2. 05-04-2019 2
CO-GUIDE:
Dr.Poornima Jalawadi MS(Ayu)
Asst.Professor
Dep of PG studies in Shalya Tantra
JSS Ayurveda Medical College
Mysore-28
PRESENTER:
Dr.Abhishek S L BAMS
PG Scholar
Dept of PG studies in Shalya Tantra
JSS Ayurveda Medical College
Mysore-28
GUIDE:
Dr.Siddayya Aradhyamath MS(Ayu),Ph.D
Professor and Head
Dep of PG studies in Shalya Tantra
JSS Ayurveda Medical College
Mysore-28
4. INTRODUCTION
• Fistula In Ano is commonly seen in Ano rectal surgical practice,
which is a raising problem and a challenge to surgeon.
• Fistula implies to a chronic granulating track communicating two
epithelial surfaces. These surfaces may be cutaneous or mucosal.
• The occurrence rate is more in male adults.
• The most commonly used treatment is excision and healing by
secondary intention.
05-04-2019 4
“If a patient of Fistula-in-ano comes to your clinic, refer the patient to your professional rival.”
5. • Ayurveda describes a disease, Bhagandara which can be correlated to
the symptoms of Fistula In Ano.
• Sushruta considered Bhagandara as one amongst the
ASHTAMAHAGADAS (8 diseases which are difficult to treat)
• Sushruta has advocated a very unique, minimally invasive treatment i.e.
Kshara Sutra procedure can be used for the management of Bhagandara.
• In this presentation an attempt has been made to understand the concept
of both Bhagandara and Fistula in ano with their effective management
which is the need of hour.
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7. • Fistula in ano is a track lined by granulation tissue which opens deeply in the
anal canal or rectum and superficially on the skin around the anus.
- Bailey and Love
• Fistula implies a chronic granulating track communicating two epithelial
lined surfaces. These surfaces may be cutaneous or mucosal.
- John Goligher
• Fistula is an abnormal track leading from a mucous membrane to another
mucous surface or to the skin.
- Miller
05-04-2019 7
Definition
8. BACKGROUND –
➢The incidence of Fistula-In-Ano developing
from an anal abscess ranges from 26-38%.
➢A study conducted by Sainio P showed that the prevalence rate of Fistula-In-
Ano is 8.6 cases per 1,00,000 populations.
➢The prevalence in men is 12.3cases per 1,00,000 populations and in women
is 5.6 cases per 1,00,000 population.
➢The male and female ratio is 2:1. The mean age of patients is 40-60 years.
05-04-2019 8
9. ➢An acute abscess in one or more potential spaces around anorectal canal.
➢Source of infection could be a number of predisposing conditions like :-
• Infected condition of the anal crypts (crypto glandular apparatus).
• Anal fissure.
• Infection from hair follicles.
• Infection from an ulcer at the root of the pile mass.
• Infected sebaceous glands.
• Infected sweat glands.
Causes of Fistula in ano
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10. • Foreign body penetrating from outside.
• Inflammed/ thromobosed previously existing pile masses.
• Retained sutures after haemorrhoidectomy.
• Injection of chemicals for treating pile masses.
• Radiation burns from X-ray and Radiotherapy.
• Other disorders, which may cause fistula in ano are Ulcerative colitis, Crohn’s
disease, Tuberculosis, Carcinoma.05-04-2019 10
12. Mechanism of fistula formation
4 stages
• Stage of infection
•Stage of burrowing
•Stage of Abscess formation
•Stage of Secondary opening 1205-04-2019
13. Stage of infection
• Infection of the anal crypts which becomes distended and forms a
primary opening.
• Later on crypts become edematous and the infection spreads.
1305-04-2019
14. Stage of burrowing
• It starts with burrowing
• The infection extend in one or more than one direction.
• Subcutaneous.
• Submucous.
• External sphincter .
• Internal sphincter, or between them.
• Infection may go either or inferior to levator ani muscle.
1405-04-2019
15. Stage of Abscess formation
•Abscess may be formed in
• Submucous
• Subcutaneous
• Deeper tissues
1505-04-2019
16. Stage of Secondary opening
• Abscess rupture
• Secondary opening forms
• This opening maybe either inside the rectum or
on the external surface of the anal canal.
