Abstract

Overreliance on imaging techniques like Magnetic Resonance Imaging (MRI) at the expense of clinical evaluation of Bhagandara (anal fistula), may lead to suboptimal outcomes. This case report presents an externally blind inter-sphincteric horseshoe anal fistula with bilateral ischio-anal fossa involvement on MRI, whereas clinical examination indicated only unilateral (left) involvement. A novel surgical management was planned here based upon clinical assessment, with drainage achieved through a posterior midline incision. Two Ksharasutra were employed for tract ligation and eradication of the cryptoglandular source. Postoperative care included Tab. Moxifloxacin 400mg (3 days), Tab. Aceclofenac (100mg) + Paracetamol (325mg) + Serratiopeptidase (15mg), Kanchanara guggulu, Tab. Septilin, Varunadi Kashaya, Isabgol husk (8 weeks), wound care with Triphala Kwatha and Jatydai Taila. Complete healing was achieved within 11 weeks, with no recurrence observed at 6 months. This case highlights the critical role of clinical judgment in fistula management. It emphasizes the need for surgical training to strengthen clinical assessment skills and developing the orientation for correlate them clinically in proctology. The posterior midline incision and dual Ksharasutra procedure offers an effective approach for treating complex horseshoe fistulas.

Key words: Ayurveda, Bhagandara, Fistula-in-ano, IFTAK, Ksharasutra