Shreyas Ano-Rectal Hospital & Research Centre

It is a common affliction of mankind, causing inconvenience and pain to the sufferer. Different methods ranging from Kshar-sutra to Fistulectomy and uses of laser beams, for the management of Bhagandara have evolved over the time. In our practice of over 14 years, we have been using different procedures like Chhedana-Fistulectomy, Kshar sutra ligation, Laser surgery for the treatment of different type of Bhagandara & other Ano-Rectal diseases like Arshas, (Hemorrhoids, Polyps, Sentinel piles)Fissure etc. We have however found that in most of the Bhagandara-fistulas, especially in Horse-shoe fistula and in multiple fistula where there are multiple external openings or multiple tracks, usually interlinked, this method i.e. partial Fistulotomy together with Kshar-sutra ligation renders maximum benefits. Partial Fistulotomy (Chhedana) from the external opening up to the anal sphincter facilitates easy drainage and reduces the number of follow up procedures (changing of Kshar-sutra), ultimately leading to quicker recovery.

The chances of sphincteric damage and hence incontinence are not increased as the Kshar-Sutra is used for the remaining part of the track, involving the sphincteric muscle. The chances of recurrence which are found to be quite high after Fistulectomy in such cases are also reduced because of the constant Lekhana-Ropana Karmas of the drugs which are continuously discharged from the Kshar-Sutra in the track. We have performed not less then 200 such procedures at the Shreyas hospital & Ano-rectal research centre during the past 10 years and have procured excellent results.

A fistula, as we all knows is an abnormal passage leading from one internal cavity to another or to the surface. Most anal fistulas seem to be the results of an infection of the anal glands that traveled down different planes to form a draining perianal abscess. These abscesses may drain in any direction and in any planes thus giving rise to different kinds of fistulas.

Different fistulas are treated in different ways by both, the followers of the modern medical science as well as Ayurvedists. Surgeons of the modern medical science prefer Fistulectomy. This sometimes, especially in the complex types, is performed in two or more steps interspaced by duration of few weeks. Most Ayurvedists however prefer Kshar-Sutra ligation in all types of fistulas irrespective of the position of the external opening and the course, the complexity and length of the tracks.

Spontaneous healing of anal fistulas, especially complex anal fistulas is practically unheard. If neglected or ill treated fistulas may cause repeated abscesses and ill health and long-standing fistula may eventually lead to malignant disease.

The procedure in discussion here is an excellent combination of the conventional type of surgery i.e. Fistulotomy and the age-old Kshar-Sutra ligation procedure, very well-known amongst present Ayurvedists. It is worth noting that even the conventional type of surgery adopted at present by most surgeons is actually a modified form of Chhedana mentioned by Sushruta in the treatment of Bhagandara. We have followed this method in the treatment of not less than two hundred patients of complicated or complex fistulae like

The combination is preferred to avail of the benefits of both the methods and is planned in such a way that the two methods are applied to the parts of the fistulous track for which they are best suited. That is, Fistulotomy is preferred for the external part of the track where as Kshar-Sutra ligation for the interior portion of the track i.e. the part where the sphincteric muscles are involved.

We discuss here the application of partial Fistulotomy with Kshar-Sutra ligation in one of the most complicated forms of anal fistulas i.e. The Horse shoe Fistula. As the name suggests the fistulous track in a Horse shoe fistula resembles the shape of horse shoe.

The main track of an ischiorectal fistula follows the roof of the ischiorectal fossa i.e. it lies on the under surface of the Puborectalis muscle. The track is therefore of horse shoe shape, if both sides are involved, with the anterior extension on each side passing deep to the transverse perineal muscle. The communication with the anal canal is most frequently in the mid line posteriorly but not invariably so. The track leading to the external opening on the skin is usually a vertical track which may descend from any part of the main one.