1605-04-2019
18. (according to the relationship of primary tract to the anal sphincters)
• Intersphincteric
• Trans sphincteric
• Supra sphincteric
• Extra sphincteric
Park’s classification
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19. Inter sphincteric fistula
• Simple low tract
• High tract with rectal opening
• Extra rectal extention05-04-2019 19
23. Morgan’s classification
1. Low level fistula :- opens into anal canal
below the anorectal ring.
e.g - Subcutaneous, Low anal,
Sub mucous.
2. High level fistula :- Opens into anal canal at or
above the anorectal ring.
e.g., High anal, Pelvi-rectal.
(Based on level of internal opening related to Ano rectal ring )
05-04-2019 23
24. Clinical Presentation
• Perianal discharge - intermittent or constant, either bloody or purulent
• Perianal pain- worse during defecation, may be constant
• Swelling /lump in the perianal area
• Diarrhoea
• Discoloration of skin surrounding the fistula
• External opening in the perianal region.
• Fever
05-04-2019 24
25. Clinical Examination
➢ Inspection
❖Presence of external opening/s in anal region.
❖Little pink or red nodule may be present at the opening.
❖Induration and Scars of previous operations.
➢ Palpation (D.R.E.)
➢ Palpation of perianal region may result in expression of pus.
➢ A distinct cord like induration can be felt from external opening to anal verge.
➢ Palpation of anal canal may detect an area of induration or an actual opening.
➢ Probing
➢ Injection of Methylene blue/H2O2 + betadine into the track to find out the internal opening.
Pimple out side Dimple inside
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26. Goodsall’s rule :
• In order to help the examiner predict the
trajectory of the tract and probable location of the
internal opening, Goodsall's Rule can be applied.
• With the patient in the lithotomy position :–
• If the external opening is anterior to an imaginary line drawn-across the midpoint of the anus,
the fistula runs straightly into the anal canal.
• If the external opening is situated posterior to the line, the track usually will curve and the
internal opening will be on the midline posterior of the anal canal.
• An exception to this rule is when the external opening is anterior to this imaginary line but is
situated more than 1 ½ inches away from the anus. In this case the track will curve
posteriorly and end in posterior midline.
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32. Pre operative procedures
• Investigation .
• Part preparation.
• NBM
• Enema on the day of surgery.
• Test dose of Xylocaine 2%.
• Injection .Tetanus toxoid.
• IV line.
• An informed consent should be taken in the presence of a witness.
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34. Fistulectomy
• Fistulectomy is a surgical procedure where a fistulous tract is excised
completely.
• Complete fistulectomy creates larger wounds that take longer to heal and
offers no recurrence advantage over fistulotomy.
• When a fistula lies either too close to the sphincter or goes through it then it is
not possible to lay it open or remove it without the risk of incontinence.
• In those cases the treatment consists of drainage of abscess or infection
along with placement of a seton.05-04-2019 34
35. Setons
•Seton is derived from the Latin word seta , meaning “bristle.”
•These materials may include : - Silk, Rubber bands, Nylon
or poly propylene, and Braided steel wire.
• Setons are useful in the management of complex anorectal
fistulas where there is an appreciable incontinence
risk of or poor healing.
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36. Fibrin Glue
• Fistulous track is closed by injection of fibrin glue, which results in formation of
a clot within the fistula, helps to promote healing of the track.
• Fibrin glue is mixture of 2 components.
a) Fibrinogen solution : (fibrinogen, aprotonin + fibronectin + plasminogan)
b) Thrombin solution : (Thrombin + cal-cium chloride)
• Alternative mode of treatment in complex cases for which standard treatment has
failed.05-04-2019 36
37. Anal fistula plug
• Cone-shaped plug created from a bioabsorbable xenograft made of
lyophilized porcine intestinal submucosa.
• The fistula plug is inserted into the primary opening of the fistula and secured
into place with one or two interrupted stitches.
• Material :-
▪ which has inherent resistance to infection.
▪ No foreign body or giant cell reaction.
