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Anal fistula, closure with Anal Fistula Plug® (AFP®) - general and visceral surgery
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Excising the fistula opening
Inserting the plug
Insert a stay suture. Pull the tapered end of the AFP attached to the stay suture into the tract through the internal opening and the tract to the outside. Keep the plug under slight tension until it is firmly seated in the lumen of the fistula. Trim the internal excess such that the plug is flush with the mucosa.
Anchoring the plug
Anchor the plug, usually with 2 PDS sutures (3-0 or 2-0) through the internal sphincter or muscularis propria. With the proper stitch direction, this should also close the mucosa and anoderm respectively. Alternatively, close it with a new suture. Some authors dissect a mucosal flap akin to that used in plastic fistula closure. Finally, trim the external excess to just below skin level. The plug does not have to be anchored here.