Endoscopic
Anorectal Surgery

The term anorectal refers to conditions related to the anus or rectum. These conditions are mainly caused due to some sort of overgrowth or abnormal growth of tissues in the anus and rectum region. While discussing these issues might be embarrassing, living with them can be downright painful.

Anal Fistula

An anal fistula is a small channel that can develop between the end of the rectum/anal canal and the skin near the anus. An anal fistula can cause bleeding and discharge when passing stools and can be painful. An anal fistula can occur after surgery to drain an perianal abscess.

Causes

The most common cause of the development of an anal fissure is injury to the skin at the anal opening due to a hard, dry bowel movement. Other causes include digital insertion (during examination), foreign body insertion or anal intercourse. Pregnant women may also develop a fissure during childbirth.

Diagnosis

  • Physical examination is normally carried out for diagnosis.
  • In some cases proctoscopy and other tests like anal endosonography can be used for diagnosis.

Treatment

Surgery, performed by a specialist, is usually necessary to manage an anal fistula. During surgery, the surgeon will assess the depth and extent of the fistula tract.

The following types of surgery are commonly used for the treatment:

Minimally Invasive Fistula Treatment (MAFT): It is a minimally invasive laparoscopic technique.

  • Fistulotomy/Fistulectomy: Most fistulas are treated with a fistulotomy, in which the skin and muscle over the tunnel are cut open, converting it into an open groove. This will allow the fistula tract to heal from the inside out.

Minimally Invasive Fistula Treatment (MAFT)

MAFT (VAAFT) is a major breakthrough treatment option for complex fistulas. VAAFT (The Video assisted Anal Fistula Treatment) or MAFT (Minimally Invasive Fistula Treatment) are alternatively used terms.

Procedure:

  • This technique involves the examination of the fistula path using an endoscope to determine the point of the internal opening of the fistula.
  • This is followed by closing the internal opening of the fistula using a stapler and the entire fistula tract is destroyed under direct telescopic vision by electrocautery.

MAFT (VAAFT) over conventional procedure

  • No surgical wounds on the buttocks or in the perianal region
  • No damage to the anal sphincters
  • Less pre-operative investigations to ascertain type of fistula
  • Early recovery and return to work and normal actions.
  • Can be done as a Day-Care procedure
  • Possibilities of localization of the internal fistula opening (key point in all fistula surgical treatments) is much higher
  • Fistulous tract can be completely destroyed from within, without damaging any other tissues

Piles

Piles are also called haemorrhoids. Hemorrhoids are masses, clumps, cushions of tissue in the anal canal - they are full of blood vessels, support tissue, muscle and elastic fibers.

Haemorrhoids are classified into two general categories: internal and external.

Internal haemorrhoids lie far enough inside the rectum that you can't see or feel them. They don't usually hurt because there are few pain-sensing nerves in the rectum. Bleeding may be the only sign that they are there.

External haemorrhoids lie within the anus and are often uncomfortable. If an external haemorrhoid prolapses to the outside (usually in the course of passing a stool), you can see and feel it.

Causes

Piles may develop due to chronic constipation which leads to excessive straining resulting in swelling of the veins in the rectal area. Pregnant women may also develop piles due to increased pressure on the veins in the pelvic area.

Diagnosis

Physical examination and proctoscopy aid in the diagnosis of piles.

Treatment

In the early of cases, piles resolve on their own without the need for any treatment. Treatments can help significantly reduce the discomfort and itching that many patients experience.

The treatment options available are as follows:

  • Depending on the diagnosis, the doctor advises if home treatment is all you need or further intervention is required. Lifestyle and dietary modifications such as regular physical exercise, plenty of fluids and a high fibre diet provide symptomatic relief.
  • Surgery: Surgery is used for particularly large piles. Generally, surgery is used when conservative treatment/management is not effective. Sometimes surgery is done on an outpatient basis - the patient goes home after the procedure.

Types of surgery available for piles treatment

  • Haemorrhoidectomy (open surgery of the piles): the excess tissue that is causing the bleeding is surgically removed. This can be done in various ways. It may involve a combination of a local anesthetic and sedation, a spinal anesthetic, or a general anesthetic. This type of surgery is effective in completely removing piles, but is associated with pain for few days.
  • Minimally Invasive Procedure for Hemorrhoids (MIPH): This technique uses stapler for performing the surgery. It is relatively painless and be done as a day care surgery.

Minimally Invasive Procedure for Hemorrhoids (MIPH)

Procedure:

In this technique, 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.

Advantages:

  • Minimal postoperative pain
  • Shorter hospital stay
  • Quicker recovery and return to normal activities
  • Excellent cosmetic outcomes

Fissures

An anal fissure is a small tear in the skin lining the opening of the anus. Fissures can cause severe pain and bleeding, especially during bowel movements. Anal fissures can be caused by hard or difficult bowel movements. Changes in diet resulting in softer stools, as well as topical anesthetics to reduce pain, are common nonsurgical treatments. If surgery is required, your surgeon will work to relax the anal area so there is less anal pain.

Causes

The most common cause of the development of an anal fissure is injury to the skin at the anal opening due to a hard, dry bowel movement. Other causes include digital insertion (during examination), foreign body insertion or anal intercourse. Pregnant women may also develop a fissure during childbirth.

