Back to RegistryChief Complaint Recurrent perianal discharge with external opening Duration of Symptoms 3 weeks Diagnosis Trans-sphincteric Anal Fistula
Planned Treatment Seton Placement
RK
Rekha Kumar
Under Follow-upPT-10281MRD/2024/513864 yrs · Female+91 85859 58274Kochi
Blood Group
A-
BMI
21.1
Surgeon
Dr. Leela Krishnan
Surgery Date
10 Jul 2026
Patient Information
- Full Name
- Rekha Kumar
- Age / Gender
- 64 yrs · Female
- Contact
- +91 85859 58274
- MRD Number
- MRD/2024/5138
- Blood Group
- A-
- City
- Kochi
- Admission Date
- 09 Jul 2026
- Anaesthesia
- Local
- BMI
- 21.1
Clinical Findings
Symptoms
Skin excoriationPerianal discharge
Past Medical History
Prior anorectal surgeryDiabetes Mellitus Type 2
Investigations
| Test | Result | Status |
|---|---|---|
| Complete Blood Count | Hb 13.4 g/dL | Normal |
| MRI Pelvis / Fistulogram | Trans-sphincteric tract noted | Abnormal |
| Proctoscopy | Chronic fissure | Abnormal |
| Histopathology | Benign, no malignancy | Normal |
Surgery Details
- Procedure
- Seton Placement
- Surgeon
- Dr. Leela Krishnan
- Anaesthesia
- Local
- Duration
- 78 min
- Blood Loss
- 63 ml
- Date
- 10 Jul 2026
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
- 13 Jul 2026Pain score: 6/10Recovery: SlowMedication: Metronidazole 400mg
Wound healthy, no discharge
- 13 Jul 2026Pain score: 6/10Recovery: GoodMedication: Diosmin + Hesperidin
Advised high-fiber diet
- 13 Jul 2026Pain score: 3/10Recovery: On trackMedication: Sitz bath advice
Mild residual discomfort
Diagnosis & Treatment
Primary Diagnosis
Trans-sphincteric Anal Fistula
Anal Fistula
Next visit: 01 Aug 2026
Complications
No complications recorded — uneventful recovery.
Attached Images
Pre-op Photo
MRI Scan
Histopath
Post-op Photo
Sample attachments · demo placeholders