Annals of Coloproctology

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Benign proctology,Surgical technique

Two-Stage Complete Deroofing Fistulotomy Approach for Horseshoe Fistula: Successful Surgery Leaving Continence Intact: Asami Usui, Gentaro Ishiyama, Akihiko Nishio, Maiko Kawamura, Yukiko Kono, Yuji Ishiyama; Ann Coloproctol. 2021;37(3):153-158. Published online January 12, 2021; DOI: https://doi.org/10.3393/ac.2020.06.08

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Purpose
Surgery of the horseshoe fistula is challenging due to its complex configuration and sphincter muscle involvement. Complete deroofing fistulotomy for horseshoe fistula is highly curative with the eradication of all fistulous lesions but has been discredited for its high incontinence rate. It was replaced with the more conservative Hanley’s procedure leaving the lateral tracts intact, despite its issue of recurrence. Our study aimed to report the outcomes of a procedure dividing complete deroofing fistulotomy for horseshoe fistula into 2 stages to avoid impairment of sphincter function.
Methods
We retrospectively reviewed 139 patients who underwent surgery for horseshoe fistula using the 2-stage complete deroofing fistulotomy method between 2014 and 2017. The first surgery deroofed the lateral tracts with an arch-like incision severing the anococcygeal ligament. The primary lesion was also drained and curetted. A seton was placed in the primary tract which was laid open in the second surgery after the lateral wound had partially healed.
Results
Recurrence was observed in 12 patients. All were superficial recurrences except for 1, in which recurrence was confirmed in the primary lesion. Those with blind intersphincteric upward extensions had a significantly higher recurrence rate. Furthermore, patients who resided far from the hospital and could not make visits for frequent wound inspections also had a significantly higher recurrence rate. No patient had any continence issues at the end of the follow-up period.
Conclusion
Managing horseshoe fistula with the 2-stage deroofing fistulotomy approach allows for eradication of the fistula tract without compromising anal sphincter function.

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Successful management of a rare horseshoe perianal fistula using the modified Hanley procedure: a case report
Ibnu Kharisman, Ida Bagus Budhi Surya Adnyana, Suryo Wahyu Raharjo
International Surgery Journal.2025; 12(11): 1991. CrossRef
Clinical efficacy of the bared external anal sphincter (BEAS) in high horseshoe-shaped anal fistulas: Protocol for a real-world, prospective cohort study
Qianqian Ye, Ye Han, Peixin Du, Min Yang, De Zheng, Zubing Mei, Qingming Wang
Heliyon.2024; 10(15): e35024. CrossRef
Evaluating the efficacy of multi-incision and tube-dragging therapy combined with laser closure for high horseshoe-shaped anal fistula: Protocol of a prospective, randomized, controlled trial
Min Yang, Zubing Mei, Qingming Wang, Ye Han, De Zheng, James Mockridge
PLOS ONE.2024; 19(9): e0307653. CrossRef
A systematic review of translation and experimental studies on internal anal sphincter for fecal incontinence
Minsung Kim, Bo-Young Oh, Ji-Seon Lee, Dogeon Yoon, Wook Chun, Il Tae Son
Annals of Coloproctology.2022; 38(3): 183. CrossRef

Self-pulsed Washable Seton during a Modified Hanley Operation for a Deep Horseshoe Fistula.: Choi, Donghwi , Seo, Hyung Il , Kim, Hyunsung , Oh, Nahmgun; J Korean Soc Coloproctol. 2008;24(4):246-251.; DOI: https://doi.org/10.3393/jksc.2008.24.4.246

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1 Citations

Abstract PDF

PURPOSE
The modified Hanley technique, which is used for treatment of a deep horseshoe fistula, has reduced damage to the external anal sphincter compared to the classic Hanley technique, but its shortcoming is that it causes inconvenience to the patient due to the fact that a drainage tube must be left in place for a long time. To solve this problem, the authors devised a self-pulsed washable seton and then compared the results of its use to determine its clinical usefulness.
METHODS
The subjects of this study were 34 patients who were diagnosed with a deep posterior complex anal fistula and who were operated on by using the modified Hanley technique between January 1999 and December 2004. Twelve patients who were treated with the self-pulsed washable seton were classified as Group A, and 12 patients who were treated by using a conventional loose seton were placed in Group B. These two groups were compared for period of purulent discharge, period of leaving the seton alone, and recurrence rate.
RESULTS
The period of purulent discharge was 18.75 days (15~24) for group Aand 29.75 days (24~37) for group B. The period of leaving the seton was 21.58 days (18~29) for group A and 32.58 days (28~39) for group B. The recurrence rate after surgery was 8.3% in group A and 16.7% in group B.
CONCLUSIONS
The self-pulsed washable seton devised by the authors shortened the treatment period through more effective wound management, so we propose using it as a new method for treating a deep posterior horseshoe fistula.

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Patient-Performed Seton Irrigation for the Treatment of Deep Horseshoe Fistula
Donghwi Choi, Hyun Sung Kim, Hyung-Il Seo, Nahmgun Oh
Diseases of the Colon & Rectum.2010; 53(5): 812. CrossRef

Modified Hanley's Operation in the Treatment.: Rhyou, Jai Hyun , Shim, Kang Sup , Kim, Kwang Ho; J Korean Soc Coloproctol. 1999;15(1):55-63.

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Abstract PDF: PURPOSE
Horseshoe type-ischiorectal fistula is originating initially from infected anal gland that connect with an anal crypt usually situated in the posterior midline of the anal canal. In the modified Hanley's operation, a prove inserted into the primary opening in directed into the posterior anal space. A straight incision from the primary opening toward the tip of the coccyx is made to unroof the posterior anal spcae and the anal portion of the fistulous tract. The secondary external fistula openings are incisied to permit better external drainage. The tracts are curratted but their entire lengths are not unroofed. This study presents the clinical features and the results obtained with modified Hanley's operation in the surgical management of horseshoe fistula.
METHODS
This report is based on the clinical analysis of 22 cases of horseshoe type among 329 cases of fistula in ano, which were treated at the Department of General Surgery of Ewha Womans University Hospital from October 1993 to May 1998.
RESULTS
The male to female ratio was 3.7:1 and the age was range from 19 years-old to 61 years-old. The symptom were anal discharge and pain. The previous or combined anal disease were anal abscess and hemorrhoids. The internal openings were located at the dentate line in 18 cases and anterior portion in 5 cases. Horseshoe ischorectal fistula included 17 cases of semi-horseshoe fistula and 1 case of horseshoe fistulous sinus. The spinal anesthesia and lithotomy position was used for operations. The cutting seton was applied in the 4 cases for preservation of sphincter function. The average hospital stay was 7.6 days and average wound healing time was 5.4 weeks. The postoperative complication of urinary retensio was found in the 2 cases. Recurrence, fecal incontinence, anal deformity and anal anterior diaplacement was not developed during following periods.
CONCLUSIONS
We confirm that the modified Hanley's operation is a effective and conservative surgical procedure that minimizes the disadvantages of complete unroofing method & useful method for preservation of sphincter function.

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