**2.2 Ligation of intersphincteric fistula tract (LIFT)**

LIFT is a sphincter sparing technique introduced by dr. Arun Rojanasakul in 2007. It is based on the concept of secure closure of the internal opening and concomitant removal of infected cryptoglandular tissue in the intersphincteric plane.

The procedure is performed by identifying fistula tract and internal opening using jet irrigation through external opening or by using metal probe. Next step is making a curvilinear incision on the anocutaneous border and identifying Intersphincteric plane with fistula tract. Intersphincteric portion of fistula tract is then ligated on the side of the internal anal sphincter and cut (**Figure 3**). Rest of the tract is excised along with affected cryptoglandular tissue followed by curettage of the rest of tract through external opening. The defect in the external anal sphincter is sutured and the incision closed [13].

Two available meta-analyses showed that overall rate of success was 76.4 and 78% respectively. The weighted mean complication rate was 5,5–13.9%. The most common complication was wound dehiscence, others being infection, bleeding, anal discharge, anal fissure, and hematoma. Fecal incontinence was recorded in 1.4% of patients, but only of minor grade [14, 15].

LIFT has an advantage over other methods in that it is easily reproducible without investment in potentially costly equipment. Due to specific surgical technique and access in the intersphincteric plane, it is logical to conclude that its role lies mostly in treatment of transsphincteric anal fistula. In case of procedure failure or persistence of fistula, repeated LIFT on the same place might be a problem because of the tissue scaring. Therefore in such cases it would be best to consider some other sphincter preserving technique like VAAFT that has the added value of visualizing branching tracts that might have been the cause of failure in the first place.

While it is always best for transsphincteric fistula to heal primarily, an important observation when dealing with wound dehiscence after LIFT on the anocutaneous border is that loose seton can be inserted through the wound, which converts

**Figure 3.** *Anal fistula tract dissected and ligated in the intersphincteric plane.*

transsphincteric into simple intersphincteric fistula that can be dealt with later by lay open technique without fear of continence disturbances.
