FISTULECTOMY

• Prepared by;
• MR. DOMINIC D.
NICRT
• MS. REJOY D. NICART
NTRODUCTIION
• A FISTULECTOMY is a procedure that fully
removes the fistulous tract. This increases the
likelihood of damage to the sphincters and is
therefore often not preferred. However, this
may be necessary if there is a large amount of
tissue that is blocking normal function, or if
there is a high likelihood of recurrence.
• An anal fistula is an abnormal connection
between the epithelialised surface of the
anal canal and (usually) the perianal skin.
Anal fistulae originate from the anal glands,
which are located between the two layers
of the anal sphincters and which drain into
the anal canal. If the outlet of these glands
becomes blocked, an abscess can form
which can eventually point to the skin
surface. The tract formed by this process
is the fistula
• Abscesses can recur if the fistula seals over, allowing the accumulation
of pus. It then points to the surface again, and the process repeats. Anal
fistulas do not generally harm and they often do not hurt, but they can be
irritating because of the pus-drain (and, it is not unknown for formed
stools to be passed through the fistula); additionally, recurrent abscesses
may lead to significant short term morbidity from pain, and create nudes
for systemic spread of infection. A fistula is a tiny channel or tract that
develops in the presence of inflammation and infection. It may or may
not be associated with an abscess, but like abscesses, certain illnesses
such as Crohn’s disease can cause fistulas to develop.
• The channel usually runs from the rectum to an opening in the
skin around the anus. However, sometimes the fistula opening
develops elsewhere. For example, in women with Crohn’s
disease or obstetric injuries, the fistula could open into the
vagina or bladder. Since fistulas are infected channels, there is
usually some drainage. Often a draining fistula is not painful,
but it can irritate the skin around it. An abscess and fistula
often occur together. If the opening of the fistula seals over
before the fistula is cured, an abscess may develop behind it.
• An anal fistula is almost always the result of a previous abscess.
Just inside the anus are small glands. When these glands get clogged,
they may become infected and an abscess can develop. A fistula is a
small tunnel that forms under the skin and connects a previously infected
anal gland to the skin on the buttocks outside the anus. After an abscess
has been drained; a tunnel may persist connecting the anal gland from
which the abscess arose to the skin. If this occurs, persistent drainage
from the outside opening may indicate the persistence of this tunnel. If
the outside opening of the tunnel heals, recurrent abscess may develop.
Symptoms related to the fistula include irritation of skin around the
anus, drainage of pus (which often relieves the pain), fever, and feeling
poorly in general.
• Surgery is necessary to cure an anal fistula.
Although fistula surgery is usually relatively
straightforward, the potential for complication exists,
and is preferably performed by a specialist in colon and
rectal surgery. It may be performed at the same time as
the abscess surgery, although fistulas often develop four
to six weeks after an abscess is drained, sometimes even
months or years later.
• Fistula surgery usually involves opening up the fistula
tunnel. Often this will require cutting a small portion of the
anal sphincter, the muscle that helps to control bowel
movements. Joining the external and internal openings of the
tunnel and con-verging it to a groove will then allow it to heal
from the inside out. Most of the time, fistula surgery can be
performed on an outpatient basis. Treatment of a deep or
extensive fistula may require a short hospital stay. Discomfort
after fistula surgery can be mild to moderate for the first week
and can be controlled with pain pills.
• The amount of time lost from work or school is
usually minimal. Treatment of an abscess or fistula is
followed by a period of time at home, when soaking the
affected area in warm water (sitz bath) is recommended
three or four times a day. Stool softeners or a bulk fiber
laxative may also be recommended. It may be necessary
to wear a gauze pad or mini-pad to prevent the drainage
from soiling clothes. Bowel movements will not affect
healing.
TH
E
DI
SY G
ST ES
EM TIV
E
 DIGESTIVE FUNCTIONS
 Ingestion occurs when foods enter the digestive tract
through mouth.
 Mechanical processing is the physical manipulation of solid
foods, first by the tongue and the teeth and then by swirling
and mixing motions of the digestive tract.
 Digestion refers to the chemical breakdown of food into
small organic fragments that can be absorbed by the
digestive epithelium.
 Secretion aids digestion through the release of water, acids,
enzymes and buffers by the digestive tract and accessory
organs.
 Absorption is the movement of small organic
molecules, electrolytes, vitamins, and water
across the digestive tract.
 Excretion is the elimination of waste products
from the body. Within the digestive tract,
these waste products are compacted and
discharge through the process of defecation
Histological Features
 Four Major Layers of Digestive
Tract
1. Mucosa
 Inner lining.
