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University of North Alabama.

All these cellular specializations help in platelet functions: adhesion discount cialis professional 40 mg with visa erectile dysfunction treatment high blood pressure, aggregation purchase genuine cialis professional on-line medicare approved erectile dysfunction pump, activation discount cialis professional master card erectile dysfunction gnc products, and secretion. Primary hemostasis (temporary hemostatic plug formation) is the first and important step in hemostasis, which mainly depends on platelets. Platelet also paly role in clotting by activating few clotting factors and promoting clot retraction. Platelet count less than 50,000 per cu mm of blood is called critical count, as bleeding is significant below this count. In theory examination, “Role of platelets in hemostasis”, “Steps and regulation of thrombopoiesis”, and “Structure, properties and functions of platelets” may come as Long Questions. Temporary hemostatic plug, properties of platelets, thrombopoiesis, platelet granules, cytoskeletal and canalicular systems of platelets, functions of platelets, and platelet function tests may come as Short Questions in exams. Appreciate the physiological basis of use of fibrinolytic agents in coronary artery disease and stroke. List the investigations for detection of defects in temporary and definitive hemostatic plug formation. Later, few more were Coagulation of blood is a vital physiological process, as added to the list. Blood is maintained in a Scientist contributed fluid state in the vascular compartment, yet swiftly coagu- lates to seal a vascular injury. Failure to form clot results in In 1905, Paul Morawitz was the first scientist who systematically assembled coagulation factors into hemorrhage or thromboembolic phenomenon. Paul Morawitz hemostasis is the coagulation of blood, the process which is simultaneously activated along with the activation of Factor I platelets. It is a dimeric glycoprotein with molecular weight of present in their inactive form in plasma. The genes for three chains of fibrinogen are found in reactions involving clotting factors. It is an important physiological initiator of extrinsic pathway for blood coagulation. Fibrinogen is present in plasma and α-granules of vasation of blood from the injured vessel, circulating platelet. Fibrin forms the structural meshwork that transforms steps of intrinsic and extrinsic pathways of blood coagula- the loose platelet plug into a solid hemostatic plug. This is a large glycoprotein with molecular weight 333,000 and plasma half-life of about 12h. It is a single chain zymogen with molecular weight thrombin to thrombin, though it also participates in 72,000 and plasma half-life of about 60 h. The gene for human prothrombin is located on chro- glutamic acid residues that are important in activating mosome 11 close to the centromere. This activity is physiologically expressed on the surface of Oscar D Ratnoff and Joan E Colopy worked in the field of blood coagulation. It possesses receptor contains 731 amino acids with molecular weight of mediated proinflammatory activity. The gene for thrombomodulin is located on chromo- platelets, monocytes and macrophages. When thrombin binds with thrombomodulin, the the gene for B chain is located on chromosome 1. Thrombin causes cleavage of A and B subunits of in turn, causes 2000-fold activation of protein C. In addition to its nonenzymatic function in contact Protein S activation, it acts as a thiol protease inhibitor. It is cleaved by prekallikrein to bradykinin, a potent Protein S is a single-chain glycoprotein cofactor synthe- vasodilator. It is also synthesized by endothelial cells, megakaryocytes, Leydig cells and osteoblasts. Scientist contributed Protein Z Prekallikrein was initially described by Dr Hathaway et al, in 1965 after encoun- Protein Z is synthesized in liver. Exposed collagen stimulates platelet adhesion and of prothrombin activator) aggregation before initiating blood coagulation. Factor Xa is called prothrombin activa- tor as it activates prothrombin to form thrombin. Chapter 21: Blood Coagulation 201 Step 4 (Activation of X) thrombin, in the presence of platelet phospolipid, calcium and activated factor V (Va). Factor Va acts as cofactor for Final step in activation of prothrombin activator is activa- acceleration of this process. Thus, it In the intrinsic system of blood coagulation, activation of provides positive feedback to the coagulation process. It activates procarboxypeptidase B that inhibits plas- sequent factors in a series of steps. Thus, thrombin balances Extrinsic Pathway the coagulation and anticoagulation