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Operative management of anorectal fistulas

Bradley J Champagne, MD, FACS, FASCRS
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD


An anorectal fistula is an inflammatory tract or connection between the epithelialized surface of the anal canal and most frequently, the perianal skin or perineum. It often evolves from a spontaneously draining anorectal abscess. Perianal fistulous disease has significant implications for patient quality of life as sequelae range from minor pain and social hygienic embarrassment to frank sepsis. The management of the anorectal fistula (also called fistula-in-ano) remains one of the most challenging and controversial topics in colorectal surgery. Surgery is the mainstay of therapy with the ultimate goal of draining local infection, eradicating the fistulous tract, and avoiding recurrence while preserving native sphincter function [1,2]. The surgical approach depends on several factors, such as the etiology, location, type, and duration of the fistula as well as previously performed procedures and preoperative sphincter function.

This topic will discuss surgical management of anorectal fistulas. The causes, clinical manifestations, diagnosis, and classification of anal fistulas can be found elsewhere. (See "Anorectal fistula: Clinical manifestations, diagnosis, and management principles" and "Perianal complications of Crohn disease".)


Most internal openings of the fistula are located around the anal glands surrounding the dentate line [3,4] since over 90 percent result from a cryptoglandular abscess originating from the crypts of Morgagni, which are located between the two layers of the anal sphincter (figure 1). Fistulas that occur between the anal orifice and the dentate line are referred to as anal in origin, while fistulas that originate above the dentate line are rectal in origin. Less commonly, fistulas occur between the anal canal or rectum and the vagina or bladder. (See "Urogenital tract fistulas in women".)

The course of an anorectal fistula follows one of four paths: intersphincteric (45 percent), transsphincteric (30 percent), suprasphincteric (20 percent), or extrasphincteric (5 percent), before exiting at the perianal skin (figure 2 and figure 3) [5].


A thorough knowledge of the anatomy of the anal canal, ischiorectal fossa, perirectal tissues, and the sphincteric muscles is imperative before proceeding with any operative procedure to treat an anorectal fistula (figure 4 and figure 5). The following is the anatomical description of the anal region [6-8].

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Literature review current through: Oct 2017. | This topic last updated: Jun 27, 2017.
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