Back to RegistryChief Complaint Recurrent perianal discharge with external opening Duration of Symptoms 3 weeks Diagnosis Trans-sphincteric Anal Fistula
Planned Treatment Fistulotomy
LP
Lakshmi Patel
Under Follow-upPT-10304MRD/2025/546245 yrs · Female+91 79835 59362Kottayam
Blood Group
B+
BMI
20.9
Surgeon
Dr. Thomas Mathew
Surgery Date
21 Jun 2026
Patient Information
- Full Name
- Lakshmi Patel
- Age / Gender
- 45 yrs · Female
- Contact
- +91 79835 59362
- MRD Number
- MRD/2025/5462
- Blood Group
- B+
- City
- Kottayam
- Admission Date
- 19 Jun 2026
- Anaesthesia
- Spinal
- BMI
- 20.9
Clinical Findings
Symptoms
External openingPerianal discharge
Past Medical History
SmokerIschemic heart disease
Investigations
| Test | Result | Status |
|---|---|---|
| Complete Blood Count | Hb 11.8 g/dL | Normal |
| MRI Pelvis / Fistulogram | Trans-sphincteric tract noted | Abnormal |
| Proctoscopy | Grade III piles | Abnormal |
| Histopathology | Granulation tissue | Normal |
Surgery Details
- Procedure
- Fistulotomy
- Surgeon
- Dr. Thomas Mathew
- Anaesthesia
- Spinal
- Duration
- 45 min
- Blood Loss
- 109 ml
- Date
- 21 Jun 2026
Operative Note
LIFT procedure with ligation of intersphincteric tract.Post Operative Notes
Hemostasis achieved. Anal pack in situ, removed after 24 hours. Advised sitz baths.
Follow Up History
- 30 Jun 2026Pain score: 7/10Recovery: ExcellentMedication: Metronidazole 400mg
Suture line clean
- 13 Jul 2026Pain score: 4/10Recovery: GoodMedication: Topical GTN 0.2%
Fully healed, discharged from care
Diagnosis & Treatment
Primary Diagnosis
Trans-sphincteric Anal Fistula
Anal Fistula
Next visit: 25 Jul 2026
Complications
No complications recorded — uneventful recovery.
Attached Images
Pre-op Photo
MRI Scan
Histopath
Post-op Photo
Sample attachments · demo placeholders