Fistulectomy and primary repair of wound and anal sphincter by Lasheen's sutures for high perianal fistula

Abstract

Aims: several techniques have been described for the management of fistula-in-ano. Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. this study offers our technique to achieve this goal. Methods: between January 2013 and December 2014, 77 patients with high perianal fistula were treated by fistulectomy and repair of the anal wound and sphincter by multiple Lasheen's sutures. the clinical outcome was assessed in terms of continence and recurrence for follow-up period (ranged from 3 to 24 months). results: the anorectal wounds were healed within 4 to 6 weeks. Early complications included superficial wound infection in 27 patients (35%), urine retention 21 patients (27%), transient incontinence in 41 patients (53%) for flatus for period ranged from 2 to 3 weeks. No permanent incontinence, no deep infection, or abscess formation, or recurrence was recorded during the follow-up period. conclusion: Our technique is easy, novel, and associated with good results for high perianal fistula management.

Full text

Edorium Journal of Surgery, Vol. 2; 2015.
Edorium J Surg 2015;2:16–20.
www.edoriumjournalofsurgery.com
Lasheen et al. 16
CASE REPORT OPEN ACCESS
Fistulectomy and primary repair of wound and anal
sphincter by Lasheen’s sutures for high perianal fistula
Ahmed E. Lasheen, Khaled Safwat, Basem Sieda, Mostafa Baiomy,
Ashraf Ismaeil, Zaki Allam, Wael Awad
ABSTRACT
Aims: Several techniques have been described
for the management of fistula-in-ano. Ideal
surgical treatment for anal fistula should aim
to eradicate sepsis and promote healing of the
tract, whilst preserving the sphincters and the
mechanism of continence. This study offers
our technique to achieve this goal. Methods:
Between January 2013 and December 2014, 77
patients with high perianal fistula were treated
by fistulectomy and repair of the anal wound
and sphincter by multiple Lasheen’s sutures.
The clinical outcome was assessed in terms of
continence and recurrence for follow-up period
(ranged from 3 to 24 months). Results: The
anorectal wounds were healed within 4 to 6 weeks.
Early complications included superficial wound
infection in 27 patients (35%), urine retention
21 patients (27%), transient incontinence in 41
patients (53%) for flatus for period ranged from 2
to 3 weeks. No permanent incontinence, no deep
infection, or abscess formation, or recurrence
was recorded during the follow-up period.
Conclusion: Our technique is easy, novel, and
associated with good results for high perianal
fistula management.
Keywords: Anal sphincter, Fistulectomy,
Lasheen’s suture, Perianal fistula, Wound
Ahmed E. Lasheen1, Khaled Safwat1, Basem Sieda1, Mo-
stafa Baiomy1, Ashraf Ismaeil1, Zaki Allam1, Wael Awad1
Affiliations: 1General, laparoscopic Department, Zagazig
University Hospital, Zagazig University, 44519, Egypt.
Corresponding Author: Ahmed E. lasheen, Postal address:
General Surgery Department, Faculty of Medicine, Zaga-
zig University 44519, Egypt; Ph: 0020552343035; Email:
lasheenahmed@yahoo.com
Received: 11 June 2015
Accepted: 03 July 2015
Published: 07 September 2015
How to cite this article
Lasheen AE, Safwat K, Sieda B, Baiomy M, Ismaeil A,
Allam Z, Awad W. Fistulectomy and primary repair
of wound and anal sphincter by Lasheen’s sutures for
high perianal fistula. Edorium J Surg 2015;2:16–20.
Article ID: 100007S05AL2015
*********
doi:10.5348/S05-2015-7-OA-5
INTRODUCTION
Fistula-in-ano is a common condition associated
with appreciable inconvenience and morbidity to the
patients. Centuries have passed but the basic principles
of management of anorectal sepsis remained the same
which revolves around resolution of anorectal sepsis and
treatment of fistula without hampering continence [1].
Conventional classification and treatment depends on the
level of the internal opening and extent of involvement
of the external sphincter by the fistulous tract [2, 3]. For
the simple and most distal fistula, conventional surgical
treatment such as lay – open of the fistula tract as a
complete transaction of the tissue between the fistula
tract and anoderm is very effective with a success rate
of up to 100% [4]. High fistulas have been treated by a
number of techniques (fistulotomy, rerouting fistula
tracts, loose and tight seton sutures) with variable results
in terms of recurrence and a disturbance [5, 6]. Core
fistulectomy and closure of internal opening techniques
have been reported with some difficulties [7, 8]. In this
article, using fistulectomy and repair of anal sphincter
by Lasheen’s sutures in high perianal fistula treatment,
surgical technique and the clinical results are discussed.
ORigiNAl ARTiClE PEER REviEwEd | PROviSiONAl Pdf

