Abstract
F
istula in ano is a track lined by granulation tissue which connects perianal skin superficially to anal canal, ano rectum or rectum deeply. It is usually occurs in a pre-existing anorectal abscess which either bursts spontaneously or inappropriately drained. Other rare causes include inflammatory bowel disease, tuberculosis, carcinoma and trauma1. Perianal fistulous disease has significant implications for patient's quality of life as sequelae range from minor pain and social hygienic embarrassment to frank sepsis. The management of the anal fistula remains one of the most challenging and controversial topic in anorectal surgery2. Surgery remains the mainstay of therapy with ultimate aim of draining the abscess, eradicating the fistulous tract and avoiding recurrence with preserving anal sphincter function3. Treatment depends on where the fistula lays, which parts of the anal sphincter it crosses, etiology, duration of the fistula as well as previously performed procedures3,4. Most anal fistulae are simple and can be treated using a fistulotomy which has good results, low recurrence rate and an acceptable rate of morbidity5. Treatment of a complex anal fistula, however, which is defined as these fistulae which open into the anal canal at or above the internal ring and whose treatment poses an increased risk for a change in continence still represent a challenge. Complex are anatomically higher, involve significant portions of the sphincter musculature, may have multiple tracts, involve other organs
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