Rectal Surgery - Anal SurgeryBirmingham, Alabama

Anal Surgery — Rectal Surgery

Anal Fistula

What Is an Anal Fistula?

An anal fistula is a small tunnel whose inside opening is in the anal canal (the last 2 inches of the rectum) and whose outside opening is to the skin near the anal opening.

What Causes Anal Fistulas?

Most anal fistulas are caused by the plugging of an anal gland. Humans have 7 and 14 anal glands which open into the anal canal less than an inch inside the anal opening. For unknown reasons these glands can become plugged somewhat like a pimple. However, the glands are so deep that  passable distance for the pus may be to go through the sphincter muscle to the surface of the skin and make an abscess which can be surgically drained or sometimes may burst on its own. If the opening on the inside does not heal then this becomes the path of least resistance for stool and results in continuous drainage. These may also be caused by other conditions such as Crohn’s disease of the rectum.

Anal Fistula Surgery

  1. Fistulotomy – A fistulotomy is generally an outpatient procedure performed under either spinal or general anesthetic. A probe is passed through the fistula tract or tunnel. If it is very close to the surface then the tract may be divided converting the tunnel into an open trench. The edges of the skin are sewn down so that they cannot reconnect and recreate the tunnel or fistula. Scar tissue then fills in this surgeon created small trench thereby healing the fistula and preventing drainage. Fistulotomies are done for fistulas that are not very deep and do not require the dividing of very much muscle.
  2. Seton placement – If during fistula surgery following passage of a probe through the tunnel it is determined that the amount of sphincter muscle divided to open the fistula would result in incontinence or inability to hold the stool, the surgeon may elect to pass a sterile rubber band called a Seton through the tract and tie it at the skin level. This is tightened in the office every 2 weeks thereafter and it slowly divides through the sphincter muscle with scar tissue filling in behind. This slowly elevates the fistula tract out of the body and the Seton falls off. Fortunately the muscle never fully separates and thus with an intact ring of muscle the ability to hold bowel movements is preserved.
  3. Endorectal advancement flap – The endorectal advancement flap was originally designed to treat fistulas between the rectum and the vagina so as to avoid a temporary colostomy and allow healing. With this technique the surgeon gains exposure to the rectum and anal canal and creates a flap in the shape of a tongue by dissecting mucosa, submucosa and a tiny amount of muscle off the fistula. The tip of the flap containing the internal fistula opening is then surgically removed, the muscular hole is identified and over sewn with dissolvable sutures. The flap is then pulled down over this fresh repair and sewn back in placed with dissolvable sutures. This technique has a success rate of approximately 75%. It frequently requires an overnight stay in the hospital.
  4. Collagen plug procedure – A number of devices have been developed to try to close the fistula tunnel by filling it with material allowing the body’s natural healing mechanism to close the fistula. These include a collagen plug and other absorbable materials. When used alone or in conjunction with fibrin glue their success rate is less than 30%. However, in combination with an endorectal advancement flap this technique may help complex or recurrent fistulas to heal.
  5. LIFT procedure - The LIFT procedure means the ligation of intersphincteric fistula tract. With this technique on an outpatient basis and under general or spinal anesthesia, an incision is made just outside the anus. Dissection is carried out in between the internal and external anal sphincter muscles and the fistula tract is identified. It is tied off with dissolvable sutures on either end, and the small length excised. The incision is then closed over a drain with or without a sheet of biologic material to help prevent fistula tract recurrence. Success rates in literature vary between 40 and 75% with this technique

After Anal Fistual Surgery

Following fistula surgery patient’s are to shower only and not sit in a bathtub until the 5th day after surgery. Patient’s should plan not to drive until they are able to slam the brakes in their parked car in their driveway proving that they can perform a panic stop maneuver before actually getting the car out on the road. Both constipation and diarrhea should be avoided. We recommend that most patients take 2-3 Colace capsules 2-3 times a day increasing or decreasing the amount depending on the results. In addition, MiraLax may be used once or twice a day to help in this regard. Heavy lifting or straining should be avoided until it can be carried out without causing pain at the surgery site.

Patients are encouraged to take a multivitamin such as Centrum or Centrum Silver daily, eat a high protein diet, take a probiotic such as Activia yogurt or any over-the-counter probiotic tablet or capsule. We also encourage a daily nap until endurance begins to return.

