Division of Minimally-Invasive Proctology

The Division of Minimally Invasive Proctology (MIP), First Division in Asia-Pacific region was launched on 25th June 2011 under Max Institute of Minimal Access, Metabolic & Bariatric Surgery at Max Super Speciality Hospital. The Division was launched by Dr. Tehemton E. Udwadia, Founder President –IAGES, Dr. Suresh Deshpande, President - IAGES & Prof. Dr. Piercarlo Meinero, Chief of Proctology, Rapallo Lavagna Hospital, GE- Italy.

The Division of MIP performs Minimally Invasive surgery for:-

MINIMALLY INVASIVE PROCTOLOGY [FISTULA, PILES, FISSURE, PROLAPSE]

Introduction
Anorectal symptoms and complaints are common and may be caused by a wide spectrum of conditions. Their prevalence in the general population is probably much higher than that seen in clinical practice, since many patients with symptoms referable to the anorectal region do not seek medical attention.

Common anal conditions

  1. Anal fistula (Low, High or Complex)
  2. Hemorrhoids / Piles (Internal or external)
  3. Anal fissures (Acute or chronic)
  4. Rectal Prolapse

Common Presenting Symptoms

  1. Anal pain
  2. Bleeding per rectum 
  3. Pus discharge from and around anus 
  4. Mass protruding from anal verge
  5. Anal pruritus  (itching)
  6. Passage of mucus per rectum
  7. Constipation or fecal obstruction

Diagnosis
The history gives a clue to the underlying cause, diagnosis is confirmed by examination. Examination is done in a left lateral posture. Internal examination is performed digitally and with the anoscope (hollow cylindrical device). This is done in an outpatient setting. Sometimes the examination may have to be done under anesthesia, a process known as EUA or Examination under anesthesia. The history, as well as the physical examination, can distinguish anal pain due to hemorrhoids, fissure, abscess. The most frequent causes of rectal bleeding are hemorrhoids, fissures and polyps.

ANAL FISTULA

What is an anal fistula?

Anal fistula, or fistula-in-ano, is a common anorectal problem in which an abnormal connection develops between the inner surface of the anal canal and the skin around the anal verge.

Why do anal fistulas develop?

Anal glands located between the two layers of the anal sphincters (muscles which open and close the anal orifice) and draining into the anal canal are the site where these fistulae originate. It is the blockage of the outlet of these glands which cause secretions to accumulate inside and an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula.

Can these fistulas spread?

Yes! The fistula tract can branch into the fascial layers of the perianal region. Abscesses can also recur if the fistula seals, allowing the accumulation of pus. It may then point to the surface at the same site or a different site, and the process repeats. This way more than one fistula opening can develop. Patients suffering from Crohn’s disease are more likely to have multiple fistulous tracts and complex fistulas

Can anal fistulas recur?

The recurrence after surgical treatment of anal fistulae is possible due to various reasons. Most recurrences develop within a year following surgery. Factors associated with recurrence included complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening and previous fistula surgery.

Treatment

The aim of treating an anal fistula is to prevent it from occurring again with no damage to the sphincter muscles.     
Current surgical technique for complex anal fistulas are based on three main principles

a) To identify the fistula tract or path with its internal and external openings,
b) To destroy this fistula path,
c) To preserve function of the anal sphincter (muscle which controls ability to pass stools).

Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.

  1. Lay-open of fistula in ano tract (fistulotomy) – The fistula tract is cut open leaving a raw wound. This wound requires daily dressings and is painful. This option is not suitable for fistulas that involve the entire anal sphincter as surgery may damage the sphincter.
  2. Excision of entire fistulous tract (fistulectomy) – A probe or dye inserted into the tract from one opening to the other defines the entire tract which is excised in toto leaving behind a raw surface area which requires daily dressings till complete healing is achieved.
  3. Seton insertion – In the event of a high fistula involving a significant amount of the sphincter muscle a seton (a thin tube/ thread) is inserted through the fistula tract and its ends tied together outside of the body. The seton is tightened over time, gradually cutting through the sphincter muscle and healing it as it goes. This option minimizes scarring but can damage the sphincter in a small number of cases. Once the fistula tract is in a low enough position it may be laid open to speed up the process, or the seton can remain in place until the fistula is completely cured.
  4. . Fibrin glue injection is a method explored in recent years, with variable success. In this method the fistula is injected with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. Very high recurrence rate is seen in this method.
  5. Fistula plug involves plugging the fistula with a device made from small intestinal submucosa. Success rates are variable and high recurrence rates are directly related to previous attempts to correct the fistula. High recurrence rate is seen in this method.
  6. LIFT Technique (ligation of inter sphincteric fistula tract). LIFT procedure is based on secure closure of the internal opening and removal of infected cryptoglandular tissue between the intersphincteric plain. Can be done in less number of patients

What are the complications of conventional anal fistula surgeries?