Edorium Journal of Surgery, Vol. 2; 2015.
Edorium J Surg 2015;2:16–20.
www.edoriumjournalofsurgery.com
Lasheen et al. 17
MATERIALS AND METHODS
This research was discussed and approved from the
ethical Committee of Zagazig University in December
2012. All information about this study was discussed
with all patients, and all patients gave writing consent
for inclusion of their data in this study. Between January
2013 and December 2014, the study population consisted
of 77 patients (50 male and 27 female) suffering from
high perianal fistulas according to the criteria of Parks
et al., with a median age of 45 years (18–62 years)
[9]. Five patients (9%) had previously undergone
one or more repair attempts before referral for this
technique. Before operation every patient underwent a
digital examination, transrectal endosonography, and
fistulography. All patients were continent. All patients
underwent a mechanical bowel preparation, and received
systemic antibiotic 12 hours preoperatively and 7 days
postoperatively. Under general or spinal anesthesia,
the patient was placed in the lithotomy position. The
fistulous tracts, and external and internal openings were
located. Complete and close fistulectomy was done.
Then, repair of anal wound and sphincter was done by
multiple double incomplete circular sutures (Lasheen’s
suture) passed under the wound floor using Vicryl No.
2/0 on round needle. The needle with Vicryl passed
from one edge of wound through the sphincter muscle,
under the wound floor until reaching to another wound
edge. Then, returned in opposite direction to the starting
point by same manner with distance between two limbs
of suture about 1 to 1.5 cm. Also, the distance between
each suture and another was about 2 cm. Now, one suture
becomes complete and two suture limbs were holed by
tissue forceps Figure 1 and Figure 2. Multiple sutures
were used, where were tied them making the wound and
muscles edges become close to each other Figure 2. So,
primary repair of anal sphincter and wound was achieved
by our sutures without forming closed space of wound,
which allows for free drainage of the wound through
its length and depth. Local wound care was continuous
cleaning of wound and application of topical ointment
contains local anesthetic and promotes healing agents.
The follow-up period was ranged from 3 to 24 months
(mean-20 months) for this patients group.
RESULTS
Our technique was done under general anesthesia in
57 patients and 20 patients under spinal anesthesia. The
two limbs of each suture must be passed at big distance
(3–5 cm) from both edges of anal sphincter muscles and
just under the wound floor (0.5 cm). The sutures were
tied only after finishing of putting all needed sutures. This
technique is easier with using long (5–7 cm), curved and
rounded needle. All anorectal wounds and sphincter were
healed within 4–6 weeks. Early complications included
superficial infection in 27 (35%) patients, urine retention
21 (27%) patients, transient incontinence in 41 (53%)
patients for flatus only for period ranged from 2–3 weeks.
No permanent incontinence, or deep infection or abscess
formation, or recurrence were recorded in this patients
group during the period of follow-up.
Figure 1: (a) Needle with Vicryl No. O, (b) Subcutaneous and
submucosa layer, (c) Sphincter muscle layer, (d) Anal wound,
(e) Incomplete double circular berried stitch. The needle with
Vicryl was passed from one wound side under the superficial
layer, through the muscle sphincter, under the wound floor until
reaching the superficial layer from other wound side, and return
in opposite direction until coming from near the first step.
Figure 2 The incomplete double circular berried suture
(Lasheen’s suture) was tied putting the two sphincter ends
close to each other without forming closed space of the wound
allowing for free drainage of anal wound. This leads to good
wound healing without fecal diversion.

