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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 151-154

Substantiating accuracy of Goodsall's rule in fistula-in-ano (Bhagandar) with anatomical consideration


Department of Shalya Tantra, KLEU'S Shri B. M. Kankanwadi Ayurveda Mahavidyalaya, Belagavi, Karnataka, India

Date of Web Publication18-May-2018

Correspondence Address:
Dr. Pradeep Shahajirao Shindhe
Department of Shalya Tantra, KLEUfS Shri B. M. Kankanwadi Ayurveda Mahavidyalaya, Shahpur, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_271_17

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  Abstract 


BACKGROUND: The exact identification of the internal opening in the surgical treatment of anorectal fistulae is of basic importance for effective management, and the same concept was existed long back which was described by Acharya Sushruta in the context of Bhagandar (Arvachina and Parachina).In the current practice, the rule of Goodsall enables identification of the internal opening whether anterior or posterior with relation to its external opening.
OBJECTIVES: The objective of this study is to substantiate the accuracy of Goodsall's rule and to establish rationality of the rule with anatomical consideration
MATERIALS AND METHODS: A total of 53 operated (kshara sutra ligation) cases of fistula-in-ano during 2014–2015 were retrospectively assessed for locations of the primary (Arvachina) and secondary (Parachina) openings from the case sheets. The normal distribution test was used for the data analysis.
RESULTS: Totally 46 anal fistula patients followed the Goodsall's rule while 7 patients were not as per rule, and all of them were falling in anterior external opening group.
CONCLUSION: Posterior external opening fistulas were as per Goodsall's rule and anterior opening >3.25 cm or far had a straight or radial fistulous tract, which are against the Goodsall's rule.

Keywords: Arvachina, Bhagandar, fistula-in-ano, Goodsall's rule, Parachina


How to cite this article:
Shindhe PS, Killedar RS. Substantiating accuracy of Goodsall's rule in fistula-in-ano (Bhagandar) with anatomical consideration. Indian J Health Sci Biomed Res 2018;11:151-4

How to cite this URL:
Shindhe PS, Killedar RS. Substantiating accuracy of Goodsall's rule in fistula-in-ano (Bhagandar) with anatomical consideration. Indian J Health Sci Biomed Res [serial online] 2018 [cited 2020 Feb 28];11:151-4. Available from: http://www.ijournalhs.org/text.asp?2018/11/2/151/232691




  Introduction Top


Kshara sutra is a boon for ayurvedic surgeons in the effective management of Bhagandar (fistula-in-ano). Fistula-in-ano is very challenging for a surgeon to treat, because of its complexity in identifying the tract, and this can be achieved only by knowing the primary and secondary opening; let, any surgical procedure (fistulotomy, fistulectomy, seton, kshara sutra, etc.) may be adopted.[1] One of the chief reasons of failure to cure anal fistula is misconception as to the point of origin of the disease.[2] The primary aim is unroofing the tract (in single or staged procedure) to achieve utmost cure. Several times, it becomes very difficult to identify the course of the tract because the external manifestation as a pointing abscess, single/multiple sinus, or hard indurations, but the location of the internal opening may be uncertain as the tract may have ramifications.[1] In the current surgical practice, we rely on the Goodsall's rule for diagnosing and treating the fistula-in-ano, particularly it helps to identify the internal (primary) opening, and till today, it is said to be gold standard.


  Materials and Methods Top


We tried to substantiate his postulation by analyzing retrospectively about 53 patients of fistula-in-ano who underwent kshara sutra ligation for fistula-in-ano at our institution in the year 2014–2015. The analyzed data were systematically presented in the form of tables.

Inclusion

All patients underwent kshara sutra ligation for fistula-in-ano irrespective of age, sex, and religion.

Exclusion

Those cases were fistula-in-ano was secondary to any underlying disease (Crohn'sdisease, ulcerative colitis, and rectal malignancies).


  Results Top


Among 53 reviewed anal fistula patients the location of external and internal openings were recorded in which 37 (70%) patients were having posterior external opening [Table 1], among them 31 (84%) patients had midline posterior internal opening and 6 (16%) patients had posterior off midline internal opening. In remaining 16 (30%) patients the external opening was seen anteriorly [Table 2] among them 12 (75%) patients had midline interior internal opening and 4 (25%) patients had anterior off midline internal [Figure 1].
Table 1: Course of anal fistula with posterior external opening

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Table 2: Course of anal fistula with anterior external opening

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Figure 1: Diagram showing percentage of distribution of internal and external opening of fistulous tract in concerned to anterior and posterior perineum

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In the present study, totally 46 anal fistula patients followed the Goodsall's rule while 7 patients were not as per Goodsall's rule, and all of them were falling in anterior external opening group [Table 2].


