The LIFTS Technique for Fistula-in-Ano

• If you experience symptoms of anal pain persisting for a number of days, unusually severe pain when straining or having a bowel movement, blood or pus drainage from an abscess in the perianal area, itching around the anus, or any inflammation, pain, swelling, redness, or heat in the skin of the anal area, you should see a doctor for diagnosis and treatment.
• Perianal abscesses, if left untreated and chronic symptoms appear, can develop into fistula-in-ano.
• Fistula-in-ano surgery using the specialized LIFTS technique has up to a 97% success rate (fistula healing rate) even after just one surgical treatment.

A perianal abscess is an infected cavity filled with pus found near the anus or rectum. A fistula-in-ano is a small tunnel or track that connects an infected gland in the anal canal to an opening on the skin around the anus. A perianal abscess, if left untreated until chronic symptoms appear, can develop into a fistula-in-ano. (Image 1)

The anal glands—approximately 6-14 of them—run along the anal canal. When these glands become clogged or infected for any reason, such as frequent bowel movement, constipation, or frequent diarrhea, or due to a blockage from fecal or foreign matter, this can cause a perianal abscess.

If treatment of a perianal abscess is delayed the abscess can break outward through the skin in the anal area (point D in the image) and can result in a chronic fistula-in-ano (points 1, 2, 3, 4 in the image). Even with treatment, however, there is still a 10-50% chance of developing a fistula-in-ano, depending on the physical condition of the individual. The anal anatomy is complex, and so the symptoms of perianal abscesses and fistula-in-ano can be different for each individual patient. It is important, therefore, not to delay, but to receive diagnosis and treatment from a colorectal surgery specialist as quickly as possible for best results.   

1. Anal pain that persists for days
2. Abnormally severe pain when straining or having a bowel movement
3. Blood or pus drainage from an abscess in the perianal and buttocks area, with symptoms coming and going
4. Itching around the anus, or inflammation, pain, swelling, redness, and a hot feeling in the skin of the anal area
5. You may or may not have a fever.

A colorectal surgeon can diagnose perianal abscesses and fistula-in-ano by reviewing the patient’s history in detail and conducting a physical examination of the patient. In a small number of cases, however, such as in patients who have undergone multiple fistula-in-ano surgeries, additional examinations may be required using more specialized tools, such as an endorectal ultrasound or Magnetic Resonance Imaging, for diagnosis and further treatment planning.

While a general surgeon can diagnose and perform the surgical procedure to treat fistula-in-ano, if you want to ensure you receive the most appropriate diagnosis and treatment a doctor who specializes in the colon and rectum should be consulted. Such specialists will have had the most thorough surgical experience in these areas, and will have an in-depth, comprehensive understanding of all possible aspects of fistula-in-ano, allowing them to create an efficient treatment plan.

For treatment of a perianal abscess, the doctor must carefully and correctly cut and drain the abscess so as not to harm the anal sphincter and to avoid fecal incontinence. Surgery should be performed by a specialist colorectal surgeon in order to increase chances of recovery, reduce any risk of fecal incontinence, and minimize the risk of complications from the treatment. 

In the past, traditional surgery involved the doctor making a small cut in the anal sphincter to drain the pus from the cavity. However, this method has potential side effects—patients may experience fecal incontinence after surgery. Currently, however, there is a new treatment known as LIFTS (Ligation of Intersphincteric Fistula Tract Surgery). LIFTS involves newly-developed surgical techniques that reduce damage to the anal sphincter and increase the rate of recovery. Former methods used in traditional surgery provided only a 30-60% chance of recovery and carried a high risk of damage to the anal sphincter muscles. With LIFTS surgery, however, the surgeon will use absorbable sutures so that the patient does not need to return for the stitches to be removed by a doctor. During recovery, the patient does not need to take sitz baths (soaking of the buttocks in warm water) as were necessary with the previous method. Also, post-surgical pain is greatly reduced, allowing the patient to walk normally 1-2 days after surgery.

Classification of the types of fistula-in-ano is important in determining the most appropriate course  of treatment and has been divided into 4 main types according to Park’s classification. (Image 2)

 Cited from (Click)

1. Intersphincteric fistula (blue marked area): This is the most common type of anal fistula. It starts with an infection in a mucous-secreting gland in the anal canal which then becomes an abscess in the intersphincteric space (between the internal and external anal sphincters). If the infection and pus move downward toward the anal opening it will create a fistula in this area, which is generally quite easy for a doctor to find and identify.  
   With the LIFTS (Ligation of Intersphincteric Fistula Tract Surgery) technique, the doctor will perform division and ligation of the fistula tract using absorbable sutures. (In image below, a and b show the before and after respectively. Note the arrows indicating the point of division and ligation of the tract.)
   
   Cited from (Click)
   Video demonstration (Click)

2. Transphincteric fistula (yellow marked area): This is the second most common type of fistula. In this type, the infected tract passes through both the internal sphincter and the external sphincter before breaking through the perianal skin or perineum. This type of fistula is quite difficult to perform surgery on.

3. Suprasphincteric fistula (green marked area): This type of fistula is quite uncommon. It passes from the internal opening to the intersphincteric space and first turns upward before extending downward and then creating an opening through the perianal skin.  

4. Extrasphincteric fistula (orange marked area): This type of fistula is rarely found. It passes through both the internal and external sphincters, rises upwards as in type 3, and then opens into the rectum.
   

Dr. Pornthep Prathanvanich specializes in laparoscopic and minimally invasive surgery, including colorectal surgery,  laparoscopic hernia surgery, appendectomy, gastrointestinal and abdominal surgery, and laparoscopic surgery for obesity.

• More than 10 years of laparoscopic surgery experience
• Has also carried out more than 1,000 surgeries for hemorrhoids, anal fistulas, colon cancer, laparoscopic hernia surgeries and appendectomies.
• Has carried out more than 700 laparoscopic hernia repair surgeries
• More than 5 years experience in 3D laparoscopic and robotic-assisted surgery in the United States
• Is a board member of the Laparoscopic Surgery Association of Thailand and the Hernia Surgery Association of Thailand
• Is a member of the American Society for Metabolic and Bariatric Surgery