**7.1 Benefits and disadvantages**

Major guidelines recommend that immediate fistulotomy should be undertaken only by experienced surgeons, and a more conservative practice of simple abscess drainage in most circumstances is safest. Fistulotomy should only be done in low or simple fistulas [13, 25, 26]. This approach is known to be beneficial for 2 reasons: 1) Simple incision and drainage procedure, especially as an office procedure, allows quick return of function and daily living, thus avoiding prolong wound healing and hospital stay [2, 27]. 2) Less experienced surgeons may be confused with the exact anatomy of the fistula, or may cause iatrogenic injury and incorrect fistulotomy [6].

However, in the author's view, definitive surgery during the acute abscess stage has its advantage. Sharing Eisenhammer's view, the ideal management should be during the acute abscess stage [6]. Treating the fistula during acute abscess stage will reduce the number of chronic fistula formation [19]. A meta-analysis showed that definitive treatment leads to a risk reduction of 83% in recurrent fistula [24]. Furthermore, this is cost effective for health care facilities in general as the burden of treating chronic fistula is greatly reduced by reducing the need for re-operations.

#### **7.2 Challenges**
