Fistula-in-ano is a disease which has challenged surgeons for centuries because of high postoperative complication rates including recurrences, and symptoms of postoperative gas and stool incontinence. The paper addresses the surgical method of fistula excision followed by sphincter reconstruction. The procedure is not new, but it has gained popularity in recent years. The primary indications for its use include complex high anal fistulas, posterior transsphincteric fistulas in patients with good baseline continence, and fistulas of “borderline” height, involving approximately 50% of the external sphincter mass. In cases of high and/or complex fistulas, the first stage of management is typically loose seton drainage to reduce the risk of infection. Prior to surgical intervention, it is important to assess the patient’s preoperative continence status. The paper presents the surgical technique of the intervention, outlines possible complications, and reviews the literature reporting the experiences of other authors who use the method. Fistulotomy followed by sphincter reconstruction is a bold surgical approach. It requires extensive experience in performing colorectal surgical procedures, and it is suitable for a selected group of patients. On account of possible complications including impaired postoperative gas and stool continence, the patient should receive appropriate information before surgery, and sign the surgical consent form. Fistulotomy followed by sphincter reconstruction is a good therapeutic option in patients with recurrent high anal fistulas unsuccessfully treated by other methods.
Proctogyneacology deals with conditions involving the anal canal, anal sphincter muscles, rectum, rectovaginal septum, and the female reproductive tract. They may be due to sagging of the pelvic floor and the rectovaginal septum (rectal, vaginal or uterine prolapse, enterocele and rectocele), perinatal injury, including sphincter damage, rectovaginal fistulas, endometriosis with anal sphincter and rectovaginal septum involvement, proctological inflammatory diseases in pregnancy, as well as radiation-induced rectal damage after gynaecological cancer treatment. There are no set guidelines defining which specialist should operate on these patients. We attempted to systematise this issue in the form of an algorithm. An interdisciplinary dialogue allowing for our professional development and, most of all, therapeutic success and reduced risk of postoperative complications, seems to be crucial.
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