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

Video-assisted anal fistula treatment (VAAFT) procedure is the only technique that enables visualization and operation of anal fistula from within fistula tract, using specially designed equipment. This sphincter preserving technique was developed by Meinero who described short and long-term results [22].

Using a special instrument (fistuloscope), the surgeon visualizes the fistula tract from inside, which helps to identify possible secondary branches of the fistula tract,

**Figure 5.** *Intraoperative view of the fistula tract through fistuloscope.*

**Figure 6.** *Fulguration of the fistulous tract.*

**Figure 7.** *View of the debris after fulguration.*

abscess cavities and later destroys all chronic granulation tissue in the fistula tract making in that way an acute wound which should heal by secondary intention. The important part of this technique is also to identify the internal fistula opening inside the anal canal and to close it securely (**Figures 5**–**9**).

Many surgeons worldwide accepted this technique in their everyday practice for the treatment of complex anal fistulas [22, 38, 44–46].

The main indication for this technique is the treatment of complex anal fistulas, especially cases with multiple secondary branches which are deep in

## **Figure 8.**

*Postoperative view after VAAFT for complex horseshoe fistula.*

**Figure 9.** *Healed wounds in the same patient.*

## *Anal Fistula: Contemporary View of Complex Problem DOI: http://dx.doi.org/10.5772/intechopen.102752*

the ischioanal fossa and are not easily reached. Also, VAAFT has its benefits in treatment of patients who have anal fistula associated with Crohn's disease, helping to ameliorate symptoms associated with chronic anal fistula such as pain and soiling, thus significantly increasing patient's quality of life [44, 47]. VAAFT technique is comparable with other sphincter preserving techniques to healing and patient satisfaction. Diminished postoperative pain, earlier recovery after surgery and smaller postoperative perianal wounds allows for earlier return to normal activities [48].

In case of failure, this technique can be repeated because there is no risk for any continence disturbance following this procedure. The proposed mechanism whereby repeated procedures have an incremental effect is the conversion of complex fistula with multiple tracts into a more manageable, low or simple fistula, which can be called conversion of the fistula [38].

VAAFT technique has been proven to be a safe procedure, associated with good functional outcomes and a very low incidence of complications [22, 44, 45], which was shown in a published meta-analysis [46]. It showed a 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.

#### **4.3 Rectal advancement flap (RAF)**

This technique is one of the oldest techniques which were and still are reserved for the treatment of complex anal fistulas especially in cases with large internal fistula opening. When discussing this technique, we can't talk about the "pure" sphincter preserving technique because flap should be performed by dissection of anorectal mucosa and adjacent internal anal sphincter muscle, so in that way, internal anal sphincter muscle does not stay intact.

When doing this procedure surgeon should identify and excise the internal fistula opening in the anal canal. Then the U-shaped or rhomboid flap with a wider base side should be performed by dissecting anorectal mucosa and adjacent internal anal sphincter muscle. Curettement and irrigation of the whole fistula tract should be performed, followed by suture of a defect in sphincter complex left by earlier fistula tract. The site is then a covered by previously prepared flap and sutured. Even though much research has been made about optimal flap thickness, researchers found that there was a statistically higher rate of primary healing in cases with thicker flaps, but also have noticed a higher rate of mild postoperative continence disturbance which was more severe than the thicker flap was (**Figure 10**) [41, 49, 50].

There have been many publications and several systematic reviews and metaanalyses on this technique where the effectiveness was shown to be 60–80%, but the same cases also reported some degree of postoperative fecal disturbance [42, 50, 51].

Factors that could affect healing after flap procedure are obesity and smoking, so patients should be advised to quit smoking and to try to reduce their weight prior to flap operation [52–54]. To increase the effectiveness of this technique one should perform bigger rhomboid or U-shape flaps using the minimally invasive approach, avoiding tissue trauma made by surgical cautery, avoiding excessive grasping as well as the too big strain of suture line.

**Figure 10.** *Formed rectal advancement flap.*
