SLOFT SURGERY PRESENTATION
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Transcript of SLOFT SURGERY PRESENTATION
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SUBMUCOUS LIGATIONOF
FISTULA TRACT (SLOFT)
Dr D.U.PathakMS FACRSI
Jabalpur (M.P) India
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Development of Ano -Rectum
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Development of Anus
• Hind gut fuses with proctodeum below to make anal canal
• Both carry different Blood , Lymphatic and nerve supply
• The mucosa above is columnar and becomes gradually stratified below• Two different cultures
meet each other
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SURGICAL ANATOMY OF ANO RECTUM
• Anatomical anal canal is 2cms – Anal valves to anal verge
• Surgical anal canal is 4 cms Anal ring to anal verge
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Surgical & Anatomical anal canal
• Surgical anal canal extends from Ano rectal ring to anal verge. It is 4 cms.
• Anatomical anal canal is only 2 cms from dentate line to anal verge.
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Surgical anatomy of Ano-rectum
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Ano rectal ring
• The deep fibres of external sphincteres and pubo rectalis sling form the upper end of Ano rectal margin and the ring
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Dentate (Pectinate) line
• It is the junction of upper 2/3rds and lower one third of anal canal
• Fusion of hindgut and proctodeum
• Hence Endoderm above and Ectoderm below
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Dentate line
• Blood supply is from superior rectal above and middle and inferior rectal below
• Nerve supply above is inferior hypogastric plexus conducting stretch and
• Inferior rectal nerves carrying pain to cut and burn through pudendal.
• Lymphatics below drain to inguinal and above to pararectal
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Hilton’s line
• First landmark above the anal verge.
• More felt than seen – inter-sphincteric groove
• It is muco cutaneous junction
• Below is Keratinized stratified squamous epithelium
• Below it the lymphatic drainage is to inguinal nodes.
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Pectin
• A small strip of 1 cm below the Dentate line and is called Pectin
• It is a transitional zone with cuboidal epithelium and no skin appendages
• Here the mucosa is very adherent to the surroundings hence abscesses are very painful
• Ischio rectal abscesses usually drain below this area• Below this the skin gradually thickens and
appendages develop near the verge
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Anal verge
• Below the Hilton’s line• Distal collapsed rugous end of the anal canal • Surrounded by superficial anal sphincter• Transitional area of epithelium of the anal
canal and perianal skin
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Sphincters
Internal• Pearly white condensed
circular smooth muscle fibres
• Extend from ano rectal junction all along the anal canal.
• Thickest - 3-5 mms at the verge
• Lower level than external• Autonomous nerve supply
External• Skeletal voluntary red
muscles, supplied by somatic nerve supply
• Divisions have no clinical significance, all merged
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Surface landmarks
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Anal glands
• Lie in the inter sphincteric and sub mucous planes
• Two to ten in number• Secrete lubricating
material in anus• Internal opening is in the
crypts at dentate line• Highly susceptible for
infection
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Anal gland
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Ano-rectal diseases
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Crypto glandular infection
• The infection usually starts in the crypts• Common organisms are Staphylococci,
Streptococci, E coli or Proteus• Recently also anaerobes like Clostridium
Welchii and bacteroids• Sometimes mixed with tubercular
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Sites of abscess
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Spread of sepsis
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Ano Rectal Fistula
• It is sequel of crypto glandular abscess• The infection is of anal gland• Anal glands are 6-8 in number• Their function is to lubricate the anal canal• All open at the dentate line
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Location of Internal opening
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Basic understanding
• The internal opening is always at the dentate line.
• High opening is usually Iatrogenic, other uncommon causes are tuberculosis and malignancy, rarely Crohns
• The usual pyogenic abscess can never perforate a normal rectal wall and create a high opening
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Formation of fistula
• A crypto glandular abscess with inadequate drainage from the internal opening spreads in loose inter sphincteric planes and ultimately finds its way somewhere to drain out, making an external opening.
• The collections develop a protective wall around them, which becomes more firm, shrinks in size, takes a tubular shape to make a so called fistula tract.
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Investigations
• To diagnose• To assess• To rule out• To know the synchronous problems• To follow up the progress of recovery
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The best investigation remains …
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If you don’t want to put your foot in rectum …
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Fistulography
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Conventional USG
• Readily available• Gives information about
the maturity of tract• Of more help when
combined with other imaging like fistulography
• Detects the hidden abscesses
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Endo SonologyTrans sphincteric
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Endo Sono - Horseshoe
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MRI
• CT could not give proper information about the soft tissues
• It helps in 90% cases to localize the internal opening
• Helps in mapping , planning and projecting the prognosis.
• Worth in recurrent fistulae
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Chest X Ray
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Classification
• Vertical • Parks Simple, Inter
sphincteric and trans sphincteric.
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Goodsal’s Rule
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Extensions
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Why do we classify an disease??
• To plan the treatment.• When the treatment is same you do not
bother for classification like – hernia.
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Existing procedures
• Aim towards separate treatment for different types.
• The approach is from distal – external opening to proximal – internal opening
• Hence the knowledge of anatomy of the tract was compulsory
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The Aim of treatment
• Control of sepsis
• Prevention of incontinence and recurrence
• Giving him less pain, morbidity and job loss
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Existing methods
• Lay open • Seton• Kshar sutra• Cut and repair of the sphincter after excision
of the tract.• Fistula plug• VAAFT• LIFT
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Lay open
• Big painful wound with long term recovery
• Makes the patient incontinent at least for flatus.
