- Identify and prepare the tract
- Gentle curettage and irrigation of the fistula tract
- Probe the tract to confirm direction and internal/external openings
- Measure fistula tract length
- Choose appropriate size plug (usually made of porcine submucosa)
- Soak the plug in saline to rehydrate
- Insert the plug
- Pull through until the wide “head” of the plug sits flush within the internal opening
- Fix the plug at the internal opening
- Secure with absorbable sutures to internal sphincter or mucosa
- Trim the plug flush at the external opening
- Do not close external opening—leave for drainage
- Post-op care
- Usual perianal hygiene, avoid constipation, regular follow-up for plug retention and healing