Endoscopic Identification of a Hidden Internal Opening Using Video-Assisted Anal Fistula Treatment (VAAFT)

The purpose of this study is to present our experience with video-assisted anal fistula treatment (VAAFT) in a patient with a complex and recurrent anorectal fistula, whose internal opening could not be identified through multiple prior surgical interventions. A 36-year-old male patient with a history of nine previous fistula surgeries presented with persistent symptoms and a newly developed lateral external opening in the right gluteal region. VAAFT was performed under general anesthesia with the patient in the prone position. The fistuloscope was advanced through the external opening, allowing visualization of both the primary and secondary tracts. The internal opening was identified, and the fistulous tracts were thoroughly debrided. A draining seton was placed while preserving the integrity of the sphincter complex. At the four-month follow-up, all secondary tracts had successfully closed. However, due to the presence of false tracts resulting from prior interventions, the primary tract had evolved into a suprasphincteric fistula. The patient remains under regular follow-up with a seton in place and has reported significant improvement in both symptoms and overall quality of life. Our experience indicates that VAAFT is a valuable option in selected cases of complex and recurrent anal fistulas, especially when the internal opening cannot be identified using conventional methods.