Staged hybrid sphincter-preserving surgery with Video-Assisted Anal Fistula Treatment (VAAFT) and Ligation of Intersphincteric Fistula Tract (LIFT) for complex horseshoe trans-sphincteric anal fistula: A case report

Background Horseshoe trans-sphincteric anal fistula is a complex variant of cryptoglandular fistula characterized by circumferential lateral extension within the deep postanal space and significant sphincter traversal, leading to a high risk of recurrence. Optimal surgical management remains challenging because procedures focusing solely on internal opening ligation or tract clearance may inadequately address this dual-mechanism anatomy. Case presentation We report a 29-year-old woman with recurrent perianal abscesses and persistent purulent discharge for two years. Pelvic magnetic resonance imaging demonstrated a horseshoe trans-sphincteric fistula with bilateral posterior extensions across the deep postanal space. An anatomy-driven staged surgical strategy was performed. On the left side, limited fistulectomy with seton drainage was initially conducted for infection control, followed by ligation of the intersphincteric fistula tract (LIFT) during the second-stage operation. On the right side, video-assisted anal fistula treatment (VAAFT) was used for endoscopic tract visualization and clearance, with a second VAAFT session performed to enhance cumulative tract sterilization. Postoperative recovery was uneventful, and satisfactory wound healing without recurrence or continence impairment was observed at 3-month follow-up. Conclusion Side-specific staged sequencing that aligns operative techniques with tract depth and sphincter involvement may represent a rational strategy for managing complex horseshoe trans-sphincteric fistulas while preserving sphincter function.