▪ Becomes repopulated with host cell tissue during a period of 3 months.05-04-2019 37
38. Post Operative procedures
• After completion of surgery, the patient is transferred to the post anesthesia care
unit and closely monitored.
• Patient is allowed to take orally after 6-8 hours of surgery.
• During the post-operative period, the patient's general function is assessed, the
outcome of the procedure is assessed, and the surgical site is checked for signs of
infection.
• Antibiotics and sedatives are given.
• Catheterization.
• Fluid electrolyte.05-04-2019 38
39. Complication
• Recurrent infections causes pus discharge and foul smell .
• Abscess formation .
• Sphicter loss.
• It is prone to recurrence after surgical removal .
• Rarely malignant changes may occur .
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40. Causes of Reoccurrence:
• Incomplete excision of track
• Entry of new foreign body
• Irregular shaving of hair
• Improper perianal hygiene
• Improper drainage of the pus
• untreated crohn’s Disease , Ulcerative Colitis , T.B. etc..
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41. Inspite of all the advancements and developments
that has happened in the field of surgery why isn’t
there a permanent solution to stop the reoccurrence
of the present condition????
WHAT COULD BE THE BEST POSSIBLE WAY TO AVOID THIS
REOCURRENCE?????
05-04-2019 41
42. This is where the, so called
“alternate” medicine stands as
the “ultimate”
05-04-2019 42
45. BHAGANDARA
Paribhasha
ते तु भगगुदबस्ततप्रदेशदारणाच्च ‘भगन्दरा’ इत्युच्यन्ते |
As it creates a tear in the area of pelvis, rectum and urinary bladder it is
known as Bhagandara.
The word bhagandara is the combination of two words "Bhaga" and "Daran" which are
derived from root Bhaj and Dri respectively.
• Bhaga means all the structures around the guda including yoni and basti.
• Daran means tear of surface associated with pain.05-04-2019 45
46. Nidana
• Hasti ustra aswa gamana – Riding on elephant, horses, Camel.
• Katina utkatakaasana – Sitting on hard seats.
• Arsha nidanabhihita – Causative factors of Arshas.
• Anistadista paakena – Sins of past and present life.
• Sadhu garhana – Showing disrespect to saints.
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48. यानयानान्मलोत्सगावत् कण्डूरुग्दाहशोफर्ान् |
पायुभवर्ेद्रुजः कटयाां पूर्वरूपां भगन्दरे ||
• Itching
• Pain
• Burning Sensation
• Swelling
In the anus and waist during riding
in vehicles/animals or during
elimination of faeces.
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49. Samprapti
Due to Nidana sevana
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Dosha prakopa
Mamsa sontita dusti leads to formation of nadi and goes deeper
Localised in guda pradesha
Formation of pidaka
Pooya srava
Bhagandara
50. BHEDHAS
According to Dosha
1. Sataponaka - Vataja
2. Ustragriva - Pittaja
3. Parisravi - Kaphaja
4. Sambukavarta - Sannipataja
5. Unmargi - Aagantuja
6. Pariksepi - Vata-Pittaja
7. Riju - Vata-Kaphaja
8. Arsobhagandara - Pitta-Kaphaja
According to Opening – S.S. Chi. 8/4
1) Bahirmukham 2) Antarmukham
According to VAGBHATA
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51. Shataponaka
• Pakwa Pidaka - Ripened pidaka.
• Daruna Ruja - Severe pain.
• Bhinna Aruna Phena Vahini - When pidakas open it presents aruna and
froathy discharge.
• Aneka Vrana - multiple openings.
• Mutra Pureesha Retasaam Agamane - Discharge of urine, stools and semen
through multiple openings.
• It originates from vitiated vata.
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52. Ushtragreeva
• Ashupaaki - Lesions get ripened quickly
• Ushna sraava - Hot discharges
• Puti srava - Foul smelling discharge
• Ushtra shiro gharam - Shape of the blister resembles the neck of camel.
• It originates from vitiated pitta.
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54. Shambhukavarta
• Features of all doshaja bhagandara
• Bahu varna srava – discharge of various colours
• Shambuka avarta iva - resmebles the shape of conch shells.
• It originates from vitiated 3 doshas.
