Robotic-Assisted Endorectal Advancement flap: a novel technique for supralevator fistula repair


Division of Colon and Rectal Surgery, Advocate Illinois Masonic Medical Center

Division of Colon and Rectal Surgery, Advocate Illinois Masonic Medical Center


Anal fistulas are abnormal inflammatory tracts associated with anorectal abscesses most commonly caused by cryptoglandular disease but also trauma, inflammatory bowel disease, and anal fissures.1 Anal fistulae are defined as "complex" when one of the following are present: horseshoe configuration, multiple tracts, anterior location in a female, recurrent fistula, a history of pelvic radiotherapy, pre-existing incontinence, the presence of Crohn's disease or a tract that crosses/involves more than 30% of the external anal sphincter (high transsphincteric, suprasphincteric, and extrasphincteric).2-4 The incidence of these anal fistulae is estimated to be 2 per 10,000 annually in the United States.5 Fistulotomy is not recommended for these patients due to extensive sphincter involvement and high likelihood of stool incontinence. Endorectal advancement flap is a surgical option for the management of complex fistulae where, a tension-free, well vascularized mucosal flap is created and mobilized to cover the internal opening of the fistula. Open transanal endorectal repair has an estimated success rate of 60 to 93%. 6 These repairs, however, have been limited by the confinement of the rectal lumen.7 Transanal minimally invasive surgery (TAMIS) has evolved to overcome these challenges and to obtain better exposure while reducing injury to the sphincter and preventing stool incontinence. Studies show an approximate success rate of 75% with TAMIS.8-9 Robotic transanal surgery is one of the newest developments which has arisen from the natural evolution of minimally invasive surgery. Robotic assisted endorectal advancement flap provides excellent exposure at the anorectal junction. Robotic instruments have multiple degrees of freedom minimizing collision of instruments when compared to TAMIS. The robot provides improved ergonomics when compared to other approaches allowing for better dissection, mobilization of the flap, and intraluminal suturing.10 This video shows the technique and benefits of robotic assisted advancement flap. See Video at http://links.lww.com/DCR/B462 .

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