processes in the Extrinsic pathway of blood coagulation occurs in three body. Proteolysis of Soluble Fibrinogen Note: Though there are intrinsic and extrinsic systems of Fibrinogen has three domains: two peripheral (D) domains blood coagulation, recently it is believed that these two and one central (E) domain. Thrombin binds with central domain and proteo- factors are interrelated for homeostasis. Release of fibrinopeptides leads to the formation of vated Stuart-Prower factor (Xa) converts prothrombin to fibrin monomer (Flowchart 21. Mechanism of Clot Retraction the platelets form spicules (filopodia) that extend along the fibrin threads. Also, protofibrils of thick fibrin strand get embedded within the filopo- dia by the action of membrane cytoskeleton. About 15 to 20 protofibrils aggregate to form thick A retracted clot is a consolidated and stable thrombus, fibers of fibrin. Protofibrils also branch out to form into a meshwork sel, but also has other functions. Covalent cross-linking of fibrin polymers provides and completes in 18 to 24 hours. Red cells and platelets are trapped inside the fibrin receptors results in inhibition of clot retraction that meshwork to give the volume to the clot. Fibrin (Fibrinolysis) threads spread in all directions and adhere to the endothelial wall. When blood is allowed to clot in a test Tendency of blood to clot in vivo is prevented by naturally tube, the fibrin mesh spreads all around trapping all the occurring anticlotting mechanisms. However, within minutes to hours, clot ance between clotting and anticlotting mecahnisms. The basal coagulation may be due vivo that causes consolidation of thrombus (intravas- to minor injuries to blood vessels that occur during cular clot).

Spermatozoa from tubu- lar fluid and rete testis are transferred to epididymis almost passively as they are essentially immotile generic cialis professional 20 mg mastercard erectile dysfunction 18-25. In epididymis buy cialis professional 20 mg free shipping erectile dysfunction homeopathic, they acquire the capacity for progres- sive forward movement and the ability to attach to zona pellucida of ovum and penetrate into it purchase 20 mg cialis professional overnight delivery erectile dysfunction treatment. Thus, the sperms obtained directly from testis are functionally immature, whereas sperms obtained from body of the epididymis or further down in the male genital tract are fertile. Note, testosterone secreted from Leydig cells enters Sertoli cell and voided through ejaculation is not clearly known. Similarly, estradiol produced in that these sperms are ultimately phagocytosed by macrophages in Sertoli cells enters Leydig cell and control Leydig cell functions. Therefore, in practice of yoga, it has been advised to conserve and properly utilize the energy of the semen. Proximal part of vas deferens like epididymis stores Estrogen produced in Sertoli cells diffuses back the sperms. The movement of sperm in vas deferens is active as Functions of Testis they are capable of motility. Spermatogonia are located attached to the basement membrane of the seminiferous tubule. From puberty onwards, these cells divide mitotically to continu- ously supply spermatocytes that form spermatozoa. From puberty onwards, spermatogenesis continues Seminal Vesicle throughout life, though the process declines at old age. They secrete a viscid and alkaline fluid called seminal Steps of Spermatogenesis vesicular fluid. Seminal vesicular fluid contributes to 70% of the total the process of spermatogenesis can be divided into three volume of the semen. Spermatogonium undergoes mitosis to fluid and fluid secreted from accessory sex glands, and produce primary spermatocytes that undergo two meiotic 10% is contributed by sperms. Most of the prostaglandins found in semen are con- Mitosis tributed by seminal vesicle. The primitive germ cells (spermatogonia) that are present in the basal lamina of seminiferous tubules undergo mitotic Accessory Sex Glands divisions to from primary spermatocytes. This is called Accessory male sex glands are prostate gland and bul- spermatocytogenesis (Fig. The Prostate Gland Spermatogonia A: Spermatogonia A formed by mitotic the ejaculatory duct enters the prostatic portion of the divisions resemble the original spermatogonia and are the urethra after passing through the prostate. Prostate gland consists of 30–50 branched tubulo- they form the spermatogonia reserve pool in the testis. Spermatids contain half of the number of chromosomes the enzyme hyaluronidase that facilitates penetrability of (23 chromosomes, i. Of every four spermatids formed from primary sper- primary spermatocyte, each cell contains 46 chromosomes and matocytes, two