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55. Unmargi
• Asthi shalya or any foreign substance ingested with
food, which on reaching guda causes trauma to
develop Bhagandara.
• Discharge of puya(pus) and rudhira(blood)
• Formation of krimi- that eats away the guda pradesha and
produces tears/cuts in the walls in the sides of the guda(rectum).
• From these tears; urine, feaces and semen comes out.
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56. TRENCH AROUND FORT
Pariksepi
• It originates from vitiated vata and pitta.
• It manifests as tamra varna pidika with burning sensation and pain in the
perianal region.
• The track is of curved type.
• Arunadutta and Indu states that the track of parikshepi
bhagandara surrounds the guda as the trench and this can
be compared to a posterior horse-shoe ischiorectal fistula.
05-04-2019 56
57. Riju
• The vitiated vata and kapha produces the pidika, which later on suppurates
and form a straight track in the anal region.
• Because of its straight nature of track, it is called riju bhagandara.
• Fistula arising from the anterior half of the anal canal
are usually straight in nature can be compared as
Riju Bhagandara
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58. Arsobhagandara
• Shopha - Swelling
• Kandu - Itching
• Daha - Burning Sensation
• Sheegra pakva - It Bursts Open Quickly
• Moolam arshasaha – Associated with root of pile Mass
• It originates from vitiated pitta and kapha.
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59. Saadhya - Asadhyata
• All types of Bhaganadara are Kashta Saadhya
• Tridoshaja and Agantuja are Asaadhya.
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61. • Snehana.
• Swedana by Avagaha (Tub Bath )
• Chedana / Agni karma / kshara karma can be performed.
05-04-2019 61
Samanya chikitsa
62. Vishesha chikitsa
• The specific feature of this bhagandara is multiple openings on the external surface
of skin.
• It has been suggested that one track should be excised at once and after the
previous wound has healed, the remaining tracks should be operated similarly.
• If multiple tracks are excised by single incision such wound causes guda vidirana
i.e. cause injury to the rectal walls and sphincters and leads to impairment of
sphincteric function and may lead to leakage of flatus, faeces, urine.
shataponaka
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63. Ushtragreeva
• Two procedures are indicated: Chedana and Kshaara Karma.
• Agnikarma is contraindicated.
• Application of Tila and Ghrita,
• Parisheka with Ghrita are indicated.
05-04-2019 63
64. Parisravi Bhagandara
• In this type, first the track is located with probe, then it has to be excised and the
wound should be cauterises with Kshara or Agni.
• Later the wound is washed with warm water and basti of warm M.N.taila is
given.
Pt Name : 123
Age : 17 years
Diagnosis : parisravi Bhagandara
05-04-2019 64
66. Unmargi Bhagandara
• It is described as asadhya, even though management has been described by
both Sushruta and Vagbhata.
• It is caused due to injury from foreign body hence the principle of
treatment is excision of track and removal of foreign body followed by
cauterization with agni. Later krimihara drugs are applied locally and also
taken internally.
05-04-2019 66
67. Parikshepi Bhagandara
• Vagbhata has suggested that it has to be treated on the lines of
Nadivrana with kshara sutra.
Pt Name : 123
Age : 38 years
Diagnosis : parikshepi Bhagandara05-04-2019 67
68. Riju Bhagandara
• No specific treatment is described for this Bhagandara. Therefore, it can
be treated same as the other simple types of Bhagandara.
Pt Name : 123
Age : 30 years
Diagnosis : Riju Bhagandara
05-04-2019 68
69. Arsho Bhagandara
• It is the coexistence of Arshas along with Bhagandara. So, here Arshas and
Bhagandara should be treat simultaneously
Pt Name : 123
Age : 55years
Diagnosis : Arsho Bhagandara
05-04-2019 69
70. Management of Fistula-In-Ano with K.S.
1. Purva karma
2. Pradhan karma
3. Paschat karma
Purva Karma
• Written informed concent of the pt. and attendent
• Inj . T.T.