Edorium Journal of Surgery, Vol. 2; 2015.
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Lasheen et al. 18
Figure 3: (A): One patient was suffering high perianal fistula
(probe inside the tract through external opening), patient
under general anesthesia and at lithotomy position, (B) Core
fistulectomy after division of anal sphincter superficial to fistula
tract was done. Then, three incomplete double circular berried
sutures (Lasheen’s suture) were putting and holding by tissue
forceps, (C) All sutures were tied putting the two sphincter ends
close to each other without forming closed space of the wound
allowing for free drainage of anal wound, (D) Same patient after
two weeks of operation, the anal sphincter was well healed and
there is small raw area, (E) Figure 3e : Same patient after four
weeks, showed complete healing for anal sphincter and wound,
leaving the anus normal in function and morphology.

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Lasheen et al. 19
DISCUSSION
The ideal surgical treatment of anal fistula should
eradicate sepsis and promote healing of the tract,
whilst preserving the sphincters and the mechanism of
continence. For the low perianal fistula, conventional
surgical treatment such as lay-open of the fistula tract
is very effective method [4]. However, if applied to
high perianal fistulas, this technique often leads to
incontinence and perianal scarring which may further
compromise the functional outcome [10, 11]. Surgical
pathology of perianal fistula is the presence of internal
opening at anorectal area, presence of fistula tract
which may be partial epithelized, and presence of sepsis
collection. In high perianal fistula the tract passes
through the upper two third of external sphincter [12].
The traditional method of laying open the fistula tract is
undoubtedly successful in achieving eradication of the
fistula, but leads to fecal incontinence in high fistula type
[13]. There are various treatment options for treating high
perianal fistula, all depend on core fistulectomy, closure
the internal opening and leaving the external opening
for drainage [8]. There are many options for closure of
internal opening as endorectal flap [14], fistula wall flap
[8], fibrin glue [15], fistula plug [16], stem cells [13].
Many authors using these techniques reported variable
recurrence rates ranging from zero to 30% and 8% fecal
incontinence [17–19]. I think, this is due to difficulties to
complete closure of internal fistula opening or difficult to
complete excision of tract leading to fistula recurrence or
more excision of muscle sphincter around the fistula tract
leading to fecal incontinence. Seton are other optional
treatment for high perianal fistula, the seton placement
has been advocated either loose, to control infection,
or cutting through the sphincter muscle gradually or as
bridge between two separate partial fistulotomies [20,
21]. Incontinence still continues to complicate seton
treatment, through they are projected as sphincter saving
procedures and the reasons for this could be hard gutter
shaped scars, loss of anal sensations. The use of setons in
modern day practices is restricted [1]. In our technique,
the core fistulectomy was done close and complete after
division of muscle of sphincter superficial to tract from
external to internal openings. Then, by Lasheen’s sutures
primary repair of sphincter and wound was done putting
the both ends of sphincter close to each other, without
producing closed space. This is allowing to free drainage
of all length and depth of wound through all stages of
healing. So, healing of anal wound and sphincter was
happen well and without any gutter formation or keyhole
deformity
CONCLUSION
Our technique, offers novel method easy, associated
with good results in form no recurrence and no permanent
incontinence in treatment of high perianal fistula.
*********
Author Contributions
Ahmed E. Lasheen – Substantial contributions to
conception and design, Acquisition of data, Analysis
and interpretation of data, Drafting the article, Revising
it critically for important intellectual content, Final
approval of the version to be published
Khaled Safwat – Analysis and interpretation of data,
Revising it critically for important intellectual content,
Final approval of the version to be published
Basem Sieda – Analysis and interpretation of data,
Revising it critically for important intellectual content,
Final approval of the version to be published
Mostafa Baiomy – Analysis and interpretation of data,
Revising it critically for important intellectual content,
Final approval of the version to be published
Ashraf Ismaeil – Analysis and interpretation of data,
Revising it critically for important intellectual content,
Final approval of the version to be published
Zaki Allam – Analysis and interpretation of data, Revising
it critically for important intellectual content, Final
approval of the version to be published
Wael Awad – Analysis and interpretation of data,
Revising it critically for important intellectual content,
Final approval of the version to be published
Guarantor
The corresponding author is the guarantor of submission.
Conflict of Interest
Authors declare no conflict of interest.
Copyright
© 2015 Ahmed E. Lasheen et al. This article is distributed
under the terms of Creative Commons Attribution
License which permits unrestricted use, distribution
and reproduction in any medium provided the original
author(s) and original publisher are properly credited.
Please see the copyright policy on the journal website for
more information.
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