of them contain X chromosome and from secondary spermatocyte to spermatozoa, each cell contains 23 chromosomes (number indicated against each category of cells two Y chromosomes. Normally after undergoing several mitotic and two meiotic divisions in the process of spermatogenesis, each spermatogonium yields 512 spermatids. Spermiogenesis the process of development of spermatids into matured spermatozoa is called spermiogenesis. Formation of a middle piece and a tail piece with the ability to move efficiently and swiftly. All these changes occur in mature sperms to enable them to survive in a foreign and even hostile environment (acidic vaginal pH) in the female genital tract and to recog- nize and fertilize the ovum. These changes mainly help the sperm to move forward towards the ovum in the female genital tract, the movement known as progressive moti- lity of the sperm. Spermiation Spermatozoa, after they are formed, remain in the lumen of the seminiferous tubule sticking to the apical membrane of the Sertoli cells. The process of detachment of head of spermatozoa and their free release into the luminal fluid is called spermiation. This includes increase in further motility of sperms by which it propels the body of the sperm in forward and preparation for acrosomal reaction. The twisting movement occurs due to the tation is not so much essential for fertilization as fertiliza- interaction between tubulin fibers and dynein side tion can also occur in vitro. The axoneme is surrounded by a fibrous sheath Structure of Spermatozoa that provides strength to the tail. The exact function of this enzyme is not about 65 µm long with average diameter of 2 µm. Head Role of CatSper protein: the principal piece of tail con- Head contains a prominent nucleus at the center, which is tains a protein called CatSper protein, which is a calcium condensed with chromatin. Acrosome is like a lysosome rich in proteolytic enzymes such as hyaluronidase, acrosin, neuraminidase and ester- Duration of Spermatogenesis ases that are activated during acrosomal reaction and In human beings, the process of formation of sperm from help in sperm penetration of the ovum at the time of ferti- the spermatogonium takes 65–74 days. The nucleus decondenses and becomes a pronu- stages of development of sperms are collectively called as cleus at the time of fertilization. Primary spermatocytes to secondary spermatocytes is dria in the form of a spiral sheath surrounding a long axial 23–25 days. Secondary spermatocytes to spermatids is approxi- nine peripheral doublet microtubules surrounding a cen- mately 1 day. The mitochondria provide energy for sperm metabo- Hormones like gonadotropins or androgen influence lism and motility. Normally, new cycles are initi- the tail piece is divided into a principal piece and an end ated in every 2 to 4 weeks before the completion of old cycle. Chapter 67: Male Reproductive System 597 Rate of Production of Sperms (spermatids developing to spermatozoa) is andro- gen dependent. This is roughly same as the the spermatozoa concentrated, which is required for number of sperms in an ejaculate in a normal healthy sperm maturation. Expressed per unit weight of testicular tissue, about that enters rete testis and epididymis unless absorbed 6–7 million sperms are produced per gram per day. The rate of production of sperms falls progressively in the fluid by facilitating fluid reabsorption. The decrease in production in elderly is due to degen- gametogenic functions of testis. Environmental Factors Differences between Spermatogenesis and It is mainly the temperature that influences spermatogen- Oogenesis esis. Lower environmental temperature facilitates sper- There are few basic differences in the process of game- matogenesis. In females, mitotic proliferation of germ cells com- increased temperature inhibits spermatogenesis. There- pletes before birth, whereas in males, spermatogonia fore, in persons taking repeated hot bath or those who grow only at the time of puberty and then continue to regularly use insulated athletic support for the scrotum, proliferate throughout life. In female, the meiotic division of primary oocyte pro- more in comfortable winter and less in intense summer. In female, second meiotic division is completed only upon fertilization, whereas in males second meiotic Semen analysis is one of the important tests for assess- division is completed during spermatogenesis. It is also performed Factors Controlling Spermatogenesis after vasectomy, to check its completeness. Factors controlling spermatogenesis can be broadly divided Analysis of freshly collected sample of semen gives the into two categories: hormonal and environmental.

