The Standard Operation for Posterior Deep Complex Fistulas Based on Anatomy and Pathophysiology

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  • 痔瘻術後の再発を考える　　ＶＩ．解剖・病態に則した後方複雑痔瘻のスタンダード手術

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Abstract

PATHOPHYSIOLOGY: The primary opening of a posterior deep complex fistula is usually a posterior midline anal crypt. The primary duct proceeds to the cranial side toward the primary lesion (PL) passing diagonally through the internal sphincter. The PL is formed in the posterior deep space (PDS); the anterior border is the internal sphincter, the superior border is the inferior surface of the puborectalis, and the inferior border is the anterior surface of the external sphincter. Due to the raised abscess pressure, it penetrates the external sphincter. If it penetrates at a shallow portion of the PDS, it can reach the low ischiorectal space, and if at a deeper portion, it can reach the high ischiorectal space.<br> FISTULA OPERATION: The skin and external sphincter incision were made along the posterior midline. The incision was advanced until the PL could be visualized directly. The outer wall of the lesion was excised, and the PL was then exposed. The secondary ducts were treated by excision or curettage. The primary duct was exposed reserving the bottom of the internal sphincter. Then the internal sphincter outside of the primary opening was excised. Finally, the hemorrhoids around the excised region were treated, and the operation was completed.<br>

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