High fistula-in-ano (which involve more than one-third of sphincter complex) pose a therapeutic challenge. The conventional sphincter cutting procedures like fistulotomy and cutting seton (ksarsutra) entail a high risk of incontinence in such patients [1, 2]. Newer sphincter-sparing procedures are usually recommended for such fistulas [1] [2] [3] [4] [5]. However, if these high fistulas get associated with wide internal opening (caused by injudicious use of cutting seton), then even the newer

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... hincter-sparing procedures become ineffective in these fistulas making their treatment even more challenging. In these difficult fistulas (high fistulas with wide internal opening), FATS procedure seems to be an effective sphinctersparing procedure. The experience of FATS procedure in three patients is being described. A 55-year-old male presented with regular pus discharge due to recurrent fistula operated three times earlier over a period of five years. He had undergone a tightening seton procedure (ksarsutra) by an ayurvedic doctor. Due to this, the whole tract in right posterior region had been partially cut leading to widening of external as well as the internal opening [Table/ Fig-1,2] . The tract was involving more than 75% sphincter complex and was graded as per different classifications [1] .