  Discussion Top


Studies have shown that even fistulae described as simple with a superficial, subcutaneous, or low transsphincteric path have high complication rates after the fistulotomy due to the presence of secondary paths or flaws in the identification of the primary internal opening.[3],[4] In the year 1900, David Henry Goodsall described a rule regarding relationship of “external opening to the tract” in cases of fistula-in-ano. According to Goodsall's rule, “if the external opening is anterior to the transverse anal line and within 3 cm, from the anal verge, the internal opening will be in straight radial line. However, if the external opening is behind the transverse line or >3 cm, from the anal verge, the internal opening will be at the posterior midline of the anal canal.” In such cases, the tract will be a tortuous one [5] [Figure 2].
Figure 2: Structures piercing the perineal membrane

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Pathology

Anal crypts found at the dentate line are the openings to variable number of straight and branched anal glands. These glands can be potentially blocked with debris and form abscess that can extend into the intersphincteric space, adjacent tissues planes and after surgical drainage they may develop into a fistula.[6]

The geography of anorectal spaces

The perineum is a diamond-shaped structure and it is subdivided by a theoretical line drawn transversely between the ischial tuberosities. This split forms the anterior urogenital and posterior anal triangles [Figure 3].
Figure 3: Diagram showing fistulous tract as per Goodsall's rule

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Anterior urogenital triangle

Anterior (urogenital) triangle has important structure, i.e., perineal membrane [Figure 2] which intervenes between the superficial perineal pouch below and the deep perineal pouch above, and it is an important key factor in preventing perineal infections going into deeper planes [Figure 4].
Figure 4: Coronal Section of anterior anal triangle. Note: OE – Obturator externus muscle, DPP – Deep perineal pouch, OI – Obturator internus muscle, B –Bladder, P – prostate, EUS – External urethral sphincter, SPP – Superficial perineal pouch, IPR – Ischiopubic rami

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Posterior anal triangle

Superficial, deep post anal space and the ischiorectal fossa are the potential spaces surrounding the rectum and anal canal that are having surgical significance. Ischiorectal fossa is further divided into the perianal space and ischio anal space.

The perianal space surrounds the lowest portion of the anal canal and is confined by the radiating elastic septae of the conjoined longitudinal muscle attachments to the anoderm, and perianal skin contains finely lobulated fat, delicate branches of hemorrhoidal vessels, nerves, and lymphatics. The ischioanal fossa surrounds the upper portion of anal canal to the level of the anorectal ring [Figure 5]. The roof of this pyramid-shaped space is composed of the levator ani muscles, and laterally, it is bounded by the obturator internus muscle which lines the pelvic side walls. It is filled with coarsely lobulated fat and contains the inferior rectal vessels and nerves; it has relatively large space and can harbor a substantial abscess with only minimal involvement of the overlying gluteal skin. The superficial postanal space is located in the posterior midline between the skin and anococcygeal ligament, and it is frequently involved with anorectal abscess. The deep postanal space (retrosphincteric space of Courtney) located deep to the anococcygeal ligament and the upper portion of external sphincter, levator ani muscle.
Figure 5: Coronal section of posterior anal triangle. IAF – Ischioanal fossa, A – Anus, R – Rectum

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Interpretation of fistulous tract according to anatomical spaces

Majority of the anal glands are located in the posterior side which explains the prevalence of anorectal abscess in this region when this posterior midline infection erodes into adjacent spaces such as perianal space, ischiorectal fossa, and superficial and deep postanal space. Improper management leads to the formation of fistulous tracts, and the following directions may be postulated according to anatomical spaces.

  1. Perianal space infection – Probable course of fistulous tract tends to have radial fashion in subcutaneous plane
  2. Superficial postanal space – Probable course of fistulous tract tends to have radial fashion in subcutaneous plane and opens in midline posterior
  3. Ischiorectal fossa – Probable course of fistulous tract tends to have curved fashion and is deep and opens in the corresponding side of posterior midline
  4. Deep postanal space – It is of surgical significance because abscess frequently occurs in this region and also this space serves as a window to the left to right ischiorectal spaces which can result in horseshoe abscess or fistula.


