Anorectal Surgery

ANAL SURGERY

ANAL FISSURE

What is the problem?

You have a split in the sensitive skin just inside the anus. The medical name for the split is an anal fissure. The fissure causes pain on passing a motion, and often some fresh bleeding. It is made worse by tightening or spasm of the anal sphincter that opens and closes the anus.

The aims of surgery: 
The aim is to weaken the sphincter muscle by cutting one side of it. This is called a lateral sphincterotomy. This lets the fissure heal up within a week or so. The sphincter muscle will also recover in a week or two.
You should be able to have your operation as a day case, which means you come into hospital and go home the same day.

The benefits:

The pain and bleeding should stop. We will also examine the bowel with a type of telescope, called a sigmoidoscope, to make sure the tissues above the anus are healthy. This procedure is called a sigmoidoscopy and is often done at the same time as the operation.

Are there any alternatives?

The first line of treatment is usually a course of bathing and special creams containing muscle relaxants or local anaesthetic. If they do not work, the sphincterotomy is usually the next step.
Stretching the muscle is an alternative to cutting it, but there is a greater chance of poor control of your wind and motions after stretching, especially in older patients. There is also a higher chance of the fissure coming back.
If the anal sphincter is already weak, there is a higher than normal chance of poor control of the wind and motions after the operation. The sphincter may already be weakened in:

  • The elderly
  • Those who have already had operations on the anus, such as hemorrhoidectomy
  • Women who have had stitches to repair tears during childbirth episiotomies.Very mild stretching or continuing with creams may be better alternatives in these cases.Cutting out the fissure is not usually needed but if we are concerned that another condition is present, we would cut the tissue out and send it for examination under the microscope.

Botox injection:
A new technique is the injection of Botox into the area of the internal anal sphincter. The Botox causes paralysis of the internal anal sphincter within a few hours and weakening of the muscle for three to four months. This reduction in the resting pressure of the anal muscle is similar to a surgical lateral internal sphincterotomy and allows the fissure to heal.

What if you do nothing?

If you do nothing, the fissure may heal by itself. It is likely to come back, on and off, over time. The fissure may become thickened with scarring and not heal quickly after an operation in the future.
There is a small chance, perhaps one in 50, that there is a polyp or tumor in the bowel above the fissure. This would be missed if you did nothing.

ANAL FISTULA

What is the problem?
You have a channel or tunnel running from inside the anus to the nearby skin. The medical name for the channel is an anal fistula. There may be more than one fistula.
The fistula discharges yellow or brown liquid onto the skin. There may be attacks of pain and swelling at the skin opening and bleeding. A fistula tracks near the anal sphincter that controls the opening of the bowel. If it runs just inside the sphincter or just through a small part of it, it is called a low fistula. If it runs from well above the sphincter, it will be right outside the sphincter and is a called a high fistula. These are important matters when treating a fistula.
What has gone wrong?
The most common cause of a low fistula is infection of a little gland just inside the anus. Instead of draining back into the anal canal, the infection burrows through the wall of the anus. It may form an abscess in the skin near the anus, called a perianal abscess. The pus may discharge through the skin. 
About half of these abscesses do not heal, but go on to form a fistula. These fistulas are usually single.
A high fistula is less common. The lining of the lower bowel may be affected by an inflammatory condition, called Crohn’s disease. Infection burrows through the wall of the bowel like a simple fistula, but usually from a much higher level. These fistulas are often multiple, complex and more difficult to treat. More rarely still, the cause of the fistula may be a bowel tumor. Special tests, such as MRI’s, scans, a barium enema, x-rays and injection of x-ray liquids down the fistula may be needed to give more information about the problem.

The aims of surgery:
The aims are to find the track of a low fistula, cut down onto it and allow it to heal. Imagine a tunnel being changed into a trench, by taking the roof off. The wound heals from the floor of the trench to form a flat scar, which may take several weeks. The operation aims to avoid damage to the anal sphincter.
A piece of the wall is taken for examination under the microscope to rule out Crohn’s disease or a tumour. You should be able to have your operation as a day case, which means you come into hospital and go home the same day.
The treatment of a high fistula aims to do the same, but is more complex, because of the anal sphincter and the underlying disease in the bowel. Sometimes it is not possible to tell before surgery the extent of the fistula and decisions are made when you are under anaesthetic.
The benefits:
The discharge and bouts of pain, swelling and bleeding should stop as the fistula heals. If there is Crohn’s disease or a tumour, more treatment will be planned.
Are there any alternatives?
If you do nothing, the fistula may heal up by itself. More often, the discharge continues. Perianal abscesses may form in the same place over time. With some very complex high fistulas, just treating the abscesses that appear from time to time may be the best treatment. An older treatment was to pass a thread from the skin opening, through the fistula, out through the anus, and to tie the thread in a loop. The loop would pass through the tissues over several weeks. The fistula heals as the tissues also heal.

HEMORRHOIDS

What is Hemorrhoidectomy?

Hemorrhoidectomy is the removal of hemorrhoids which are swollen enlarged veins around the anus that cause itching, pain and discomfort. Hemorrhoids may be a result of straining to remove waste, pregnancy, aging or chronic constipation. During hemorrhoid surgery, incisions are made in the tissue around the hemorrhoid and the enlarged veins are removed. Hemorrhoid surgery can be performed either with local or general anesthetic.

Who are candidates for Hemorrhoid Surgery?

Hemorrhoid removal may be recommended for severe hemorrhoids when non-surgical treatment has not provided adequate relief from:

  • Persistent itching
  • Anal bleeding
  • Pain
  • Blood clots (thrombosis of the hemorrhoids)
  • Infection

Bowel preparation:

You will be given a preparation to take the night before, and/or the morning of your operation. This will clean out your intestines so the doctors can do the operation.

What is the Hemorrhoid Surgery recovery process?

The outcome is usually very good in the majority of cases. To prevent a recurrence of hemorrhoids, some preventive measures should be taken. A high fiber diet to avoid constipation may help.
You may experience considerable pain after surgery as the anus tightens and relaxes. Medications to relieve pain may be used. To avoid straining, stool softeners will be used. Avoid any straining during bowel movement or urination. Soaking in a warm bath can bring additional comfort. Avoid heavy lifting for two to three weeks. Expect complete recovery in about two weeks.

What are alternatives to Hemorrhoid Surgery?

When hemorrhoids aren’t severe other treatments may include a fiber-rich diet, laxatives, stool softeners, suppositories, medications and warm sitz baths.