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Its distribution (whether some of the other episodes that were treated would have half-life is much longer (2–3 hours) buy discount cialis professional 20mg online impotence in the bible, and its elimination half-life terminated without treatment is unknown) [64] purchase cheap cialis professional on-line erectile dysfunction doctor in nj. Its efects purchase cialis professional cheap online injections for erectile dysfunction that truly work, therefore, are new-onset seizures in children found that half of the children had sei- longer lasting than are those of diazepam. Also, because of its lower zures lasting longer than 5 minutes, and 92% of the seizures stopped lipid solubility, it can be administered as a faster bolus than diaze- spontaneously; indeed, approximately three-quarters of the seizures pam as there is no frst-pass efect in brain uptake. In this study, although not statistically signifcant, lorazepam had a more impressive efect Acute repetitive seizures (serial seizures, seizure clusters) than diazepam. Tere have been fve other randomized studies, and Emergency drug therapy is also indicated in a situation where sei- several meta-analyses (see for example [67,68]) comparing diaze- zures are likely to recur within minutes. The purpose here is to pre- pam and lorazepam, and some have shown no diference and some vent the recurrence. The dif- Drugs used in the emergency therapy of acute repetitive ferences between diazepam and lorazepam though are slight, and the seizures and prolonged seizures studies difcult to compare because of diferent, and in some rather The drug treatment in these situations takes the form of parenter- low, dosages. In both studies rectal diazepam reduced the risk of on- Tese routes are appropriate only if the medication is quick acting going seizures compared with placebo. Tere have been many studies of efcacy and study comparing 30 mg with 20 mg diazepam rectally in adults with the timing of seizure control, and this is one area of epilepsy where serial seizures [72] and 30 mg was found to have superior efcacy there is generally an excellent evidence base. Rectal diazepam epam or diazepam (diazepam is far more widely available world- has also been used as the active comparator in six randomized trials wide, but in terms of outcome lorazepam is slightly superior). It is available as a midazolam hydrochloride (Epistatus) and midazolam Intravenous diazepam and lorazepam maleate (Buccolam) [65,66,67,68]. All studies have found that buccal when compared with lorazepam: (i) its short redistribution half- administration is easier to perform, and far more acceptable to pa- life (less than 1 hour) and large volume of distribution (1–2 L/kg) tients and carers (see for example [78]), and so buccal midazolam which result in serum and brain concentrations that rapidly fall has become the currently preferred therapy. Emergency Treatment of Seizures and Status Epilepticus 229 Intranasal benzodiazepines advocates especially for use in children. However, paraldehyde is Midazolam has long been used via the intranasal route to control difcult to use and administer and its use has in recent years been seizures, although no commercial preparations are licensed for use superceded by other more convenient therapies [1,89]. In four there was no diference, but zures without prior benzodiazepine use, and these include bolus in one intranasal midazolam was found to be more efective than doses of levetiracetam, valproate, phenytoin, phenobarbital, ket- rectal diazepam [79,80,81,82,83,84]. Each has shown zolam, intranasal midazolam was easier and quicker to administer efcacy but in general none have superseded benzodiazepines for than rectal diazepam and this route of administration is also used general applicability in acute seizures. Tere are no comparisons of buccal with intranasal midazolam, and this would be an important study to carry out in the future. In- Treatment of tonic–clonic status tranasal instillation is quick and easy, and may become a preferred epilepticus option, although the authors would be concerned about the risk of overuse by anxious patients misinterpreting symptoms of impend- Diagnosis ing seizures. Non-epileptic attacks are frequently prolonged and can be confused Intranasal lorazepam has also been trialled, and found to be of with status epilepticus. The risk is lessened by formulating the drug in a tus or in