Altemeier Procedure for Rectal Prolapse

Full rectal prolapse results when the supporting structures of the rectum internally weaken such that the rectum can turn itself inside out and actually come out through the anal opening. This painful and embarrassing condition can be treated laparoscopically in patients who are a good risk for general anesthesia, but those patients in poor health or with multiple medical problems which would increase the risk from prolonged anesthesia or who have had so much abdominal surgery that laparoscopy would be difficult if not impossible, an attractive alternative is the Altemeier procedure.

Rectal Prolapse Surgery

Preoperative preparation includes a full bowel prep. The patient is taken to the operating room and under general or spinal anesthetic the patient is placed on his or her back and the legs held up in stirrups. The prolapsed rectum is pulled out. Incision is made around the prolapsed rectum through the first layer of the bowel wall. The remaining redundant bowel is then carefully pulled out and its attachments carefully divided until all the excess slack is removed. The bowel is then reconnected with numerous sutures along the inner bowel wall to the outer bowel wall and the connection allowed to retract back into the pelvis. Normally this requires a 2-3 day hospitalization. The risks of this procedure are extremely low. There is typically very little pain. Recurrence rate of rectal prolapse after an Altemeier procedure approaches 30% at 2 years, however, if the prolapse recurs the procedure can almost always be repeated.

After Rectal Prolapse Surgery

Following fistula surgery patient’s are to shower only and not sit in a bathtub until the 5th day after surgery. Patient’s should plan to not drive their cars until they are able to slam the brakes in their parked car in their driveway proving that they can perform a panic stop maneuver before actually getting the car out on the road. Both constipation and diarrhea should be avoided. We recommend that most patients take 2-3 Colace capsules 2-3 times a day increasing or decreasing the amount depending on the results. In addition, MiraLax may be used once or twice a day to help in this regard. Heavy lifting or straining should be avoided until it can be carried out without causing pain at the surgery site.

Patients are encouraged to take a multivitamin such as Centrum or Centrum Silver daily, eat a high protein diet, take a probiotic such as Activia yogurt or any over-the-counter probiotic tablet or capsule. We also encourage a daily nap until endurance begins to return.

Bowel Incontinence / Fecal Incontinence

What is Incontinence?

Incontinence is the decreased ability or inability to hold stool or gas.

What causes Incontinence?

The most common cause of bowel incontinence is an injury to the sphincter muscles which occurs during childbirth. Usually the gynecologist will detect this and repair it at the time of delivery, however, over time the repair may weaken and the muscle separate and be unable to perform its normal squeeze allowing control of the bowels. Sometimes a portion of the muscle may be divided during rectal surgery resulting in decreased control. Certain conditions such as Crohn’s disease or nerve damage may also result in severe weakening of these muscles. It is well known that the strength of the muscle slowly decreases with age. Treatment options include medications to firm the stool, biofeedback training, and surgical repair of the separated muscle.

Surgery for Incontinence

The most common operation performed is called an overlapping sphincteroplasty which is done for women who have separation in the front portion of the sphincter muscle often as a result of injury during delivering a baby. Preparation does require a bowel prep. Under anesthesia the legs are held up in stirrups and a small incision made in between the vaginal and the rectal opening. The ends of the muscle are dissected out and overlapped prior to being sewn together. The slightly smaller opening requires less squeeze ability in order to achieve control of the bowels. Generally the stay in the hospital is one night.

After Incontinence Surgery

Usually a tiny drain will be left in place at the time of surgery which is removed a week later. The skin stitches are left in place for 2 full weeks after surgery prior to removal. At least 80% of patients note significant improvement if not cure of their incontinence with this type of surgery.

Anal Fissure

What is an Anal Fissure?

An anal fissure is a small split or tear at the edge of the rectum (anal opening). It is believed to be caused either by unusually hard or large diameter bowel movement which causes the tear. Because the skin of this area is so exquisitely sensitive, during elimination when stool touches the area the resulting pain causes spasm of the internal anal sphincter muscle. Nonetheless the stool must be pushed through forcing it through a spasming muscle which theoretically keeps the tear from being able to heal.

What are the Symptoms of an Anal Fissure?

Most people report significant pain during bowel movements. Often this will be described as though they are “passing a razor blade”. Bright red rectal bleeding is also extremely common.

How is an Anal Fissure Treated?

