Difference Between Fistulectomy and Fistulotomy
Fistulotomy involves laying open the fistula tract by cutting through the overlying tissue to create an open wound that heals by secondary intention, while fistulectomy involves complete excision and removal of the entire fistula tract including surrounding tissue. 1, 2
Technical Distinctions
Fistulotomy Technique
- The surgeon cuts through the skin, subcutaneous tissue, and any involved sphincter muscle overlying the fistula tract, converting it into an open groove that drains externally and heals from the base upward 1, 3
- The primary tract and any side tracts are laid open without removing tissue 1
- This is the preferred approach for simple, low fistulas with healing rates approaching 100% 4, 1
Fistulectomy Technique
- The surgeon completely excises and removes the entire fistula tract as a core of tissue, creating a larger wound defect 5, 3
- More tissue is removed compared to fistulotomy, resulting in a larger wound that must heal by secondary intention 2, 6
- Often combined with advancement flap procedures for complex fistulas 5
Clinical Outcomes Comparison
Operating Time and Hospital Stay
- Fistulotomy has significantly shorter operative time (21.96 ± 1.90 minutes) compared to fistulectomy (31.32 ± 2.99 minutes) 6
- Hospital stay is shorter with fistulotomy (1.32 ± 0.47 days) versus fistulectomy (2.32 ± 0.69 days) 6
Pain and Complications
- Fistulectomy results in significantly lower 24-hour postoperative pain scores (MD -0.49 on visual analog scale) 2
- Fistulotomy has significantly fewer postoperative bleeding complications (OR: 3.81) 2
- No significant difference exists in wound infection rates, incontinence rates, or recurrence between the two techniques 2
Healing Time
- There is no significant difference in overall healing time between fistulotomy and fistulectomy 2
- Both techniques achieve healing rates >95% for simple fistulas 3
Clinical Application Algorithm
When to Use Fistulotomy
- Simple intersphincteric fistulas: fistulotomy is the procedure of choice 3
- Simple low transsphincteric fistulas involving minimal sphincter muscle 1, 3
- Uncomplicated low anal fistulas after ruling out perianal abscess 4
- Fistulotomy is associated with 10-20% risk of continence disturbances and permanent cosmetic deformity 1
Absolute Contraindications to Fistulotomy
- Active proctitis or rectosigmoid inflammation 1
- Crohn's Disease Activity Index >150 1
- Evidence of perineal Crohn's disease involvement 1
- Anterior fistulas in female patients 1
- High fistulas involving significant portions of external anal sphincter 4
When to Use Fistulectomy
- High transsphincteric and suprasphincteric fistulas when combined with endorectal advancement flap, achieving 93% success rates 5
- Complex fistulas requiring complete tract removal 5, 3
- Core fistulectomy with advancement flap shows 7% recurrence rate and 8% continence disturbance 5
Critical Pitfalls to Avoid
- Never perform fistulotomy in patients with active rectal inflammation, as this dramatically increases incontinence risk 4, 1
- Avoid aggressive probing during initial examination, as this creates iatrogenic complexity 1
- Do not use cutting setons, which result in incontinence rates up to 57% and keyhole deformity 1
- For Crohn's disease patients, place loose non-cutting setons rather than performing fistulotomy, even for low fistulas with active inflammation 4
Special Considerations
Crohn's Disease Context
- Patients with Crohn's disease are more likely to have setons placed and less likely to undergo fistulotomy due to higher complication risks 4
- Seton placement combined with antibiotics (metronidazole and/or ciprofloxacin) is the preferred initial strategy 4
- Medical therapy to control disease-related inflammation is imperative before definitive surgical intervention 4