EXTERNAL HAEMMORROIDS ALONG WITH HORSESHOE SHAPED FISTULA

 have a patient 22y/f ,operated two times at sarasvati hospital,nangloi,delhi,for fistula in ano.treating surgeon incise and drained at outer opening followed by packing and dressing.but after even 2 attemps remission occours.PATIENT"S MAIN WORRY IS FISTULA. ext. openings are at 11 and 1 0-clock about 5 cm away anterioly from anus.i wants to know from experts------ (1)is ligation of arsh shold be done simultaneously along with fistula??............(2)is ligation of arsh should be done firstly and after sheding of the arsh,should procced towards fistula?? .......................(3) how to procced to minimise pain and to achive successful act.please guide me.some times ado i do a similar case but that have multiple short fistula along with ext.hemorroid,but this time fistula is horseshoe type.......


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