• Xylocaine test dose.05-04-2019 70
71. KSHARA SUTRA PRAYOGA
“ क ृ़श दुबवल भीरुणाां नाडी ममावश्रिता च या ।
क्षार सूत्रेण िन््यIत् न तु शतत्रेण बु्श्रिमान् ”
सु.स.श्रच 17/29
Kshara sutra can be performed in
➢ Krisha
➢ Durbala
➢ Bheeru
➢ Naadi vrana in Marma Sthana
05-04-2019 71
72. 72
KSHARA SUTRA BECAME POPULAR
It is also called as Magic Thread
WHEN PHYSICAL FISTULECTOMY IS
A FAILURE ?
THEN ……….
THERMAL FISTULECTOMY (AGNI KARMA)
AMONGST THEM ………
CHEMICAL FISTULCTOMY (KSHARA KARMA)
05-04-2019
73. 73
➢Slow And Gradual Cutting With Simultaneous Healing
➢ Total Destruction Of Cryptic Glands
➢With A Better Drainage
➢A novel drug delivery system to the fistula track with its 7-21 coatings
by getting dissolved one by one gradually.
HOW KSHARASUTRA DOES WONDERS
05-04-2019
74. Pradhana karma
➢Position - Lithotomy
➢Painting
➢Types of Anaesthesia : Local Anaesthesia
Short G.A, Spinal Anaesthesia.
Procedure of K.S. application
Step I – Probing :-
• Suitable probe selection.
• Anal canal is dilated and fistula track is explored with a probe by inserting through its
distal opening (external opening) and index finger is introduced into the anal canal to
guide the probe and locate the internal opening.
• Probing negotiated and advanced gently along the path of least resistance.
05-04-2019 74
75. Step II-
• A thread of suitable length is placed in the eye of probe and the probe is pulled out
through anal orifice, in order to position the thread in the tract.
• Both ends of the thread tied loosely outside the anal orifice.
Step III
➢Curettage of external orifice to remove unhealthy granulation tissues pouting from
orifice and edges of the external orifice of the tract are trimmed.
➢Dressing of the wound with medicated oil.
➢Application of bandage.
05-04-2019 75
79. Rail Load Technique for changing of Ksharsutra
➢Application of Ksharasutra after 3 or 7 days by Rail Load Technique.
➢New Ksharasutra is tied to the lateral side of knot.
➢Thread is cut between the knot and clipped artery forceps.
➢Artery forcep is gently pulled out along with the old thread such that thread (old) come
out leaving the new ksharasutra in fistulous tract.
➢Cut old Ksharasutra and ends of the new one are tied firmly.
➢Cotton soaked in Taila is placed locally and-bandage applied.
05-04-2019 79
80. Mechanism of Action of K.S.
➢Ksharsutra is a method of drug carrying system. It carries drug directly to the fistula
track hence its efficacy improves.
➢Latex of Snuhi (Euphorbia) - Proteolytic, therefore dissolves fibrous tissue and
fistulous tract.
➢Apamarg kshara – Alkali in nature which debrides the fistulous tract and liquidates
the thick pus, keep the tract clean through drainage of pus.
➢Haridra Powder – Anti-allergic, antiseptic, wound healer.
➢Special linen thread holds the medicine with the help of latex for 3-4 days in the fistulous
tract.
➢Physical pressure of K.S. keeps the passage patent and helps in drainage of pus.05-04-2019 80
81. 81
Mechanism of Kshara Sutra
Wire on ice block
bearing weight
both side
Wire cutting
through by
pressure
Ice block
reform and
healed block
05-04-2019
82. Merits of Ksharsutra Therapy
• Day surgery
• Minimal inavasive therapy.
• Minimal hospital stay.
• Complications free like - Incontinence, Deformity, Stricture.
• Patients remains ambulatory.
• High cure rates– 97%.
• Cure all type of fistula.
• Most effective, safe and ideal alternative for conventional surgery i.e. fistulectomy.
05-04-2019 82
84. Research Article
• Concept Of Bhagandara (Fistula In Ano) -A Review - N.K.Jabshetty Ayurvedic Medical
Collage,Bidar - Dr.Ganapathirao
• Role of Udumbara Ksheerasootra in Bhagandara.Varanasi. BHU. – Dr.Raman Singh.
• Study of Guggulu based Kshara sootra in the management of high analFistula.Varanasi.
BHU. – Dr.Yadav S.K.