  1. Medical therapy – Nonsurgical treatment for an anal fissure involves a 3-prong approach. First, it is important that the stools be soft enough not to cause trauma, but firm enough not to cause burning of the raw sore. We usually recommend a combination of Colace capsules and MiraLax until the patient achieves a soft, but formed stool. In addition topical pain relief can often be achieved with 5% Xylocaine Ointment applied to the area as often as needed for comfort sake (especially immediately after bowel movements). Thirdly Nifedipine 2% ointment is often efficacious in preventing spasm and promoting healing to the area. It is applied to the fissure via the tip of a gloved finger 3 times a day.
  2. Botox injection – If the fissure is not large, deep, or has been present for many months approximately 50% of the time healing can be effected by injecting Botox into the muscle on either side of the fissure. This is accomplished by local anesthesia in outpatient surgery. If the Botox is not administered in a hospital facility the insurance company will not cover the cost of the injection. One vial of Botox costs $400.00 wholesale.
  3. Anal Fissure Surgery – Surgery for anal fissure involves a outpatient surgery. Under appropriate anesthesia the anal area is cleaned. The fissure is identified and carefully removed surgically and the skin edges brought together and closed with dissolvable sutures. Off to the side a tiny incision is made and the internal anal sphincter is divided by a couple of millimeters breaking the ability of the muscle to spasm. By the time the sphincter ends heal back together the fissure should be healed. The success of this operation is in excess of 95%. There is a tiny risk of infection and decreased continence with this procedure. It is common to miss approximately one week of work following surgery for anal fissure disease.

Postoperative Instructions for Anal Fissure Surgery

Following fissure surgery patients are on a regular diet, whatever usual activities can be accomplished without significant limitation with postoperative pain are allowed. An ice pack for the first 8-10 hours after surgery is usually helpful in limiting pain and swelling. Beginning the day after surgery warm tub soaks as needed may be used for comfort and for cleaning after bowel movements. A narcotic will be prescribed for pain control postoperatively. It is still important to keep the bowels soft with Colace and/or MiraLax. The patient should not drive until able to perform a full panic stop maneuver without restriction from the pain. Most patients are seen in the office approximately 10 days after the operation. The patient should call if they experience inability to urinate, passing large amounts of blood, significantly increasing pain, fever as high as 101, or any other relative to the surgery.

Pilonidal Cyst

What is a Pilonidal Cyst?

The word pilonidal literally means “hair nest”. It occurs at the top of the natal cleft (vertical crease between the buttocks). This is an acquired condition caused by a series of ingrown hairs. The cause is unclear. The disease may occur in people with large or tiny amounts of hair in the area.

What are the Symptoms of A Pilonidal Cyst?

Most pilonidal cysts will at some point develop an abscess because of the infected hairs. This may drain on its own or have to be drained surgically. Once this occurs repeat infection and drainage often ensues until the lesion is treated surgically.

Surgery for Pilonidal Cyst

Surgical treatment for a pilonidal cyst is  outpatient surgery which can be carried out under anesthesia ranging from sedation and local injection of the skin to full general anesthetic. We believe in a minimalist approach where the smallest possible incision is made in order to remove the entire nest of hair and its tracts. We then believe in closing the wound in layers. We use nylon skin stitches to evert the skin edges of the wound so that when new hair grows in it is less likely to ingrow once more. These stitches are removed on approximately postoperative day 7.

Prevention of Recurrence

First, every technique for treating pilonidal cyst disease has approximately 25% chance that another cyst will form when another ingrown hair occurs in the area. Thus, as soon as the sutures are removed from the incision the patients are encouraged to keep the area free of hair. Permanent hair removal procedures such as electrolysis or laser are probably the most efficacious; however, they are not covered by insurance companies for reasons which are not clear to us. Less expensive, but more labor intensive skin care would include applying Nair or other hair removal lotion to this area every other week.

Anal Warts

What are Anal Warts?

Anal warts also known as condyloma acuminata are caused by a virus growing in the skin much like any other wart. Different wart viruses prefer different parts of the body. The human papilloma virus may affect the area around the anus, the anal canal (the last 2 inches of the rectum) and as well as the male or female genitalia. Human papilloma virus subtypes 16 and 18 can result in skin cancer if left untreated.

Treatment for Anal Warts

Small warts can be usually treated in the office with a mild acid which results in their destruction. Larger warts or resistant warts may need to be cauterized or even removed surgically in the operating room.

Follow Up

Since viruses are far too small to be seen with the naked eye it is impossible for the surgeon to detect all of the skin effected by the virus at the initial visit. While visible warts may be destroyed there may be other warts about to come forth which cannot be detected with the naked eye. Thus, monthly follow up until the skin is free of warts for 2-3 months is highly advisable, otherwise the chance of wart recurrence is extremely high.

Advanced Surgeons PC

Birmingham, Alabama

Trinity Medical Center

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