• Gives a bad scar and furrow.
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Seton
• Painful long term cutting of the sphincter with pressure
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Ksharsutra- Ayurvedic thread
• Chemical cutting with a formulation of fixed ph
• It is long term painful cutting with gradual healing at the same time
• Leaves behind a bad scar
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Excision of the tract and
Primary repair of sphincter
• Needs high expertise• Associated with high incidence of
incontinence.
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Fistula plug
• Very attractive choice for affluent class
• The zero morbidity way but associated with high recurrence rate
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VAAFT
• It’s a high tech costly operation
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LIFT
• Sound surgical principle • Low morbidity • No incontinence But• Difficult to learn, to do and to teach
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Sub mucous Ligation Of Fistula Tract(SLOFT)
• Basic principle is of LIFT- ligation of the tract • In SLOFT -• It is more proximal• It is more superficial• Leaves behind a smaller stump of the proximal
tract
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Submucosal Ligation Of Fistula Tract (SLOFT)
• The approach is anti grade – from internal opening to going distal – that too only for 2 cms.
• The tract as it emerges from internal opening is always straight and superficial
• As is goes distally it changes it’s course like a river• The distal coarse is unpredictable as regards its
curvatures and depth hence existing methods are not so easy and effective for elimination of the tract.
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Schematic representation of SLOFT
Internal opening
Tract hooked
Dentate line
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Instruments
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Probing
• Probe is gently introduced to come out from internal opening
• Then it is bent and pulled out of the Anus.
Incision
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Injection Xylocaine adrenaline
• This blanches the area and does hydro dissection around the tract
Muco- Cutaneous
Junction
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Hooking the tract
• Incision is at the muco cutaneous junction
• The tract is hooked
• Here it is superficial.
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Site of ligation
• It is Sub mucous and is medial to the internal sphincter
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FAQ – How far from Internal opening?
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Division of the Tract
Anus
Anus
Hooked tract
Tract transacted
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Distal tract
• Cored out and sent for HPR .
Coring of external
tract
EAL near internal opening
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Wound
• Can be Primarily closed
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Fistula at 4-O clock
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Fistula at 2-O clock
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Multiple tracts – method is the same
Opening at 6-O clock
Opening at 2-O clock
Opening at 2-O clock
passing gas from scrotum
All the three tracts EAL done separately
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Cored after SLOFT
All three external tracts
removed by coring
Healed in 20 days
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Immediate post op picture
This patient had two tracts with one para rectal blind extension.
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Post operative period
• Discharge in a day
• No post discharge dressings
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Post op first morning can sit without pain
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They are happy
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Case -1- 091797-60854 Multiple tracts
• 45 yrs male came with recurrence after two operations in 2 ½ yrs.
• He came with • 1. impending rupture of
perianal abscess at 4-O clock
• 2.External opening at 2-O clock and
• 3. External opening at the base of scrotum from where he was passing flatus
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Internal opening at 2-O clock
• Probe coming out of opening from 2-O clock
• SLOFT done
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SLOFT
• SLOFT at 2-O clock
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Internal opening at 4-O clock
• SLOFT at 4-O clock
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Probe from scrotal opening
• Probe from scrotal opening
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Internal opening 2-O clock
• SLOFT 2-O clock
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Coring
• Coring done after confirmation of the ligation
• Wounds left open to heal
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Healed in 20 days
• Patient did not come for follow up
• He had to be called on request and the wounds were seen to be healed in 20 days
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Post op 3 weeks
• He had to be called for documentation because as such he had no problem
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Case -2 - 097132-50531
• The post op picture• SLOFT hidden in the
anal verge• Pt did not come for
follow up as the wound healed and he had no problem
• Mr Kamlesh Jharia c/o Dr R.P.Gupta 097132-50531
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Case-2-Inter sphincteric fistula-per op
• Per operative photo after SLOFT
• Hydrogen peroxide seen leaking through the peri-anal space
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Case -3- 089323-09290Recurrent fistula
• 50 yrs/M controlled DM, came with recurrence of fistula .
• SLOFT done and distal abscess cavity marsupilised
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Insertion of probe
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Ligation
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SLOFT
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Abscess marsupilised
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Post op 20 days-healing
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Almost healed
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Post op 2 monthssudden perianal abscess
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Seton tied – superficial fistula
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Abscess and rupture
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Seton cut after 15 days under LA
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Case-4- 078285-13112
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Healed in 25 days
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Post op 40 days - recurrence
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Spontaneous rupture of abscess
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Spontaneous healing
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Case-5-093031-62144
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Incision over probe
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Indwelling probe
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Tract hooked
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Ligated and transacted
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Probe in distal tract
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Distal tract excised
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Painless P/R next morning
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Next morning
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Post op 10th day
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Healed
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Post op visit
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Case-6- 098273-71437Acute abscess fistula complex
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• In spite of the acute and fragile tract, SLOFT could be done as the probe was indwelling and ano-rectum could be kept virgin
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Healed within few days with intact anus
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Case-8Internal opening not demonstrable
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Had to core, shorten the tract and gently
negotiate with the probe to come inside the internal opening.
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Follow up on request ( 094251-52818)
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First put in cradle by Dr Radhakrishna Patta
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First workshop at Mujaffarnagar
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ReproducedDr Naveen Agrawal – 097603 36161
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Recurrences ??
• Time only will tell the percentage but• They are bound to occur
Recurrence bothers the patient if
the procedure was either costly or the recovery was painful.
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Seriously looking forward for long term resultsధన్య�వాదాలు