Path taken by high posterior Horse shoe ischiorectal fistula (Horizontal plane)	Classical posterior Horse shoe Ischeo-rectal fistula

Inspection of the anal region will usually reveal an external opening or openings. A single opening is more common. Sometimes the opening may be temporarily healed and may be detected only when the surrounding skin is palpated or lightly pressed and pus escapes from the opening. The position of the external opening and the palpation of the perianal region may give some indication of the possible course of the track. Horse shoe fistulas however are usually impalpable in the perianal region because of their high position relative to the anal canal. P/R of the anal canal may reveal an area of indurations or the actual internal opening. P/R is of prime importance in diagnosing a horse shoe fistula. The track of a posterior horse shoe fistula lies close along the Puborectalis sling and hence is felt very distinctly as a thick horizontal rod of indurations on one or the both sides (as the case may be). This can be palpated and distinguished more perfectly when the horse shoe fistula is unilateral i.e. incomplete, because the palpation of the two sides reveals a striking difference. Sometimes in inexperienced hands a complete horse shoe fistula, is missed as the symmetrical posterior and lateral indurations gives a feeling similar to that of the firm Puborectalis sling.

An internal opening is generally in the midline of the posterior wall of the canal at the level of the anal crypt or even up to or above the ano rectal ring is frequently (not always) detected in such fistulas.

It is also very important to access the amount of sphincter musculature that has remained if the patient has undergone previous Ano-rectal procedures.

Probing is advisable only after proper inspection and palpation. Also, probing should be done following the Goodsall's rule to minimize the risk of hurting the patient by pursuing a faulty direction. A malleable medium sized silver probe is used. The terminal 2.5 to 4 c.m. part should be bent into a slight curve as required to probe a horse shoe fistula. When the probe is passed as far as possible into the fistula, hold it in the position. Now the forefinger of the other hand is inserted into the anal canal.

The examiner will be able to feel the tip of the probe emerging through the internal opening into the anal canal or it may be palpable through the rectal wall. The probe can be brought out by further manipulation with the help of the guidance of the finger inside the canal. However the examiner should be very careful not to create an artificial opening by force.

Proctoscopy may reveal an internal opening which may not have been detected by palpation or by passing the probe. Proctoscopy is also useful in determining weather the opening is in the anal canal or above the ano rectal ring in the rectum. Besides this, Proctoscopy shows us the state of the rectal mucosa and helps us to decide if any other underlying factors like procto colitis are present.

Radiological examination of the fistulous track after injecting Connery Dye is useful if the course of the track is doubtful. This is of value only for high ano rectal fistulas or fistulas with one or multiple tracks. MRI or CT scan of the fistula is sometimes helpful in complex cases.

Anal fistulas especially long standing ones with complex tracks are sometimes associated with active pulmonary tuberculosis. A radiological examination of the chest should be performed. The pulmonary disease must be controlled before the fistula is operated upon.

A full radiological investigation of both small and large bowl should be undertaken if there is any suggestion of Chrohn's disease. Any other abdominal symptoms particularly diarrhoea should be investigated. Sigmoidoscopy is also necessary to exclude any rectal tumor or inflammatory bowel disease involving the rectum.

The lower bowel should be emptied by an enema about an hour before the operation. Sterilization of the bowel is not necessary as routine measure.

The patient should be in the lithotomic position with buttocks pulled down over the edge of the table. The procedure can also be performed in Jack knife position.

Proper extensive shaving and painting of the perianal region should be performed. Preoperative probing is done to confirm the course of the track.

A gentle and controlled dilatation procedure is carried out. The degree of dilatation varies and it is advisable not to risk damage to the sphincter by dilating too much. Usually four finger dilatation is preferred.

A pack is secured to a thread to facilitate pulling it out when the procedure is completed. It is now introduced in the rectal canal to absorb any discharge or blood so that it does not flow out during the procedure, keeping the surgical field dry.

The external opening is located and a probe is passed into it. It will enter deeply parallel to the anal canal and the tip of the probe can be palpated through the rectal wall at a level usually above the Ano rectal ring. It must never be forced through because the real internal opening is nearly always below the Ano-rectal ring, still following the under surface of the Puborectalis. The probe is brought out from the internal opening with the help to the index finger inside the canal leaving the probe in place. We now begin to cut the track with a scalpel. Starting from the external opening we move towards the internal opening, but we do not cut and lay open the whole track. Only the external and lateral part of the track is laid open. Dissection is performed only up to the sphincteric muscles. We stop as soon as we reach this point. The remaining track entering the bowel is not dissected. A simple thread is passed from the new external opening (within the dissected part) to the internal opening with the help of probe and tied loosely around the remaining sphincteric fibers. The part of the track which is laid open does not require meticulous curetting and scraping out since this work is gradually done by the drugs coated on the thread. Minimal or no excision of the sides of the wound is needed and hence instead of a big deep wound as in the case of conventional Fistulectomy. We make a comparatively smaller wound. Flat gauze dressing moistened with any antiseptic Ayurvedic formula is applied lightly (gently pushed in to wound) to keep the edges of the wound apart and ensure the healing of the wound inside outwards.

