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AIM: To describe a method to manage complex perianal fistulas with extensive perineal involvement, allowing avoidance of exposure of wide wounds and repeated procedures. MATERIAL OF STUDY: All patients presenting with perianal fistulas extensively spreading to the perineum requiring surgery between January 2010 and December 2012 were enrolled in the present study. Diabetic patients and those with active abdominal Crohn’s disease (CD) were ruled out from evaluation. After clinical and radiological assessment, patients underwent exploration under anaesthesia, and the conventional procedures were completed with at least one wide perineal fistulotomy, managed with “perineal packing” with gauzes. Patients were followed-up for complications and healing of fistulas. RESULTS: Eight patients (3 males, mean age 38 ± 5.1 years) were enrolled in the present study. Four patients had CD, two had Hidradenitis suppurativa, and two had idiopathic fistula-in-ano. All but two patients were not required to stay overnight. Gauzes were removed in outpatient settings. One patient had bleeding requiring coagulation with electroscalpel. One patient needed to receive analgesics and four wore pads in the maturation period. No sepsis was observed. Mean time to healing was 21.5 ± 3.2 days; mean time off-work was 2 ± 1.3 days. Patients reported no significant impairment of leisure activities. No recurrences were observed at a mean follow-up of 16.4 ± 2.1 months. Major complications were not observed. DISCUSSION: All patients achieved complete healing of the perineal tracks, without significant impairment of social function and need for further surgical treatments. Patients were safely discharged and promptly returned to work or leisure activities. CONCLUSIONS: Our data suggest that the procedure is safe and effective in selected patients with extensive perineal involvement.