**4. Sphincter preserving techniques: new solutions to prevent postoperative fecal incontinence**

As mentioned earlier, the high risk of postoperative continence disturbance after treatment of complex anal fistulas with traditional techniques, have led to the need for the development of new techniques, which would be dubbed "sphincter preserving techniques." The main characteristic of such techniques is that they prevent or greatly reduce any possibility of postoperative fecal incontinence. Various sphincter preserving techniques were introduced in clinical practice in the last 10–15 years. Among these are laser treatment procedure (FiLaC®: fistula laser closure), fibrin glue treatment, anal fistula plug, VAAFT procedure (video-assisted anal fistula treatment), LIFT procedure (ligation of intersphincteric fistula tract), anal fistula treatment with platelet cells (PRP: platelet rich plasma), RAF (rectal advancement flap) and others [22, 33, 35–42].

Some sphincter preserving techniques weren't broadly accepted given high cost, high recurrence rates or inability to reproduce similar results in other centers. Of above-mentioned sphincter preserving techniques, several gained wider acceptance, such as LIFT, VAAFT, and RAF technique.

## **4.1 Ligation of intersphincteric fistula tract (LIFT)**

Ligation of intersphincteric fistula tract (LIFT) is a sphincter preserving technique first performed and published by Rojanasakul [39]. This technique satisfies all goals

of anal fistula treatment such as the closure of internal fistula opening, removal of infected intersphincteric fistula tract (anal gland) and eradication of remaining fistula tract. It is reserved for the treatment of complex transsphincteric anal fistulas. After identification of fistula tract using metal, probe surgeon makes a curvilinear incision on the anocutaneous border entering intersphincteric space and performs preparation of intersphincteric part of anal fistula, followed by removal of the intersphincteric portion of the fistula. Closure of remaining defect of anal fistula on internal and external anal sphincter muscle then follows. Curettement of remaining fistula tract from external fistula opening to external anal sphincter muscle should be performed. Intersphincteric space is then reconstructed and the perianal wound sutured.

According to the two available meta-analyses, this procedure gives an overall success rate of 76.4 and 78 % respectively, with a low complication rate 5.5–13.9%. The most common complication was wound dehiscence, and others were bleeding, infection, hematoma, anal discharge. Only a low grade of postoperative fecal incontinence in 1.4% of patents was recorded (**Figure 4**) [33, 43].

This technique is easily reproducible without the necessity of investment in potentially expensive equipment. In case of dehiscence of intersphincteric space loose seton can be inserted through the intersphincteric wound, thus making conversion of transsphincteric fistula in intersphincteric one, which can be afterward treated by fistulotomy without fear of continence disturbance.

#### **Figure 4.**

*LIFT procedure: identification of fistula tract in the intersphincteric plane; red arrow showing fistula tract.*
