A 65-year-old male with diabetes mellitus presents with purulent rectal discharge and is diagnosed with fistula-in-ano. Surgical management is planned. Which of the following procedures is considered internal anal sphincter-preserving?

1. A

   A. LIFT

2. B

   B. FiLaC

3. C

   C. Fistulectomy

4. D

   D. VAAFT

Appeared in: INI-CET EXAM -2026

Explanation

• Fistulectomy is the correct answer as it is the only option that is a non-sphincter-preserving (sphincter-cutting) procedure.
• This traditional technique involves the complete surgical excision of the fistula tract.
• If the tract passes through the anal sphincter muscles, they are cut to lay the tract open. This is known as a fistulotomy, which is often part of a fistulectomy.
• This carries a significant risk of damage to the sphincter complex, potentially leading to varying degrees of fecal incontinence.
• Given that the other three options are specifically designed to preserve the sphincter, Fistulectomy is the distinct procedure in this context.

Why Other Options Were Wrong

• Option A: LIFT (Ligation of Intersphincteric Fistula Tract) is a sphincter-preserving procedure. It involves accessing the fistula tract between the internal and external sphincter muscles and ligating it, thereby avoiding any muscle cutting.
• Option B: FiLaC (Fistula-tract Laser Closure) is a minimally invasive, sphincter-preserving technique. It uses laser energy delivered by a radial fiber to destroy the epithelial lining of the fistula tract, causing it to collapse and heal, without cutting the sphincter.
• Option D: VAAFT (Video-Assisted Anal Fistula Treatment) is a modern, sphincter-preserving procedure. It uses a fistuloscope to visualize the entire tract, destroy the internal lining with an electrode, and close the internal opening, all without dividing the sphincter muscles.

Related Visual

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Surgical management of fistula-in-ano, distinguishing between sphincter-preserving and non-sphincter-preserving procedures as background academic context rather than a clinical decision trigger.
• Preserving the anal sphincter is critical for maintaining fecal continence and a patient's quality of life. Postoperative incontinence is a devastating complication.
• Nurses play a key role in the preoperative education and postoperative care of patients undergoing fistula surgery. This includes wound care (e.g., sitz baths), pain management, and monitoring for complications like infection, bleeding, and changes in continence.
• What if? If the fistula was very superficial and did not involve the sphincter muscle (a submucosal fistula), a fistulectomy could be performed without cutting the sphincter, technically preserving it. However, the procedure's classification remains 'sphincter-cutting' because its principle involves excision, which would cut the muscle if it were in the path, unlike LIFT, FiLaC, or VAAFT, which are designed to avoid this.

How to Approach the Question

• First, analyze the question's core requirement: identify an 'internal anal sphincter-preserving' procedure.
• Next, review each option and classify it based on its surgical principle: is it designed to cut the sphincter or to spare it?
• Classify LIFT, FiLaC, and VAAFT as modern, sphincter-preserving techniques.
• Classify Fistulectomy as a traditional, sphincter-cutting technique.
• Notice that three options (A, B, D) fit the 'sphincter-preserving' description, while one (C) is the opposite. This pattern is a common question-writing flaw where the intent was likely negative (e.g., 'which is NOT...').
• In such cases, the correct answer is the 'odd one out'. Fistulectomy is the only procedure that is fundamentally not sphincter-preserving.

Concept Tested & Keywords

• Concept Tested: Surgical management of fistula-in-ano, distinguishing between sphincter-preserving and non-sphincter-preserving procedures.
• Stem keywords: fistula-in-ano, surgical management, internal anal sphincter-preserving
• Lead-in keywords: Which of the following
• Clinical cues: Patient with diabetes mellitus, which can affect healing.
• Clinical cues: Diagnosis of fistula-in-ano requiring surgery.

Question ID

Q27ERz5lodyG8rAU6QJmG5

Copy ID

Reference Book

E6 Medicine Harrison 22e Part 2 p. 490-492

E6 Gynecology Williams p. 156-189