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

Diagnosis

  • The doctor can make a diagnosis based on the symptoms and a simple look at the anal opening.
  • Sometimes, a digital rectal examination or an anoscope may be required for diagnosis.

Treatment

Anal fissures often heal within a few weeks if you take steps to keep your stool soft, such as increasing your intake of fiber and fluids. Soaking in warm water for 10 to 20 minutes several times a day, especially after bowel movements, can help relax the sphincter and promote healing.

Conservative management: Atleast 50 percent of anal fissures heal by medical management which include topical ointments, sitz baths, dietary modifications (i.e. incorporating a high fibre diet and avoiding foods that are not well digested like maida, popcorn , chips), drinking plenty of fluids, using stool softeners/ laxatives.

Surgery:

Surgery is used for treatment when fissures do not respond to other treatment. The two options available are:

Chemical Internal Sphincterotomy

It is a minimally invasive approach to relax the anal muscle by partially paralyzing it by injecting chemicals into the anal sphincter muscle.

Lateral Internal Sphincterotomy

In this surgery, a portion of the anal sphincter muscle is divided which helps the fissure to heal and decreases the pain and spasm. If a sentinel pile is present, it is removed to promote healing. It is a quick surgical process and can also be performed as a short outpatient procedure. The chances of recurrence are almost nil. It is the most effective treatment option for non healing fissures.

Prolapse

A rectal prolapse occurs when the rectum protrudes out of the anal opening due to stretching or disruption of its attachments to the abdominal wall.

Causes

The exact cause remains unclear however, the predisposing factors include prolonged straining during bowel movement, multiple pregnancies, neurological illnesses causing muscular weakness or connective tissue disorders.

Weakness of the anal sphincter muscle is often associated with rectal prolapse, resulting in leakage of stool and mucus discharge. This condition is more common in the elderly,

Diagnosis

  • History of symptoms and physical examination confirm the diagnosis of a prolapse.
  • In case of an internal rectal prolapse, defecography is required.

Treatment

In some cases of very minor, early prolapse, treatment can begin at home with the use of stool softeners and by pushing the fallen tissue back up into the anus by hand. However, surgery is usually necessary to repair the prolapse. There are several surgical approaches. The surgeon’s choice depends on patient’s age, other existing health problems, the extent of the prolapse, results of the examination and other tests, and the surgeon’s preference and experience with certain techniques.

Abdominal and rectal (also called perineal) surgery are the two most common approaches to rectal prolapse repair.

  1. Rectal (perineal) repair approaches

It includes three different methods that are used depending on the nature of the prolapse.

  • Minimally Invasive Procedure for Hemorrhoids (MIPH): this process is indicated only in cases of partial or mucosal prolapse.
  • Altemeier procedure (also called a proctosigmoidectomy): involves removal of the prolapsed part of the rectum and suturing together the cut edges.
  • Thiersch wiring: is a temporary procedure wherein the anal verge is wired to narrow the opening. The procedure is poorly tolerated.

The perineal approach being minimally invasive has various advantages such as decreased operative time, less blood loss, faster recovery and less post-operative pain

  1. Abdominal repair approaches

Abdominal procedure refers to making an incision in the abdominal muscles to view and operate in the abdominal cavity. It is usually performed under general anesthesia and is the approach most often used in healthy adults.

The two most common types of abdominal repair are

  • Rectopexy (fixation [reattachment] of the rectum). Rectopexy can also be performed laparoscopically through small key-hole incisions.
  • Resection (removal of a segment of intestine) followed by rectopexy. Resection is preferred for patients with severe constipation. This can be performed laparoscopically as well.

Frequently Asked Questions

Pre surgery instructions:
  • Some preoperative investigations are required before surgery.
  • Follow your surgeon instructions for any prescribed medications.
  • You may be asked to stop taking medicines like aspirin and all aspirin containing medications for a minimum of five days before surgery.
  • One day before surgery, the patient is usually kept NPO (nothing to be taken orally except medicines prescribed) after midnight
  • The patient is kept under observation for 2-4 hours and then shifted to the room.
  • Patient is allowed to drink oral liquids on the same day of surgery.
  • The patient is allowed to move on its own and visit the toilet on the same day of the surgery.
  • Generally the patient is discharged on the next day of the surgery.
  • The patient is advised to visit again after one week when the dressings are removed.
  • Patient should avoid wetting the dressings unless they are waterproof. After the removal of dressing, patient can have normal bath with soap and water.
  • The patient is advised to adhere to healthy eating habits, use of laxatives in the early post operative period and Kegel exercises to tone the pelvic muscles.
  • On discharge, a discharge summary with the advised medication is handed over to the patient along with the date of the first follow up appointment.
  • Regular follow up is advised.

Frequently Asked Question

'Anorectal conditions' is a term used for the problems arising in the anus and rectums collectively.

The common anorectal problems are:

  • Piles
  • Anal Fistula
  • Fissures
  • Prolapse

Generally, you can be discharged on the same or next day of the surgery.

In general, plan to take about one week off from work.

Mostly the procedure is covered under most medical insurance plans. Please confirm in your policy documents

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