**2.1 Video-assisted anal fistula treatment (VAAFT)**

Video-assisted anal fistula treatment is a sphincter preserving procedure that was developed by Italian surgeon Piercarlo Meinero in 2011 where he and others have described long and short-term results.

The operation is performed under spinal or general anesthesia using fistuloscope and specially designed equipment developed by Karl Storz (GmbH, Tuttlingen, Germany).

VAAFT procedure has two phases: diagnostic and therapeutic. The aim of the diagnostic phase is to visualize the entire fistula tract as well as the internal opening and to identify any possible secondary tracts and abscess cavities (**Figure 1**). In the therapeutic phase, complete destruction of the main and any secondary fistula tracts are preformed using monopolar electrode introduced to the fistula tract through working canal of the fistuloscope (**Figure 2**). This is followed by removal of necrotic detritus and closure of internal opening [7].

**Figure 1.** *Exploration of anal fistula tract using fistuloscope.*

*Sphincter Preserving Techniques in Anal Fistula Treatment DOI: http://dx.doi.org/10.5772/intechopen.99547*

#### **Figure 2.** *Electrofulguration of anal fistula tract using monopolar electrode.*

The main indication for VAAFT is operative treatment of complex anal fistulas, where there is a high possibility of continence disturbance if the sphincter were to be divided, and complex anal fistulas with multiple tracts [5, 8]. The VAAFT technique is comparable with other sphincter preserving techniques in relation to healing and patient satisfaction [9]. Diminished postoperative pain, earlier recovery after surgery and smaller postoperative perianal wounds allows for earlier return to normal activities. Although simple fistulas were treated with this technique, it is our opinion that VAAFT technique offers no benefit in this setting and should be reserved for complex anal fistulas.

The VAAFT technique allows multiple attempts in case the procedure is not successful in the first instance. The proposed mechanism whereby repeated procedures have an incremental effect is converting a complex fistula with multiple tracts into a more manageable, low, or simple fistula, which can be called conversion of the fistula [10].

To date, the VAAFT has been shown to be safe and associated with good functional outcomes and very low incidence of complications [7, 8, 11], which was shown in a published meta-analysis (Emile et. al). It showed recurrence rate ranging from 7,5 to 33.3% with a weighted mean recurrence rate of 17,7%. Recurrence rates varied significantly depending on the method of internal fistula opening closure (mattress suture, stapler, rectal advancement flap). No affection of anal continence was documented [12].

Compared with other minimally invasive techniques, VAAFT is the only procedure which allows intraoperative visualization of entire fistula tract, possible secondary tracts and the internal fistula opening from within the tract. Limitations of the technique are that it uses rigid instrument to examine curved tracts. Although this is not an issue in most operations due to elasticity of tissue, some fistulas, such as suprasphincteric, may prevent complete examination of the tract due to sharp angle tract makes when it passes above external anal sphincter. This could also lead to creation of false tracts if diathermy is applied unselectively or too much force is used to push fistuloscope when advancing through the tract. When operating on suprasphincteric fistulas, modification of the approach can be used so that the fistuloscope is inserted through internal opening as well as external opening. That way surgeon can explore complete length of the fistula from openings to the curve of suprasphincteric fistula.
