Back to RegistryChief Complaint Recurrent perianal discharge with external opening Duration of Symptoms 2 months Diagnosis Trans-sphincteric Anal Fistula
Planned Treatment Fistulotomy
NI
Naveen Iyer
RecoveredPT-10255MRD/2026/217552 yrs · Male+91 88261 35453Chennai
Blood Group
O-
BMI
20.4
Surgeon
Dr. Thomas Mathew
Surgery Date
03 Dec 2025
Patient Information
- Full Name
- Naveen Iyer
- Age / Gender
- 52 yrs · Male
- Contact
- +91 88261 35453
- MRD Number
- MRD/2026/2175
- Blood Group
- O-
- City
- Chennai
- Admission Date
- 02 Dec 2025
- Anaesthesia
- Saddle Block
- BMI
- 20.4
Clinical Findings
Symptoms
Perianal dischargeExternal openingRecurrent abscessPerianal pain
Past Medical History
Hypertension
Investigations
| Test | Result | Status |
|---|---|---|
| Complete Blood Count | Hb 14.1 g/dL | Normal |
| MRI Pelvis / Fistulogram | Trans-sphincteric tract noted | Abnormal |
| Proctoscopy | Grade III piles | Abnormal |
| Histopathology | Benign, no malignancy | Normal |
Surgery Details
- Procedure
- Fistulotomy
- Surgeon
- Dr. Thomas Mathew
- Anaesthesia
- Saddle Block
- Duration
- 55 min
- Blood Loss
- 84 ml
- Date
- 03 Dec 2025
Operative Note
Trans-sphincteric tract laid open (fistulotomy) with curettage.Post Operative Notes
Uneventful post-operative course. Ambulated same day. Pain controlled with oral analgesics.
Follow Up History
- 21 Dec 2025Pain score: 8/10Recovery: GoodMedication: Metronidazole 400mg
Fully healed, discharged from care
- 31 Dec 2025Pain score: 4/10Recovery: GoodMedication: Topical GTN 0.2%
Wound healthy, no discharge
Diagnosis & Treatment
Primary Diagnosis
Trans-sphincteric Anal Fistula
Anal Fistula
Next visit: Discharged
Complications
No complications recorded — uneventful recovery.
Attached Images
Pre-op Photo
MRI Scan
Histopath
Post-op Photo
Sample attachments · demo placeholders