V42 - Modified LIFT Procedure for the Treatment of Transsphincteric Anal Fistula

CME Eligible

Purpose/Background: The patient was a 24-year-old female

Main Complaint: Chronic perianal swelling, pain, and purulent sanguinous discharge for over three years.

Anal examination (knee-chest position): a fistulous opening was observed approximately 3 cm from the anal verge at the 7 o'clock position; an indurated tract was palpable.

MRI revealed a transsphincteric anal fistula in the inactive (quiescent) phase.

Other laboratory tests: no abnormality.

Methods/Interventions: The Ligation of the Intersphincteric Fistula Tract (LIFT) is a sphincter-preserving procedure for transsphincteric fistulas. The classic LIFT employs an incision within the intersphincteric groove, in contrast to the modified approach, which relocates the incision 1.5-2 cm from this landmark.

Preparation: Clean enema

Anesthesia: Spinal anesthesia

Position: Lateral position

Technique:

1. Identification of the Internal Opening and Fistula Tract.

2. A "U"-shaped flap, approximately 1.5-2 cm in length and 2 cm in width, is created at the site corresponding to the internal opening. The flap begins at the intersphincteric groove and is elevated along the subcutaneous portion of the external sphincter.

3. The intersphincteric space is dissected to separate the internal and external sphincters. The fistula tract is then isolated and skeletonized.

4. The intersphincteric tract is clamped as close as possible to the internal opening side and ligated with a 3-0 absorbable suture. The same procedure is repeated to close the external side of the intersphincteric tract.

5. The flap is secured in its original position using 3-0 absorbable sutures. During suturing, a portion of the underlying muscle may be incorporated to ensure firm fixation.

6. The external opening and any extrasphincteric portion of the fistula tract are excised in a tunnel-like manner, and the resulting wound is left open for drainage.

Results/Outcomes: The operation was completed. The postoperative management is as follows:

1. Patient can eat and drink normally 6 hours after surgery.

2. A patient-controlled analgesia (PCA) pump is used to ensure the pain remains at a tolerable level.

3. Antibiotic therapy is to be continued for 3 days.

4. Sitz bath and dressing change once a day.

5. Maintain soft stools and keep the perianal area clean.

The patient was discharged on the third postoperative day and recovered well. At the three-week follow-up, the wound healed well with no discomfort.

Conclusion/Discussion: This video presents a modified LIFT technique designed to address a major limitation of the classic procedure: the risk of infection associated with its internal incision. By creating the surgical incision externally, 1.5-2 cm from the intersphincteric groove, the modified approach reduces the potential for postoperative hematoma, fluid collection, and fecal contamination. This reduction in complications is anticipated to enhance the healing rate and lower the risk of recurrence.