 An example of a mucous membrane.
 Consist of an epithelial surface moistened by glandular
layer of loose connective tissue, the lamina propria.
 Increase the surface area available for absorption
 Permit expansion after a large meal.
 Forms fingerlike projections, called villi.
 Outer portion of the mucosa contains a
narrow band of smooth muscle and elastic
fibers
 Muscularis mucosae, move the mucosal
folds and villi.
2. Submucosa
 Second layer of loose connective tissue that
surrounds the muscularis mucosae.
 Contains large blood vessels and lymphatics
as well as network of nerve fibers, sensory
neurons and parasympathetic motor neurons.
 This neural tissue submucosal plexus helps
control and coordinate the contractions of
smooth muscle layer and also helps regulate
the secretion of the digestive glands.
3. Muscularis externa
 Collection of smooth muscle cells arranged in an
inner circular layer and an outer longitudinal layer.
 Contractions of these layers in various
combinations agitate or propel materials along the
digestive tract.
 These are autonomic reflex movements controlled
primarily by a network of nerve, the myenteric
plexus, sandwiched between the inner and outer
smooth muscle layers.
 Parasympathetic stimulation increases
muscular tone and activity, and sympathetic
stimulation promotes muscular inhibition and
relaxation.
4. Serosa
 A serous membrane
 Covers the muscularis externa along most portions of the
digestive tract inside the peritoneal cavity
 The parietal and visceral peritoneum that lines the inner
surfaces of the body wall.
 The parietal and visceral peritoneum are connected by double
sheets of serous membrane called mesenteries, loose
connective tissue sandwiched between epithelia provides an
access route for the passage of blood vessels, nerves and
lymphatics servicing the digestive tract.
The Movement of Digestive Materials
 Peristalsis and Segmentation
Peristalsis
 Waves of muscular contractions that move along the
length of the digestive tract.
 During a peristaltic movement, the circular muscles first
contract behind the digestive contents. Then longitudinal
muscles contract, shortening adjacent segments. A wave
of contraction in the circular muscles then forces the
materials in the desired direction.
Segmentation
 Movements that churn and fragment
digestive materials.
 This action results in a thorough mixing of
the contents with intestinal secretions.
Because they do not follow a set pattern,
segmentation movements do not propel
materials in a particular direction.
 The Stomach
 Located within the left upper quadrant of the
abdominopelvic cavity.
 Receives food from the esophagus.
 The stomach has four primary functions the
temporary storage of ingested food, the mechanical
breakdown or resistant materials, the beginning of
digestion by breaking chemical bonds through the
action of enzymes and acids, and the production of
intrinsic factor, a compound necessary for
absorption of vitamin B12.
 The agitation of ingested materials with gastric
juices secreted by the glands of the stomach
produces a viscous, soupy mixture called chyme.
 The principal anatomical landmark of the stomach is
a muscular organ with the shape of an expanded J.
 The esophagus connects to the stomach at the
cardia.
 The bulge of the stomach superior to the cardia is
the fundus of the stomach.
 The large area between the fundus and the curve of
the J is the gastric body.
 Pylorus the curve of the J connects the stomach with the
small intestine.
 A muscular pyloric sphincter regulates the flow of the
chyme between the stomach and the small intestine.
 The stomach resembles a muscular tube with narrow and
constricted lumen. When full, it can expand to contain 1-1.5
liters.
 This degree of expansion is possible because the stomach
wall contains a number of prominent ridges and folds called
rugae.
 The visceral peritoneum covering the outer surface
of the stomach is continuous with a pair of
mesenteries. The greater omentum extends below
that hangovers and protects abdominal viscera. The
much smaller lesser omentum extends from the
lesser curvature to the liver.
 Stomach is lined by an epithelium dominated by
mucous cells. These secreted mucus produced helps
protect the lining from the acids, enzymes, and
abrasive materials it contains.
 Gastric pits shallow depressions and open onto
the gastric surface. Each gastric pit
communicates with the gastric glands that
extends deep into the underlying lamina
propria. These glands are dominated by two
types of secretory cells: parietal cells and
chief cells. Together these cells secrete
about 1500 ml of gastric juice each day.
 Chief cells secrete pepsinogen, an inactive
form of the enzyme pepsin.
 Regulation of Gastric Activity
1. The cephalic phase the sight, smell, taste or thought of food
initiates at the cephalic phase of gastric secretion directed
by the CNS, prepares the stomach to received food. Under
the control of vagus nerve, parasympathetic fibers innervate
parietal cells, chief cells, and mucous cells of the stomach.
2. The gastric phase begins with the arrival of food in the
stomach. Stimulation of stretch receptors in the stomach
wall and chemoreceptors in the mucosa triggers the release of
a hormone, gastrin, into the circulatory system.