A Kshar Sutra is passed through the track in place of the simple thread after about seven days. This Kshar-Sutra is periodically changed as per the requirement; it gradually cuts the remaining part of the fistula Healing takes place simultaneously.

We shall first consider the draw backs of the conventional Fistulectomy, usually preferred by the surgeons of the modern medical science.

· In the conventional Fistulectomy we leave a big, deep, and wide wound which takes weeks to heal. Days of painful dressings follow the main procedure, rendering the patient unable to carry out his routine work for days.

· The procedure many times needs to be completed in two steps and hence the patient has to be operated twice. Naturally an Anesthesia too has to be administered twice. The patient has to go through the whole ordeal twice.

· The post operative dressings require more detailed attention and have to be carried out by qualified nurses. In some cases the first few post operative dressings have to be carried out under general anesthesia.

· There is some tendency for the large deep wounds to form pockets which delay healing. Hence the patient should be examined at least once a week by the surgeon and any pockets of the track that may have been overlooked should be laid open.

· One more very important negative aspect of Fistulectomy is that in many such cases division of the greater part of the anal sphincter is necessary leading to partial incontinence which is a very uncomfortable and stress rendering condition for the patient. Partial early post operative incontinence is frequent after surgery of most fistulous tracks. This temporary incontinence however normalizes within 2 to 3 weeks. But about 1/3 of the patients have some permanent disturbance in anal continence varying from loss of flatus control to severe fecal incontinence, specially when more part of the sphincter lies below the track.

We can claim without any exaggeration that all these negative aspects of Fistulectomy can be avoided to a very great extent in the procedure mentioned above.

· As we have already seen the wound left after the procedure are very small in comparison to the wounds left after conventional Fistulectomy and hence the post operative days of the patient are much more comfortable.

· Dressings are sometimes needed for just a few days in place of weeks and even these post operative dressings do not need very extensive cleaning or irrigation of the wounds.

· The sphincteric muscles are not dissected and hence the possibility of incontinence is ruled out.

· The drugs coated on the Kshar-Sutra are slowly and gradually released into the track and the wound, leaving no pockets overseen. These pockets are drained out by the action of the drugs.

· And last but not the least, the cosmetic aspect of the procedures should not be neglected just because the region involved does not usually come in view. An anorectal and perianal surgery should be performed as precisely as Maxilo-Facial cosmetic surgery'. The appearance of the perianal part, after complete healing has occurred should be as near normal as possible. Clearly, this is more possible when minimum dissection and extension of the wounds is performed. The wounds after a partial Fistulotomy with Kshar-Sutra are much smaller, there is minimal loss of the gluteal cushion, and the anatomy is least distorted.

In a typical Horse Shoe fistula, Kshar-Sutra ligation procedure has to be performed in such a way that we will have two or sometimes three different threads in the track. Changing three different threads at a sitting (during dressing) may be very painful and inconvenient to the patient.

The gradual cutting of the track takes a very long time which is significantly shortened by combining the procedures.

In some cases it is not possible to provide adequate drainage without laying a part of the track open.

Total number of patients who have undergone the different procedures - is 75. Records of patients who have been operated between 1993 and mid 1999 are taken to ensure that we have a follow up of not less than three years. Complete Fistulectomy has not been performed by us, the reason being the obvious disadvantage of the method. However, we have observed closely and recorded the detailed data of 25 patients who have undergone this procedure at other private hospitals under other surgeons of the modern discipline. The data of the patients is given for the convenience of comparative study of the methods.

The most often encountered post operative complications are surgical incontinence and recurrence. Incontinence due to damage to the sphincters is more common in complex Horseshoe Fistula because the fistulous track travels through the sphincter. Incontinence may be partial or complete.

11. Incontinence 12. Recurrence: (Post operative follow up taken not less than three yrs.)

The data clearly shows that the above mentioned method has definite benefits over the other methods and hence is the method of choice.

Extensive research is still necessary to establish the absolute supremacy of the combination of Chhedana and Kshar Sutra in treating complex transphincteric fistulas.