VAAFT

Technique

The technique comprises a diagnostic phase and an operative phase.

• 1) The diagnostic phase : The purpose of this phase is the correct location of the internal fistula opening. The fistuloscope is inserted through the external fistula opening with the washing solution (glycine 1% and mannitol 1%) already running; providing a clear view of the fistula pathway which appears on the screen. Blocking tissue can be removed using the 2 mm forceps to facilitate the insertion of the fistuloscope. The direction of the telescope is correct when the obturator appears in the lower part of the screen. The surgeon follows the fistula pathway using slow left-right and up-down movements.
  When the fistuloscope exits through the internal opening the rectal mucosa clearly appears on the screen. In some cases the internal opening might be very narrow; in this case, its location is suspected viewing the fistuloscope light behind the rectal mucosa. At this point, we put two or three stitches in two opposite points of the internal opening margin in order to isolate and, above all, not to loose it. We must be sure to capture sufficient tissue thickness.
• 2) The operative phase: Purpose of this phase is the destruction of the fistula from the inside. As a next step, the fistula canal is cleaned / the waste material removed and its internal opening is then closed hermetically. We start destroying the fistula under vision using a unipolar electrode which can be passed through the operative channel of the fistuloscope and is connected to the electrosurgical power unit. Starting at the internal fistula opening, all fragments of the whitish material adhering to the fistula wall and all granulation tissue are coagulated. We complete this phase of the operation, centimeter by centimeter, from the internal opening to the external opening not forgetting any abscessual cavity.
  
  When the tissue in the area of the internal opening is not sclerotic and allows to form a good "volcano", the stapler can be used, however if the tissue around the internal opening is too rigid and sclerotic, the use of the stapler might be difficult. In this case a cutaneous mucosal flap would be preferred.
  As a last step we insert 0,5 ml of synthetic cyanoacrylate (GLUBRAN 2 – GEM) right after the suture / staple line via the fistula pathway to further reinforce the suture. So the use of the synthetic cyanoacrylate behind the suture line or behind the flap assures the perfect opening closure. It is essential to keep in mind that not the whole fistula tract is filled up with the synthetic cyanoacrylate; only a small amount is inserted directly below the suture line. That's why the fistula pathway has to stay open to allow the passage of secretions.