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Most anal fistulas are either intersphincteric or low transsphincteric and are treated by fistulotomy with a few recurrence and minimal risk of incontinence. In high and complicated fistulas, fistulotomy should not be used because of a high chance of incontinence. High transsphincteric or suprasphincteric fistulas, anterior fistulas in female, patients with coexisting inflammatory bowel disease, elderly patients with poor sphincter function, multiple simultaneous fistulas, or patients with multiple prior sphincter injuries need alternative technique to minimize the incidence of incontinence. The alternative techniques include seton placement, advancement flap closure, muscle filling procedure, fibrin glue, etc. depending on the status of fistula and patients. The various sphincter sparing techniques used widely are reviewed.