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Microsurgery in mucosal advancement flap repair: a microscope-assisted, tissue-sparing approach for managing complex
Ignacio Fernandez-Hurtado1,2, Naila Pages-Valle3, Marta Castro-Suarez3
1Coloproctology Unit, General and Digestive Surgery Department, Son Llatzer University Hospital, Carretera de Manacor, Km 4, 07198, Palma, Mallorca, Illes Balears, Spain. ifernandez@hsll.es.
Background:
The management of complex perianal fistula remains challenging, requiring a balance between effective tract eradication and preservation of anal sphincter function. Despite multiple surgical options, recurrence rates and functional outcomes remain suboptimal. Microsurgical techniques, widely adopted in other surgical fields, may offer enhanced precision and tissue preservation. This study aims to describe the implementation of a microsurgical approach for complex perianal fistula within an IDEAL Stage 1 framework.
Methods:
A prospective single-center case series was conducted including 10 highly selected patients with complex perianal fistula undergoing a microsurgical modification of the mucosal advancement flap technique. Inclusion criteria comprised patients with a single primary tract and prior seton drainage. The primary outcome was a composite of technical feasibility and safety within 30 days. Feasibility was defined as completion of the procedure using the microsurgical approach without conversion. Safety was assessed using the Clavien-Dindo classification and the Comprehensive Complication Index (CCI).
Results:
All procedures (10/10) were successfully completed using the microsurgical approach without conversion to conventional surgery. The mean operative time ranged from 70 to 120 min, and the mean docking time was 4.6 min. Eight patients were managed as day-case procedures. One intraoperative adverse event occurred: a vasovagal episode during neuraxial anesthesia induction requiring conversion to general anesthesia (Clavien-Dindo grade II; CCI 20.9), which resolved without sequelae. No procedure-related or postoperative complications were recorded within 30 days. All prespecified success thresholds were met.
Conclusions:
The application of a microsurgical approach to complex perianal fistula is technically feasible and appears safe in this initial IDEAL Stage 1 experience. The enhanced visualization and precision offered by microsurgery may support more controlled dissection and anatomical reconstruction; however, clinical benefits such as improved healing, reduced recurrence, or better functional outcomes were not assessed in this study. Further investigation in IDEAL Stage 2 studies is required to evaluate reproducibility, clinical effectiveness, and long-term outcomes.
Clinical Registry:
ClinicalTrials.gov identifier: NCT06484660.
