DLPL: Sphincter-Saving Cure for
Complex Horseshoe Fistula
Extending to the Knee Joint

A 63-year-old male with a complex trans-sphincteric horseshoe fistula — left untreated for over 25 years — extended 110 cm from the perianal region to the posterior knee joint. Dr. Ashwin Porwal's DLPL technique cured it completely, with full sphincter preservation and no incontinence.

Background: The Challenge of Recurrent Complex Fistulas

Recurrent, highly complex anal fistulas represent one of colorectal surgery's most demanding clinical challenges. While uncommon, they can be extraordinarily difficult — and at times genuinely impossible — to cure with conventional techniques. The fundamental problem is this: the fistula tract often involves a significant portion of the sphincter muscles, and cutting through them to excise the tract (fistulotomy) risks permanent fecal incontinence.

For patients who have already undergone multiple operations, sphincter muscles are often significantly weakened — making any further disruption potentially catastrophic for their quality of life.

The Case: A 25-Year Journey

The patient was a 63-year-old male — a former army officer — who first had anorectal surgery performed by an unlicensed practitioner in 1996 for what was believed to be hemorrhoids. A perianal abscess subsequently developed and was drained locally. Intermittent anal discharge continued for years, but fear of further surgery prevented him from seeking proper evaluation and care.

• 96
  1996Unauthorised surgery for piles; perianal abscess develops and is drained locally. Intermittent anal discharge continues for years.
• 25
  yrs
  2 Decades of AvoidanceFear of surgery prevents the patient from seeking investigation. Infection silently tracks along deep fascial planes.
• Jan
  21
  January 2021 — Fever BeginsUnexplained fever with thigh pain extending to the knee. Swelling noted over bilateral thighs and knee. IV antibiotics for 2 weeks show no improvement.
• MRI
  Diagnosis via MRI PelvisComplex intersphincteric fistula confirmed with multiple tracts involving right and left buttocks. Left-sided extension from buttock → thigh → knee. Total tract: 110 cm. Sphincter involvement: ~70%.
• ✓
  DLPL Surgery — Healing Hands Clinic, PuneComplete cure. Sphincter fully preserved. Complete healing confirmed at 8 weeks on repeat 3D endo-anal imaging.

The DLPL Procedure: Step-by-Step

Pre-operative 3D endo-anal imaging was performed immediately before surgery to precisely map the primary tract, all branching extensions, and the three abscess cavities.

1. 3D Endo-Anal Imaging (Pre-op): Advanced imaging was used to map every branch, internal opening, and abscess cavity before the first incision.

2. Thorough Debridement: Systematic scooping of the entire 110 cm tract to remove infected granulation tissue, biofilm, and necrotic material.

3. Saline Flush: Complete irrigation of the debrided tract with normal saline for mechanical cleansing.

4. Radial Fiber Laser Ablation: 1470 nm diode laser at 10 W in continuous mode. 100 J per segment delivered, progressing from the internal opening outward to the external opening.

5. Internal Opening Laser Treatment: Bare-tip 1470 nm diode laser applied to the internal opening — approximately 100 J to debride the surrounding tissue.

6. Drainage Optimisation: External opening widened to facilitate ongoing post-operative drainage and prevent re-collection.

7. 3 Abscess Cavities Drained: All identified supralevator and intersphincteric collections evacuated under direct vision.

8. Repeat 3D Imaging (Post-ablation): Endo-anal imaging repeated to confirm no residual untreated pus or tract segments. Total energy: ~5,000 J.

Outcomes & Follow-Up Protocol

Post-operative management consisted of weekly clinic visits for 3–4 weeks, with bimanual palpation of the anal canal at each visit to drain residual intersphincteric collections and prevent re-abscess formation. The authors identify two pillars of success: thorough intraoperative debridement and diligent post-operative drainage over 3–4 weeks.

Why This Case Is Globally Significant

This published case represents an exceedingly rare clinical scenario — a perianal fistula extending the full length of the lower extremity to the knee — and documents the first known sphincter-preserving cure of such a case using DLPL.

• 110 cm tract length — far beyond any previously documented case in DLPL literature
• Bilateral supralevator extension — infection tracked in both directions along deep fascial planes
• ~70% sphincter involvement — conventional fistulotomy would have guaranteed permanent incontinence
• Zero incontinence post-operatively — demonstrating DLPL's ability to treat extensive, deep tracts without sphincter sacrifice
• IJCRS Second Prize Award (2021) — peer-validated recognition of exceptional clinical and technical merit

About DLPL — Dr. Porwal's Patented Technique

Distal Ligation Proximal Laser (DLPL) is an original surgical technique invented by Dr. Ashwin Porwal and is exclusively available at Healing Hands Clinic centres. It combines laser energy destruction of the fistula tract (from within) with strategic ligation at the internal opening — delivering complete eradication of the tract without a single stitch through the sphincter.

Key advantages over conventional fistula surgery:

• No sphincter division — zero risk of fecal incontinence
• Suitable for high, complex, and recurrent fistulas with multiple previous surgeries
• Day-care procedure — shorter hospital stay
• Significantly less post-operative pain vs. open fistulotomy
• Faster return to daily activities
• Suitable even when sphincter is already weakened from prior operations