Specific complications of anal fistula operation are uncommon, but can include:

What is Minimally-Invasive anal fistula treatment (MAFT)?

This Vide-assisted Anal Fistula treatment (VAAFT) is described as Minimally-invasive Anal Fistula Treatment (MAFT) technique is performed for the surgical treatment of complex anal fistulas and their recurrences. This is a major breakthrough treatment option for complex fistulas

In this technique, we first examine the fistula path with an endoscope and determine the point of the internal opening of the fistula. In the second step, the internal opening of the fistula is closed with the help of stapler and the entire path of the fistula is destroyed by electrocautery under direct telescopic vision.

There is no surgical wound in the perianal region hence no dressings needed. The risk of faecal incontinence is not there because no sphinter damages occur. The procedure is done under spinal anesthesia/ general anesthesia. There is minimal post-operative discomfort and do not need any painful dressings.

Advantages of Minimally-invasive Anal Fistula Treatment (MAFT) technique

Max Institute of Minimal Access, Metabolic & Bariatric Surgery (MAMBS)
First Centre in Asia-pacific to start the MAFT technique
Max Institute of Minimal Access, Metabolic & Bariatric Surgery is the First Centre in Asia-Pacific region to adopt this technique. It has done pioneering work in this field and now is acclaimed to be a high volume Centre of Excellence for teaching and training surgeons from across the World.

HEMORRHOIDS / PILES

What are piles?

Piles or hemorrhoids are swollen blood vessels in the anal passage. There are two circular bunches of veins, one inside the anal canal and the second at the anal verge. Accordingly they are called internal and external hemorrhoids

Why do piles develop?

There are certain conditions which predispose to formation of piles. These are

  1. Excessive straining while passing stools e.g. chronic constipation, low fibre diet, poor bowel habits
  2. Increased backward pressure on pelvic blood vessels e.g. Pregnancy, pelvic tumors

Are piles harmful?

Yes! Piles tend to worsen with time and may result in severe bleeding which requires blood transfusions. They may protrude outside the anal opening and become very painful causing significant morbidity. They are often associated with discharge soiling the under garments and causing irritation. Complications of piles include anemia due to frequent blood loss, thrombosis (bleeding into the pile mass), strangulation, ulceration and infection spreading into the liver system.

Diagnosis

Is usually made by direct examination and proctoscopy. A colonoscopy may sometimes be advised if a mass lesion or other pathology is suspected in the colon.

Treatment

Medical Management :-

Lifestyle and dietary modifications

  1. Regular physical exercise such as half an hour of brisk walking daily
  2. Plenty of fluids to stay well hydrated
  3. A high fibre diet to increase and soften the stool bulk such as fresh fruits and salads

Surgical Management:-

Minimally Invasive Procedure for Hemorrhoids (MIPH)- In this procedure the vessels at the base of hemorrhoids or piles are stapled and divided high up in the anal canal. The external piles get pulled inside. There is no external cut and pain is negligible. The procedure is performed using a special circular stapler

Others

  1. Injection sclerotherapy - the pile masses are injected with a sclerosing agent which causes them to shrink. This method is successful in early cases of piles
  2. Banding - This involves placing a band like a noose at the root of the pile mass which gradually falls off as its blood supply gets cut off.
  3. Infrared coagulation - the base of the hemorrhoid is burnt with a very short exposure to infrared rays with the help of a probe. This is also successful in early cases of hemorrhoids.
  4. Classical haemorrhoidectomy where the pile massed are surgically removed. Post-operatively it is rather a painful procedure and needs everyday dressing for few days or weeks.

Advantages of Minimally Invasive procedures for Prolapse and Haemorrhoids (MIPH):-

  1. Minimal post operative pain
  2. Much faster recovery
  3. Shorter hospital stay
  4. Less post operative discomfort
  5. No dressings
  6. Early resumption of normal activities

ANAL FISSURE

What is an anal fissure?

An anal fissure is a small tear or cut in the skin at the anal opening.  Fissures typically cause pain and often bleed.  Fissures are quite common, but are often confused with other causes of pain and bleeding, such as hemorrhoids. Most fissures occur along the mid-line - the top or bottom - of the anus.

What are the symptoms of an anal fissure?

The typical symptoms of an anal fissure are pain during or after defecation and fresh bleeding. The pain may be severe enough to cause the patients to avoid defecation.

What causes an anal fissure?

Injury: Most commonly due to a hard, dry bowel movement. Many women during childbirth develop an anal fissure. Other causes of the anal fissure are: digital insertion (during examination), foreign body insertion, or anal intercourse. A fissure may also develop following diarrhea or inflammatory conditions of the anal area.

Anal fissures may be acute (recent onset) or chronic (present for a long time or recurring frequently). Chronic fissures often have a small external lump associated with the tear called a sentinel pile or skin tag.

How can a fissure be treated?

The principle of treating an anal fissure is relieving the anal spasm and correcting the constipation. At least 50 percent of anal fissures heal by medical management alone.