• Role of Madhu Ksharasutra in the management of Bhagandara.Hassan.- Dr.Gopikrishna BJ.
• Effect of Guggulu Ksharasutra in Bhagandara. Kuthpady. Udupi,Karnataka. – Dr.Pharande
Mayur Uttam.
• Effect of madu kshara sutra in management of Bhagandara (Fistula In Ano) , SDM college ,
Hassan – Dr.Gopikrishna05-04-2019 84
85. • The description of both Fistula in ano and Bhagandara have
striking resemblances, but the concept of Bhagandara is not
just restricted to Fistula in ano as the definition of Bhagandara includes tract
formation in the Bhaga, Guda and Basti.
• The types of Bhagandara based on the doshas are indeed appreciable, the different
doshic combinations produce varied coloured pidakas and sravas that can be seen
practically. This understanding in Ayurveda is no way in comparison to the modern
parlance.05-04-2019 85
Discussion
86. • The chikitsa mentioned in Ayurveda is dosha specific wherin there is a variety
of options prescribed based on different manifestations of the vyadhi.
• In contemporary management, damage to the sphincter and recurrence of the
fistula are the most common surgical complication, which demands for a less
invasive and a better solution for fistula in ano.
• Kshara sutra is a minimally invasive, highly effective modality of treatment
which safeguards the sphincters and also avoids the recurrence.
• Apart from kshara sutra various other modalties like agnikarma, parisheka,
varti, sweda etc depending on the condition can also be selected.05-04-2019 86
87. Thus the comprehensive management of Ayurveda includes-
➢ Preventive – Nidana Parivarjana
➢Curative- Shastra karma
Varti Prayoga
Kshara Sutra Prayoga
➢Avoidance of reccurence- Kshara sutra
05-04-2019 87
88. CONCLUSION
• Bhagandara is a manifestation of the bhagandara Pidaka that has
similarity with Fistula in ano of the modern parlance.
• It is proved beyond doubt that Ayurveda provides an ideal solution for the management of
Bhagandra when compared to the contemporary management.
• Ayurveda provides different varities of chikitsa that can be choosen based on the
individual.
• The WHO has declared that Kshara Sutra procedure has high successive rate of 90%.
• Thus concluding :
“ Ayurvedo Amritanaam”05-04-2019 88
89. ಎಲ್ಾಾದರು ಇರು ಎಂತಾದರೂ
ಇರು ಎಂದ್ಂದಿಗೂ ನವ
ಕನ್ನಡರಾಗಿರು
05-04-2019 89
ತಮಗ್ಲ್ಾರಿಗು ಕನ್ನಡ ರಾಜ್ೂಯವತಸವದ ಹಾದಿೇಕ
ಶುಭಾಶಯಗಳು
90. LIST OF REFERENCE
• Sushruta Samhita; Vol – 1 Chaukhamba Surbharati Prakashan; Varanasi Edition 2004; Nidana Sthana adhyaya – 4
• Acharya Y T.Sushruta Samhita of Susrutha with Nibandhasangraha commentary, Varanasi,choukamba orientalia.
2017.
• Astanga Hridaya Vol - 3, Chaukhamba Surbharati Prakashan, Varanasi Edition 2004 uttara Stana, Chapter 33
• SRB’S Mnual of surgery : published by Dr.S R Bhat , 4th edition 2013, p.no. 1030.
• Bailey Y Love’s, Fistula-in-ano, 24th Edition, (2004), 1265 - 1267.
• Deshpande P.J., Sharma K.R.: Successful Non-operative treatment of High rectal fistula, Amer J. Procto, 39-47,
Feb, (1976).
• Dhanwantari Veera- Management of High rectal fistula by Kshara Sutra, M.D. (Ay.), Thesis, I.M.S. B.H.U.
(1983).
• Goligher J.C.: Surgery of the anus, rectum and colon, London. 5th edn, (1984).
• https://www.google.co.in/search?q=fistula+in+ano&safe=active&source=lnms&sa=X&ved=0ahUKEwjVn6yylKLe
AhUZA3IKHZOnBIIQ_AUICSgA&biw=1021&bih=570&dpr=1
05-04-2019 90
