Abstract
Background: Incidence of anal fistula is very frequent in today's clinical practice and in spite of advances in surgical techniques, management of the same is a very tedious job. Anal fistula resembles with the description of Bhagandara described in Ayurveda which is said to be difficult to cure.

Aim: Application of only Ksharasutra (alkaline seton) in high anal fistula when the internal opening is above the dentate line and when the external opening is very far away from anal verge is not only difficult but takes longer period for complete cure with varied success rate, hence a multiple stage surgical approach along with Ksharasutra has been employed in the present case.

Materials & Methods: The patient was treated with fistulotomy in three stages along with use of Ksharasutra. In the first stage external opening was widened approximately 5 cm towards anal canal along with curettage and tightly packed to achieve haemostasis. After one month, in the second stage the tract was further widened 2 cm towards the anal canal and was packed. In the third stage Ksharasutra was applied for 8 weeks till the tract was cut and healed completely.

Results: The fistulous tract was completely healed by almost five months, however the hospital stay was only for 4 to 5 days. Follow up was done for 6 months, there was no recurrence of the condition.

Conclusion: The results of the present study was encouraging and patient was treated effectively with minimal hospitalization without disturbing his daily routine life.

Key words: Bhagandara, Fistula in ano, Multi stage surgery, Ksharakarma