In immuno compromised patients such as diabetes mellitus, tuberculosis, and HIV, the infection may make a way along the course of vessels, nerves to infect deeper spaces such as pelvirectal spaces (hiatus of Schwalbe) leading to horseshoe, or multiple anal fistula.

Fistulous tract with anterior external opening tends to follow radial course of tract because of radiating elastic septae of the conjoined longitudinal muscle attachments to the anoderm, and perianal skin contains finely lobulated fat, delicate branches of hemorrhoidal vessels, nerves, and lymphatics along with muscles such as ischiocavernosus, bulbospongiosus, and superficial transverse muscle. The tough perineal membrane does not allow any infection to penetrate deep perineal spaces, so the pus remains in the superficial perineal space (between subcutaneous tissue and perineal membrane); there is no chance for pus to communicate with any another potential spaces, so the fistulous tract having anterior external opening of any length will not follow the Goodsall's rule.

Acharya Sushruta emphasized the etiology, classification and in the management of bhagandar he describes many surgical incisions like Langalaka, Arda langalaka, Sarvatobadraka, etc., in consideration with primary (Arvachina) and secondary (Parachina) which can be compared with fistulotomy, fistulectomy procedures. The recent researches and surgical outcome of kshara sutra ligation in the management of bhagandar has reduced the reoccurrence, minimal scarring, and social burden on patient. Mere kshara sutra ligation by identifying internal and external opening may not be fruitful in some cases where the tract has involved the anatomical space which needs effective drainage of area followed with scraping of fibrous tissue of fistula tract by kshara sutra.


  Conclusion Top


Bhagandar is one of the “Ashta Mahagada”[7] (eight intricate diseases) considering its morbidity, recurrence, and social burden by its nature, so meticulous planning of management is utmost essential which includes identification of internal and external openings with anatomical consideration of spaces around the anal verge.

Goodsall's rule is accurate only when applied to complete submuscular anal fistulas with posterior external anal openings because of the presence of potential spaces in the anal triangle which are filled with abundant fat and best nidus for infection and also provide area for pus collection. The rule is inaccurate in describing the course of complete submuscular anal fistulas with an anterior external opening. The rule, however, gives us a clue for suspicion of course of fistulous tract along with that other investigative tools are essential before planning surgery for fistula-in-ano.

Acknowledgment

We would like to thank Dr. B. S. Prasad MD (Ayu), PhD, Principal, HOD Department of Panchakarma, KLEU's Shri B. M. Kankanwadi Ayurveda Mahavidyalaya, Shahpur, Belagavi.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cirocco WC, Reilly JC. Challenging the predictive accuracy of Goodsall's rule for anal fistulas. Dis Colon Rectum 1992;35:537-42.  Back to cited text no. 1
[PUBMED]    
2.
Louis A. Buie, M.D Anal Fistulectomy, October 24, 1931. Jama. 1931;97(17):1208-1212. doi:10.1001/jama.1931.02730170020007.  Back to cited text no. 2
    
3.
Sangwan YP, Rosen L, Riether RD, Stasik JJ, Sheets JA, Khubchandani IT, et al. Is simple fistula-in-ano simple? Dis Colon Rectum 1994;37:885-9.  Back to cited text no. 3
    
4.
Abou-Zeid AA. Anal fistula: Intraoperative difficulties and unexpected findings. World J Gastroenterol 2011;17:3272-6.  Back to cited text no. 4
[PUBMED]    
5.
Goodsall DH, Miles WE, editors. Ano-rectal fistula. In: Diseases of the Anus and Rectum. London: Longmans, Green & Co.; 1990. p. 92-137.  Back to cited text no. 5
    
6.
Abcarin H. Anal Fistulas: Principle and Management. New York, Heidelberg, London: Springer; 2014. p. 10-1.  Back to cited text no. 6
    
7.
Shastri KA. Sushruta Samhita Ayurveda Tattva Sandipika Hindi commentary. Sutrasthana 33/4. 2nd ed., Vol. 1, 2. Varnasi: Chaukhamba Samskrita Samsthana; 1997. p. 144.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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