Endorectal Mucosal Advancement Flap

Abstract

Indications • Second-stage procedure for anal fistula repair after adequate drainage by seton. Essential Steps 1. Prone jackknife positioning. 2. Prep and drape. 3. Digital rectal exam prior to instrumentation. 4. Expose and identify the fistula tract with a fistula probe. 5. Raise a broad-based, trapezoid-shaped mucosal, submucosal, and circular muscularis flap. 6. Excise the internal opening of fistula in the anal canal or rectum. 7. Debride or excise the fistula tract. 8. Advance the mucosal flap beyond the fistula tract opening. 9. Tension-free suturing of the flap to the distal anal canal. 10. Return patient to supine position. Note These Variations • Positioning prone versus dorsal lithotomy • Surgical prep solution • Local anesthetic block (perianal field block, pudendal nerve regional block) • Fixed versus bivalve speculum for exposure • Tubular/sleeve advancement flap (circumfer-ential flap) for complex fistula disease • Thickness of flap • Drain placement through external opening of fistula • Level of advancement distally • Temporary fecal diversion • Hemostatic packing agent Complications • Recurrence of fistula • Fistula tract abscess • Dehiscence of advancement flap • Fecal incontinence