Partial Fistulotomy with Apamarga Ksharasutra in the Management of Recurrent Complex Fistula-in-Ano (Bhagandara)

Bhagandara, correlated with fistula-in-ano, is a chronic anorectal disorder that recurs after conventional surgery, particularly in complex disease. A 36-year-old man presented with perianal pain and pus discharge, pain during defecation, and constipation for six months, after fistulectomy for fistula-in-ano in December 2025. Magnetic resonance fistulography (13 May 2026) showed a recurrent complex fistula-in-ano with tracts extending along the left ischiorectal fossa up to the left pelvic sidewall, reported as Grade V of the St James's University Hospital classification. At operation, three external openings (1, 6 and 11 o'clock) were probed to internal openings at 5, 6 and 10 o'clock respectively. On 20 May 2026, partial fistulotomy was performed under local anaesthesia and Apamarga Ksharasutra was placed in all three tracts. It was changed at approximately weekly intervals, with oral Ayurvedic formulations and sitz fomentation with Tankan bhasma. The thread in the 6 to 6 o'clock tract was removed on 17 June 2026 and the remaining two on 20 August 2026. Complete healing, without active external opening or purulent discharge, was documented on 2 September 2026. This observation suggests that partial fistulotomy with Apamarga Ksharasutra may be considered in recurrent complex fistula-in-ano; longer follow-up is needed to assess recurrence and continence.