform No risk of incontinence Effective. History. First proposed 1902 (Noble) for rectovaginal fistulae Anal fistulae 1912 (Elting). Objectives. Indications Types and Techniques

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Advancement flaps for fistula in ano

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  1. Advancement flaps for fistula in ano SR Brown Sheffield teaching hospitals

  2. Perfect operation • Easy to perform • No risk of incontinence • Effective

  3. History • First proposed 1902 (Noble) for rectovaginal fistulae • Anal fistulae 1912 (Elting)

  4. Objectives • Indications • Types and Techniques • Results

  5. Indications • High trans-sphincteric/supra-sphincteric fistulae • Anterior fistulae in women • Rectovaginal fistulae • (Crohn’s)

  6. Contraindications • Acute presentation • Large opening • Rectal disease • Neoplasia • Crohn’s • Radiation

  7. Types of advancement flap • Endorectal • Full thickness • Partial thickness • mucosal • Anocutaneous • V-Y,Y-V • Rhomboid, House

  8. Method • Bowel preparation • Antibiotics • Position

  9. Essential steps • Excision of internal opening • Excision primary tract • Formation flap • Attention to external component

  10. Excision fistula tract • Sharp dissection core out/curettage • Excise secondary tracts • Continue to internal sphincter/complete tract

  11. Mobilisation rectal flap • Adrenaline (1:300,000) • Partial/full thickness internal sphincter flap (based proximally) • Divergent lateral incisions • Meticulous haemostasis • Excise internal opening +/- closure internal tract

  12. Suturing flap • Suture with absorbable Vicryl 2/0 • Tension free • Leave external opening to drain/Malecot catheter/glue • No indication for bowel confinement/stoma

  13. Principles for success • Stagger the mucosal and muscular suture line • Width of base of flap > twice the apex • No sepsis

  14. ResultsDifficulties • Due to • Population • Inflammatory/Non inflammatory • High/low fistulae • Recurrent • Surgeon • Follow up • Thoroughness of reporting

  15. ResultsEndorectal Technique

  16. Reasons for Incontinence • Direct damage to sphincter • Stretching • Scarring • Decreased sensation

  17. The anocutaneous flap

  18. ResultsAnocutaneous technique

  19. Factors that influence healing • Redo procedures • Crohn’s • Rectovaginal fistulas • Smoking

  20. Summary • Advancement flaps useful part of armamentarium for fistulas • Techniques equally effective • Consent for recurrences/incontinence particularly certain groups

  21. Rectovaginal fistulaecauses • Inflammatory • Crohn’s • Neoplastic • Post-radiotherapy • Non inflammatory • obstetric

  22. Rectovaginal fistulaetypes

  23. Types of repair • Transanal advancement flap • Lay open and primary repair (perineoproctotomy) • Transperineal repair (+/- transposition) • Transvaginal repair

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