drug-induced coma (usually secondary to large amounts of single dose inhaler. However, tients with pseudostatus had a previous diagnosis of epilepsy that midazolam, which is water-soluble in the preparation in which it may have confounded the diagnosis. Failure by admitting doctors to recognize the possibility Tere are a number of studies of tolerability and efcacy. This study, which has Tese have also been proposed to be a means of staging the sta- been rightly applauded for its design and execution, used a double tus epilepticus. This progression has been proposed to group), recurrence of seizures (11% in both groups), need for en- mirror increasing drug resistance and a worsening prognosis [60]. However, outcome is probably more related to age available or licensed for use in seizures. Other drug therapies Medical management and complications Clonazepam is an alternative benzodiazepine which has a long his- Convulsive status epilepticus is a medical emergency because of the tory of use as emergency therapy in acute seizures. Indeed, when signifcant potential for excitotoxic cerebral damage, other forms of introduced in 1975, it was considered by Gastaut to be superior to cerebral damage and associated medical complications. However, of convulsive status epilepticus can be divided into early and late there is a scarcity of published data on its efectiveness [87,88] and stages. In the early phase, cerebral autoregulation and homeostasis no controlled studies. The initial consequence of a prolonged con- half-life than diazepam and so there are theoretical reasons to fa- vulsion is a massive release of plasma catecholamines [94], which vour its use. During this stage, cardiac arrhythmias are frequently seen, which is undoubtedly highly efective and safe, and it still retains and may be fatal [95]. Cerebral blood fow is greatly increased and 230 Chapter 17 thus glucose delivery to active cerebral tissue is maintained [96]. Other the seizure continues, there is a steady rise in the core body temper- investigations depend on the clinical circumstances. If there is a history of alcoholism, or other com- production, but there is also a rise in carbon dioxide tension that promised nutritional states, 250 mg thiamine (e. This is particularly important if and hypotension and, in conjunction with the cardiovascular com- glucose has been administered, as a glucose infusion increases the promise, may result in severe pulmonary oedema [100]. Intrave- The status epilepticus then enters a second phase in which cerebral nous high-dosage thiamine should be given slowly (e. The main char- high-potency Pabrinex over 10 minutes), with facilities for treating acteristics of this phase are a fall in blood pressure, a loss of cerebral the anaphylaxis, which is a potentially serious side-efect of Pab- autoregulation, resulting in the dependence of cerebral blood fow rinex infusions. Routine glucose administration in non-hypogly- on systemic blood pressure, and hypoglycaemia due to the exhaus- caemic patients should be avoided as there is some evidence that tion of glycogen stores and the increased neurogenic insulin secretion this can aggravate neuronal damage. The combined efects of systemic hypotension and intrac- Acidosis If acidosis is severe, the administration of bicarbonate has ranial hypertension can result in a compromised cerebral circulation been advocated in the hope of preventing shock, and mitigating the and cerebral oedema [103], particularly in children. In most cases, cations may occur, including rhabdomyolysis, leading to acute tubular however, this is unnecessary and more efective is the rapid control necrosis, hyperkalaemia and hyponatraemia [104]. Establish aetiology The causes of status epilepticus difer with age, Because of these medical complications, status epilepticus that has and in the presence or absence of established epilepsy. If the status epilepticus has been precipitated by drug withdrawal, the immediate restitution of the withdrawn drug, even at lower dos- 0–10 minutes es, will usually rapidly terminate the status epilepticus. Pyridoxine should also be given intravenously to children under the age of 3 Oxygen and cardiorespiratory resuscitation It is frst essential to years who have a prior history of epilepsy and to all neonates. Oxygen should always be administered, as Physiological changes and medical complications The physiologi- hypoxia is ofen unexpectedly severe. Active treatment is most