  1. Drinking more fluids.
  2. Eating a high-fiber diet to avoid constipation.
  3. Using stool softeners.
  4. Allowing enough time for a bowel movement
  5. Sitz baths (soaking anal area in plain warm water)
  6. Avoid foods that may not be well-digested (i.e., nuts, popcorn, tortilla chips)
  7. Topical ointments

Medical treatment of an acute anal fissure may take a few days or weeks, while healing of a chronic anal fissure may take more than 6 weeks.

In case a fissure does not heal should be reexamined to determine if an underlying problem exist that prevents healing.

Can fissures recur?

Fissures can recur in some patients after a hard bowel movement. Even after the pain and bleeding has disappeared one should continue to aim for good bowel habits and adhere to a high fiber diet or fiber supplement regimen. If the problem returns without an obvious cause, further assessment may be needed.

What can be done if a fissure doesn't heal?

A fissure not responding to non surgical management will require some intervention to relieve muscle spasm. This may be by chemical internal sphincterotomy (CIS) or lateral internal sphincterotomy (LIS).

What is chemical internal sphincterotomy (CIS)?

This procedure is a minimally invasive approach to relax the anal muscle by partially paralyzing it by injecting chemicals into the anal sphincter muscle. The relief occurs within a few days and complete healing occurs in a few weeks time.

What is lateral internal sphincterotomy (LIS)?

Surgery is a highly effective treatment for a fissure and recurrence rates after surgery are low. Surgery usually consists of a small operation to divide cut a portion of the internal anal sphincter muscle (a lateral internal sphincterotomy). This helps the fissure heal and decreases pain and spasm.

If a sentinel pile is present, it too may be removed to promote healing of the fissure. A sphincterotomy rarely interferes with one’s ability to control bowel movements and is most commonly performed as a short outpatient procedure.

How long does the healing process take after surgery?

Complete healing occurs in a few days / weeks, although pain often disappears after a few days.

Can fissures become cancerous?

No! However if symptoms persist despite healing of the fissure, a careful evaluation is needed to rule out other conditions that can cause similar symptoms. You may require additional testing even if your fissure has successfully healed. A colonoscopy may be required to exclude other causes of bleeding.

Rectal prolapse

What is rectal prolapse?

A condition where in the rectum (distal most part of large intestine just above the anal canal) protrudes out of the anal opening due to stretching or disruption of its attachments to the posterior abdominal wall.

Causes of rectal prolapse?

The primary cause of rectal prolapse remains unclear.

Predisposing factors include prolonged straining while passing stools (chronic constipation), multiple pregnancies, neurological illnesses causing muscular weakness or connective tissue disorders (genetic predisposition). It is often seen in the elderly as aging causes the supporting ligaments to stretch the anal sphincter muscle to weaken.

The most popular concept is due to a functional disturbance of the pelvic floor.  Weakness of the anal sphincter muscle is often associated with rectal prolapse, resulting in leakage of stool or mucus.

What complications can occur in rectal prolapse?

The presence of a large pink mass protruding out of anal opening is embarrasing.  The mass may protrude only on bowel movements or sneezing, or chronically protrude from the body at all times.
Extreme pain and difficulties with bowel movements may also be noticed, especially if the rectum undergoes any torsion (twisting) during its collapse. Bleeding or mucus discharge from the damaged tissue, loss of urge to defecate, and fecal incontinence may also occur.

Diagnosis

Diagnosis of rectal prolapse is made on history and physical examination. In case of an internal rectal prolapse sometimes a defecography is required.

Treatment

Rectal prolapse occurring in children, during pregnancy and following childbirth are known to correct spontaneously and most often do not require any intervention.

In most cases however surgery is required to correct rectal prolapse in adults and in some children. There are 3 procedures described for repair of rectal prolapse.

  1. Perineal approach
    1. MIPH (Ref to surgical treatment of piles) indicated only for partial or mucosal prolapse
    2. Altemeier procedure (also called a proctosigmoidectomy) involves removal of the prolapsed part of the rectum and suturing together of the cut edges
    3. Thiersch wiring is a temporary procedure wherein the anal verge is wired to narrow the opening. The procedure is poorly tolerated.
  2. Abdominal approach
    1. Rectopexy - Surgical fixation of the rectosigmoid to the sacrum.
    2. Anterior resection -The redundant part of the sigmoid is resected and removed. It may or may not be accompanied by rectopexy.

Both procedures can be performed by Laparoscopic approach.

Laparoscopic surgical procedures for rectal prolapse are done under general anesthesia. In patients unfit for general anesthesia epidural or spinal anesthesia may be used.
Abdominal procedures give better results, of these Rectopexy is associated with a faster recovery.

Note: The post operative management following any of the above procedures is equally important for a successful out come. This includes

  1. Healthy eating habits for easy bowel movement.
  2. Use of laxatives in the early post-operative period to prevent straining
  3. Exercises to tone the pelvic muscles (Kegel Exercises)