3. The intestinal phase begins when chyme starts to enter
the small intestine. The purpose of this phase is to control
rate of gastric emptying and ensure that the secretory,
digestive, and absorptive functions of the small intestine
can proceed efficiently.
 Digestion in the stomach
 The stomach performs preliminary digestion of proteins
by pepsin and, for a variable period, permits the digestion
of carbohydrates by salivary amylase.
 This enzyme remains active until pH throughout the
material in the stomach falls below 4.5, usually within 1-2
hours after a meal. As the stomach contents become
more fluid and the pH approaches 2.0, pepsin activity
increases and protein disassembly begins.
 Protein digestion is not completed in the
stomach, but there is usually enough time
for pepsin to breakdown complex proteins
into smaller peptide and polypeptide chains
before the chyme enters the small intestine.
 The Small Intestine
 About 6 meters (20 ft) long and has a diameter ranging
from 4 cm at the stomach to about 2.5 cm at the junction
with the large intestine. It has three subdivisions: the
duodenum, the jejunum, and the ileum.
 The duodenum is the 25 cm (1 ft) closest to the stomach.
This portion receives chyme from the stomach and exocrine
secretions from the pancreas and liver.
 The jejunum, which is supported by a sheet of mesentery, is
about 2.5 meters (8 ft) in length. The bulk of chemical
digestion and nutrient absorption occurs in the jejunum.
 The jejunum leads us to the third segment, the
ileum. The ileum ends at the sphincter, the ileocecal
valve, which controls the flow of chyme from the
ileum into the cecum of the large intestine.
 Plicae intestinal lining bears a series of transverse
folds.
 Villi lining of the intestine is also thrown into series
of fingerlike projections.
 Small intestine were a simple tube with smooth
walls, it have a total absorptive area around 3300
square centimeters, or roughly 3.6 square feet.
 Lacteal refers to the pale, cloudy appearance of the
lymph in these channels.
 Intestinal Movements
 Two examples are the gastroenteric reflex and the
gastroileal reflex.
 Gastroenteric reflex initiated by distention, which
immediately accelerates glandular secretion and peristaltic
activity in all segments.
 Gastroileal reflex is a response to circulating levels of
hormone gastrin.
 Intestinal juice moistens the intestinal contents, assists in
buffering acids, and dissolves both digestive enzymes
provided by the pancreas and the products of digestion.
 Intestinal hormones
 Secretin is released when the pH falls in the duodenum, occurs
when acid chyme arrives from the stomach. The effect is to
increase the secretion of water and buffers by the pancreas and
liver
 Cholecystokenin is secreted when chyme arrive in the duodenum,
especially when it contains lipids and partially digested proteins,
targets the pancreas and liver, accelerates the production and
secretion of all types of digestive enzymes.
 Gastric inhibitory peptide is released when fats and glucose
enter the small intestine. This peptide hormone inhibits gastric
activity and causes the release of insulin from pancreatic islets.
 The Large Intestine
 The horseshoe-shaped large intestine begins
at the end of the ileum and ends at the anus.
 Lies below the stomach and liver.
 The principal functions of large intestine
include reabsorption of water and compaction
of feces, the absorption of important vitamins
liberated by bilateral action, and the storing
of fecal material prior to defecation.
 The large intestine often called the large
bowel.
 It has an average length of approximately 1.5 meters (5 ft)
and a width of 7.5 cm (3 in).
 It is divided into three major regions: the pouch like cecum,
the first portion of the large intestine; the colon, the
largest portion of the large intestine; and the rectum the
last 15 cm (6 in) of the large intestine and the end of the
digestive tract.
 Large intestine absorbs a variety of other substances from
the chyme Vitamins (2) bilirubin products bile salts toxins
 Movement from the transverse colon through the rest of
the large intestine results from the powerful peristaltic
contractions, called mass movement.
 The Cecum
 Material arriving from the ileum first enters an
expanded chamber called cecum.
 Ileocecal valve a muscular sphincter guards the
connection between the ileum and the cecum.
 It usually has the shape of a rounded sac and the
slender veniform appendix attaches to the cecum
along its posteromedial surface.
 Appendix is almost 9 cm( 3.5 in)
 The Colon
 The most striking external feature of the colon is the
pouches, or hustrae, that permit considerable distension
and elongation.
 Longitudinal bands of muscle, the Taenia coli, are visible on
the outer surface of colon just beneath the serosa.
 The ascending colon begins at the ileocecal valve. It
ascends along the right side of the peritoneal cavity until it
reaches the inferior margin of the liver.
 Transverse colon, colon turns horizontally, continues
toward the left side, passing below the stomach and
following the curve of the body wall.
 Descending colon turns inferiorly.
 The descending colon continues along the left
side until it curves and recurves as the sigmoid
colon.
 The Rectum