commonly required for hypoxia, 1–60/90 minutes hypotension, raised intracranial pressure, pulmonary oedema and Monitoring Regular neurological observations and measurements hypertension, cardiac arrhythmias, cardiac failure, lactic acidosis, of pulse, blood pressure, electrocardiography and temperature hyperpyrexia, hypoglycaemia, electrolyte disturbance, acute hepatic should be initiated. The dose should be titrated Emergency anticonvulsant therapy This should be started. Intensive care monitoring In severe established status epilepticus, Fify millilitres of serum should also be saved for future analysis, intensive monitoring may be required, including intra-arterial Emergency Treatment of Seizures and Status Epilepticus 231 blood pressure, oximetry, central venous pressure and pulmonary in the presence of persisting, severe or progressive elevated intracra- artery pressure monitoring. The need for active therapy is usually determined by Although magnesium is efective at preventing eclampsia, there is the underlying cause rather than the status epilepticus. Intermittent no evidence to suggest that increasing magnesium serum concentra- positive-pressure ventilation, high-dose corticosteroid therapy (4 mg tions to supranormal levels has any beneft in status epilepticus. In- dexamethasone every 6 hours), or mannitol infusion may be used (the deed, such a policy can result in motor paralysis, difculty in detect- last is usually reserved for temporary respite for patients in danger of ten- ing clinical seizure activity and hypotension [106]. The choice of drug depends on previous therapy, the type of epilepsy and the clinical setting.

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Island flap ano- as other procedures for anal fistula cialis professional 20 mg generic erectile dysfunction rings, surgeons should be plasty for treatment of transsphincteric fistula-in-ano buy generic cialis professional online xarelto impotence. Abcarian tested order cialis professional master card erectile dysfunction causes medications, either with direct probing or with injection of hydrogen Introduction peroxide or saline [2, 4, 5]. Several series report discharg- the main tenets in treating fistula in ano are the amount of ing patients with a week of oral antibiotics [2, 4, 5]. As a stan- These considerations have led to the development of various dard, at our institution, setons are used to drain all infection sphincter sparing options throughout the years. This chapter prior to undertaking definitive surgical repair of the fistula will focus on the ligation of intersphincteric fistula tract and many of the other series do so as well. The operation is appropriate for and, in many cases, easier to dissect free from the surround- transsphincteric fistulas with length sufficient enough to per- ing tissues ensuring a successful ligation [3 , 6 ]. The fibers of the internal and external sphincter lithotomy position, under either regional or general anesthe- are separated and the intersphincteric groove is entered. Some surgeons use lithotomy or prone jackknife position the fistula tract is identified (Fig. Bowel prepara- lated, severed, and suture ligated at both ends and severed tion consists of two phospho soda enemas the day before after removal of the fistula probe (Fig. Patients are administered only a single dose of ligature obliterates the internal opening. If the tract length appropriate peri-operative antibiotics intravenously, usually warrants, a portion of the tract may be excised, increasing the cefoxitin, or ciprofloxacin/metronidazole if the patient is distance between the two suture-ligated ends (Fig. At the end of the procedure, a dibucaine- the internal and external sphincter are reapproximated; coated piece of gelfoam is rolled and gently inserted into the the skin is closed loosely. The patients are not admitted for and left open to drain and heal secondarily (Fig. Results/Discussion We prefer to remove a portion of the tract if the length allows it [3]. There was no reported incontinence Department of Surgery, University of Minnesota, 1055 Westgate Drive, Ste 190 , St. Reprinted with wound is closed loosely, and external opening of the tract is enlarged to permission [3 ]. Dissection of intersphincteric groove and identification of fibrotic Drawings courtesy of Russell K. These early reports sug- illustrates the desirable points of any novel sphincter sparing gested a healing rate of 57–82 % at 