Dr Arnab Ray 
MS (Ayurveda), PhD
Ayurvedic Proctologist

In complex anal fistula the track crosses more than 30%-50% of external anal sphincter. Suprasphincteric, high transsphincteric and extrasphincteric fistulas are all complex fistula. The recurrent fistula that has multiple tracks or ramifications, anterior fistula in female patients and fistula caused by colonic diseases like Crohn's disease are also complex fistulas. Minimal invasive procedure like placement of seton or ksharasutra has good success rate in complex anal fistula

Anal sphincters are a couple of muscles known as external and internal anal sphincter. They collectively maintain the continence mechanism i.e. control the release of stool. In anal fistula surgery, every care should be taken to preserve the function of the sphincters. Minimal and calculated trauma to the sphincter are the prime focus of fistula surgery. Recurrent fistulectomy may cause irreversible injury to the sphincter muscles. Anal fistula treatment with ksharasutra, two stage seton fistulotomy, laser surgery are all good sphincter sparing surgeries. 

High anal fistulas often having supra-levator extension or involvement of pelvirectal muscle are very critical conditions. They are typically sequel of Crohn's disease and ulcerative colitis. Management of high anal fistula is more complicated compare to low anal fistula. Surgery is done in very selective cases. Minimal invasive procedures with ksharabarti or ksharasutra are often very helpful. 

Minimal invasive procedures are the choice of treatment for various anorectal diseases like piles and fistula. Days of extensive surgical excisions are gone. Nowadays, utmost attention is given on restoring the delicate anatomy of the anal canal and hence preserve the normal physiological functions of anal canal and rectum. The subtle sensation of complete evacuation, preventing leakage, holding urge are very importance issues often ignored during large dissection which in turn deteriorate the quality of life of the individual. Ksharasutra ligation in internal hemorrhoids, anal fistula treatment with ksharasutra, SLOFT, IFTAK, laser fistula ablation, laser hemorrhoidopexy are all minimal invasive procedures performed selectively. 

Ksharasutra is a medicated seton that is used for the treatment of fistula including highanal, complex, recurrent types; selected cases of internal hemorrhoids, rectal polyp and pilonidal sinus. Procedure using ksharasutra in a minimal invasive surgery with negligible loss of function of perianal sphincter complex and other delicate tissues of anal canal. It causes minimum blood loss and has a very high success rate. The qualified Ayurvedic surgeons, in particular, are extensively trained in this procedure. 

Hemorrhoids or piles are normal structures of surgical anal canal and they are considered as disease only when they become symptomatic. Non-surgical treatment like medicine, ksharakarma, sclerotherapy, banding and laser showed good result in 1st, 2nd and 3rd degree piles. A plethora of Ayurvedic medicines are available for management of piles but should always be received under medical supervision.

3rd and 4th degree piles are treated with surgical intervention. Ksharasutra ligation of internal piles, hemorrhoidal artery ligation and laser hemorrhoidopexy are gaining popularity as they are minimal invasive procedures.

Anal fissures treated conservatively at early stage are mostly reversible condition. Ayurvedic medicines for fissure are safe, effective and trustworthy. The chronic anal fissures show symptomatic improvement with medical management but may require surgical intervention.

Surgery gives the fastest relief to a fissure patient. A number of day-care procedures are there for quick relief for busy patients who do not have spare time to continue with long medical management. Chronic anal fissures with sentinel tag are better treated with surgery to prevent complications like retrofissure abscess and fissure-fistula complex.