 Forms the end of the digestive tract.

 Anorectal canal last portion of the rectum contains small
longitudinal folds joined by the transverse folds that mark
the boundary between columnar epithelium of the rectum
and a stratified squamous epithelium similar to that found in
the oral cavity.
 Anus the opening of the anorectal canal, the epidermis
becomes keratinized and identical to that on the surface of
the skin.
 The circular muscle layer of the muscularis externa
in this region forms the internal anal sphincter.
 The external anal sphincter guards the exit of the
anorectal canal. Consist of muscle fibers, is under
voluntary control.
SURGICAL PREPARATION
 PRE OP
• surgeon will explain how to prepare for your operation must do, what are the procedures
and what are the complications.
• The nurse must insure all the consent form is singed
• All laboratory result must be available
• nurse may check your heart rate and blood pressure, and test your urine.
• Your nurse will prepare you for theatre. You may need to have a bowel washout (an enema).
You may also be asked to wear compression stockings to help prevent blood clots forming in
the veins in your legs. You may need to have an injection of an anti-clotting medicine called
heparin as well as, or instead of, stockings.
• Nures must set all the materials and equipment needed during operetion
 INTRA-OPO
• Maintain the presence of mind
• Maintain the sterility of all materials
• The operation usually takes 30 minutes. The exact procedure will depend on the type of
fistula you have. Your surgeon will examine the fistula and decide the best way to treat it.
• If the fistula is superficial, it can be "laid open". This is when the fistula is opened up so that
it can heal from inside out. Sometimes it's necessary to leave a thread of, for example, suture
material in the fistula tract. This is called a seton and may need to remain in place for some
time. A dressing is usually worn over the fistula until it has fully healed.
 POST-0P
• Insure all the instrument are complete
• Take vital signs
• Do the health teaching
• You will need to rest until the effects of the anaesthetic have passed. You may
need pain relief to help with any discomfort as the anaesthetic wears off.

• You can begin to drink and eat, starting with clear fluids, when you feel ready.

• On the morning after your operation, you will need to take a bath and soak off
the dressing from your wound. It's normal to have some bleeding. Afterwards,
your nurse will apply a new dressing.
• You will need to have the wound re-dressed daily until it heals. Your
nurse may arrange for a district nurse from your GP surgery to visit you
at home. You will be given a letter to give to the district nurse. You will
also be given a date for a follow-up appointment with your surgeon.

• You may be prescribed a course of antibiotics and laxatives. If you are

prescribed antibiotics it's important you finish the course.

• You will need to arrange for someone to drive you home.

 Equipment
• Equipment required for anal fistulotomy may include the
following:
• Local anesthetic

