Sequential Surgical Management of a Recurrent Complex Transsphincteric Anal Fistula With Sphincter Disruption: A Case Report.

High transsphincteric anal fistulas represent a significant therapeutic challenge due to the risk of fecal incontinence associated with division of the sphincter complex. Management must be individualized, particularly in recurrent cases. We report the case of a 55-year-old male with a recurrent high posterior transsphincteric anal fistula who had undergone multiple previous surgical interventions. Initial treatment with fistulectomies and cryptectomies resulted in disruption of both the internal and external anal sphincters, leading to severe fecal incontinence. Due to persistent fistulous drainage, the patient underwent diagnostic laparoscopy with creation of a protective loop ileostomy, irrigation and drainage of the tract, primary transanal closure of the internal opening, and application of fibrin sealant (Tisseel®, Baxter Healthcare Corporation, Deerfield, IL). In the outpatient setting, tract curettage using a CitoBrush® (Medscand AB, Malmö, Sweden) and repeat application of fibrin sealant were performed. Subsequent examination under anesthesia revealed fibrosis without evidence of an active tract. Intestinal continuity was ultimately restored. The patient's postoperative course was favorable, with no recurrence or continence impairment. This case illustrates the importance of a stepwise surgical approach integrating conventional and adjunctive techniques for the treatment of complex anal fistulas. The combined use of sphincteroplasty, temporary fecal diversion, and biological sealants provided effective disease control while preserving sphincter function. Current evidence supports the use of fibrin sealants as adjuncts in fibrotic tracts and the role of temporary diversion in cases involving sphincter disruption. Sequential and patient-specific surgical management led to successful resolution of the fistula without compromising continence. This multidisciplinary strategy may be considered in patients with complex anatomy and a history of multiple surgical failures.