Innovative approach in the management of horse-shoe fistula-in-ano with Kṣārasūtra

Fistula-in-ano is a common surgical problem. Horse-shoe fistulas usually have an internal opening in the posterior midline and extend anteriorly and laterally to one or both ischiorectal spaces by way of the deep potential space. The "Śambukāvarta Bhagandara" described by Suśruta can be correlated with the horse-shoe type of fistula. In this condition, neither fistulotomy nor "Kṣārasūtra" treatment alone, are useful hence there is a need for newer innovative surgical techniques to tackle this challenging disease. An integral approach of incision and drainage of both the abscess on the arms of the horse-shoe fistula with Kṣārasūtra ligation at 6 o' clock position proves to be successful. We have tried the same technique with good results. No recurrence was found in the patients during the follow-up period of 6 months. A 45-year-old female with a known case of diabetes mellitus and hypertension approached with both right and left ischiorectal fossa inflammatory swelling. An innovative approach was used to manage horse-shoe fistula by making an additional opening below the anus at 6 o'clock position. Apāmārga Kṣārasūtra (medicated thread made using apāmārga) was ligated through the additional opening to the internal opening at 6 o'clock position for draining through both the cavities. Kṣārasūtra was changed weekly and the fistula healed completely by 3 months.