9–24 weeks follow-up, technique, i. In patients in whom endo- anal ultrasound revealed failure resulting in a simple fistula, Failures the patients were successfully treated with application of silver nitrate or fistulotomy. The series reports an over- categories: early (procedural failure) and late (recurrence). Including these patients in the overall randomized trials is hindered by the suitability of the healing percentage, they observed a 100 % healing rate. No Furthermore, the incontinence score after 6 months was “gold-standard” sphincter sparing technique exists [21 ]. Like other sphincter sparing later studies are minimal and on par with other sphincter techniques, the operation itself is very much dependent on sparing techniques. Subsequent studies have validated the success rates of the initial technique (see Table 16. Total series have varying healing rates; however, they are small anal sphincter saving technique for fistula-in-ano; the ligation of series and none of them have been validated or duplicated. Ligation of intersphincteric Conclusion fistula tract: early results of a pilot study. Does ligation ceric fistula tract compared with advancement flap for complex of the intersphincteric fistula tract raise the bar in fistula surgery? Fibrin glue treatment intersphincteric fistula tract in low transsphincteric fistulas: a new of complex anal fistulas has low success rate. Outcomes with the use of bioprosthetic grafts to reinforce successful closure with anal fistula plug in cryptoglandular fistulas. Ligation of the intersphincteric improve the outcome of transanal advancement flap repair for high fistula tract: an effective new technique for complex fistulas. Dis transsphincteric fistulas by additional ligation of the intersphinc- Colon Rectum. Letter to the editor on “The management of fistula-in- ligation of the intersphincteric fistula tract procedure: the Western ano: a plea for randomized trials and standard reporting of a case Hospital experience. Which tap is used depends on the position of the technique performed for the surgical treatment of complex fistula. Also in the kit are a semicircular or linear stapler and anal fistulas and their recurrences. The optimal nary gentle probing of the tract in order to explore it and to patient positioning is the lithotomic position. The fistuloscope is connected to the Karl Storz of “putting an eye” on the probe and exploring the tract from equipment and to the washing solution bag. This allows precise identifica- tion of secondary tracts and abscess cavities and minimizes the risk of creating false passages on the way to reaching the the Diagnostic Phase internal opening. After this a diatermocoagulation of the fis- tula walls and a hermetic closure of the internal opening are the purpose of this phase is to find the main and secondary performed. The accurate anatomic definition and the precise tracts and abscess cavities and to correctly locate the internal identification of the internal opening, the drainage of associ- fistula opening. At the beginning of the procedure insert a ated sepsis, the destruction of the tract, and the closure of the syringe in the external orifice and inject low-pressure saline internal opening itself are the rationale principles of anal fis- solution in order to obtain a fistula tract dilatation. This technique tissue around the external opening can be removed by elec- comprises two phases: (1) a diagnostic one and (2) an opera- trosurgical knife for ease of entry of the fistuloscope tip and tive one. During the insertion, the washing solution is already running, providing a clear view of the fistula pathway, which Materials appears on the screen (Figs. At this point, it is very important to be patient and wait for an adequate dila- Karl Storz GmbH Video Equipment (Tuttlingen, Germany) tion of the tract. The operating kit includes a fistuloscope guide it using a trans-anally inserted finger. The fistuloscope has an external opening, allows it to be straightened by a counter 8° angled eyepiece, its diameter is 3. Blocking tissue in the tract can be removed using the equipped with an optical channel and also a working and 2 mm forceps to facilitate the progression of the fistuloscope. The operative length is 18 cm without a the orientation of the fistuloscope is correct when the obtu- rator appears in the lower part of the screen. The surgeon follows the fistula pathway using slow left-right and up- down movements.