1. Advancement flaps for fistula in ano SR Brown Sheffield teaching hospitals

3. Perfect operation Easy to perform No risk of incontinence Effective

4. History First proposed 1902 (Noble) for rectovaginal fistulae Anal fistulae 1912 (Elting)

5. Objectives Indications Types and Techniques Results

6. Indications High trans-sphincteric/supra-sphincteric fistulae Anterior fistulae in women Rectovaginal fistulae (Crohn’s)

7. Contraindications Acute presentation Large opening Rectal disease –Neoplasia –Crohn’s –Radiation

8. Types of advancement flap Endorectal –Full thickness –Partial thickness –mucosal Anocutaneous –V-Y,Y-V –Rhomboid, House

9. Method Bowel preparation Antibiotics Position

10. Essential steps Excision of internal opening Excision primary tract Formation flap Attention to external component

11. Excision fistula tract Sharp dissection core out/curettage Excise secondary tracts Continue to internal sphincter/complete tract

13. Mobilisation rectal flap Adrenaline (1:300,000) Partial/full thickness internal sphincter flap (based proximally) Divergent lateral incisions Meticulous haemostasis Excise internal opening +/- closure internal tract

16. Suturing flap Suture with absorbable Vicryl 2/0 Tension free Leave external opening to drain/Malecot catheter/glue No indication for bowel confinement/stoma

18. Principles for success Stagger the mucosal and muscular suture line Width of base of flap > twice the apex No sepsis

19. Results Difficulties Due to –Population Inflammatory/Non inflammatory High/low fistulae Recurrent –Surgeon –Follow up –Thoroughness of reporting

20. Results Endorectal Technique StudyYearNo. pts.Recurrence (%) Incontinence (%) Oh19831513- Aguilar1985151210 Athanasiadas19941692021 Schouten1999442535 Ortiz20009178 Mizrahi200266339 Sonoda20025525- Dixon20042917-

21. Reasons for Incontinence Direct damage to sphincter Stretching Scarring Decreased sensation

22. The anocutaneous flap

28. Results Anocutaneous technique StudyYearNo PatientsRecurrence (%) Incontinence (%) Del Pino19961127- Nelson2000732316 Zimmerman2001265430 Amin20031817- Sungertekin20046590

29. Factors that influence healing Redo procedures Crohn’s Rectovaginal fistulas Smoking

30. Summary Advancement flaps useful part of armamentarium for fistulas Techniques equally effective Consent for recurrences/incontinence particularly certain groups

31. Rectovaginal fistulae causes Inflammatory –Crohn’s –Neoplastic –Post-radiotherapy Non inflammatory –obstetric

32. Rectovaginal fistulae types

33. Types of repair Transanal advancement flap Lay open and primary repair (perineoproctotomy) Transperineal repair (+/- transposition) Transvaginal repair