• Fistula probes
• Methylene blue, hydrogen peroxide
• Seton (Silastic vessel loop, suture)
• Additional equipment, depending on the specific approach
employed (fibrin glue or plug, bioprosthetic plug)
• series of fine scalpel blades on the no. 7 handle,
especially the curved no. 12 bistoury blade
• Chassar Moir 30° angled-on-flat and 90° curved-onflat scissors
• cleft palate forceps
• Judd-Allis, Stiles, and Duval tissue forceps
• Millin’s retractor for use in transvesical procedures,and Currie’s retractors for vaginal repairs
• Skin hooks to put the tissues on tension during dissection
• Turner-Warwick double curved needle holder, particularly useful in areas ofawkward access,
has the advantage of allowing needle placement without
the operator’s hand or the instrument obstructing
the view.
 LABORATORY TEST BEFORE THE SURGERY
• EUA: A full examination/inspection of the perineum followed by DRE &
Proctosigmoidoscopy.
•  DRE examination - area of induration, fibrous tract and internal opening may be felt.
•  Proctosigmoidoscopic inspection - to evaluate the rectal mucosa for any underlying
disease process.
 FISTULOGRAM
• is an x-ray procedure used to view a fistula, an abnormal passage between two or more
anatomic spaces or organs or a pathway that leads from an internal cavity or organ to the
surface of the body.
• performed early in the course of the disease will help to determine (1) the site of the fistula,
(2) intestinal continuity with the fistula, (3) the presence or absence of distal intestinal
obstruction, (4) the nature of the intestine immediately adjacent to the fistula, and possibly
(5) the presence or absence of an intraabdominal abscess
 ENDOANAL ULTRASOUND
• is a test that allows the doctor to evaluate in depth, using ultrasonography, the different
constituents of the wall of the anal canal and the latter part of the rectum, as well as the
surrounding area.
 MRI
• Magnetic resonance imaging (MRI) uses a large magnet and radio waves to look at organs
and structures inside your body. Health care professionals use MRI scans to diagnose a
variety of conditions, from torn ligaments to tumors.
 RETROGRADE PYELOGRAPHY

• Retrograde pyelography is a more reliable way of identifying

• the exact site of a uretero-vaginal fistula, and may be undertaken simultaneously with either
retrograde or percutaneous
• catheterization for therapeutic stenting of the ureter
 CYSTOGRAPHY
• Cystography is not particularly helpful in the basic diagnosis
• of vesico-vaginal fistulas, and a dye test carried out under
• direct vision is likely to be more sensitive. It may, however,
• occasionally be useful in achieving a diagnosis in complex
• fistulas or vesico-uterine fistulas.
 POSIIBLE COMPLICATIONS
• This is when problems occur during or after the operation.
Most people are not affected. The possible complications of
any operation include an unexpected reaction to the
anaesthetic, excessive bleeding or developing a blood clot,
usually in a vein in the leg (deep vein thrombosis, DVT).
• Specific complications of anal fistula operation are uncommon, but can include:

• infection - this can result in an anal abscess and further surgery may be necessary
• damage to the sphincter muscles - this may affect your bowel control and can lead to faecal
incontinence
• urgency and reduced ability to hold - you may find that you need to get to the toilet more
quickly to open your bowels than you did before
• re-occurrence - there is a chance that the fistula may come back
• The exact risks are specific to you and differ for every person, so we have not included
statistics here. Ask your surgeon to explain how these risks apply to you.
 DISCHARGE PLAN
• MEDICATION
• Instruct the pt. and the s.o to take all the medicines on time as prescribed by the doctor
EXERCISE
Avoid heavy lifting, straining and strenuous exercise for two weeks at a minimum (i.e.,
weightlifting, jogging, swimming, etc.)
 HEALTH TEACHING

• Maintain a liquid diet for two days after the procedure (i.e., soup, Jell-O, etc.)
• Eat a high fiber diet after two days
• Use the bathroom once a day. A warm bath may help your symptoms.
• Take over-the-counter pain medicine as needed
• Shower standing up and bathe the area with water to soothe and keep it clean.
• Do not sit in the bathtub
• Do not use topical steroids or topical agents such as
Preparation H
• Expect some drainage for two to four weeks after the procedure
as the Surgisis AFP plug is incorporated and the fistula tract is
closed.
• Using stool softeners and adhering to good hygiene, such as
sitz baths after every bowel movement, decreases discomfort
and helps for recovery.
 DIET
• A high-fiber diet causes a large, soft, bulky stool that passes through the bowel easily and
quickly. Because of this action, some digestive tract disorders may be avoided, halted, or
even reversed simply by following a high-fiber diet. A softer, larger stool helps prevent
constipation and straining. This can help avoid or relieve hemorrhoids. More bulk means
less pressure in the colon, which is important in the treatment of irritable bowel syndrome
and diverticulosis (defects in the weakened walls of the colon). In addition, fiber appears to
be important in treating diabetes, elevated cholesterol, colon polyps, and cancer of the colon.
 FOOLOW-UP CHECK UP
• Instruct the so and the patient to visit the doctor on their follow-up check up
• Report the nearest hospital if there is signs and symptoms of infection or visit the doctor
even if the follow up check up is not yet in time.