Colorectal surgery is a field in medicine, dealing with disorders of the rectum, anus, and colon.
Colorectal surgical disorders include:
- varicosities or swelling, and inflammation of veins in the rectum and anus (Hemorrhoids)
- unnatural cracks or tears in the anus (Anal fissures)
- abnormal connections or passageways between the rectum or other anorectal area to the skin surface (Fistulas)
- severe constipation conditions
- fecal incontinence
- protrusion of the walls of the rectum through the anus (Rectal prolapse)
- treatment of severe colic disorders, such as Crohn's disease
- cancer of the colon and rectum (Colorectal cancer)
- anal cancer (rare)
- any injuries to the anus
Anal fissure, also known as fissure in ano, is a linear tear in the lining of the distal anal canal.
Anal fissure is the most common cause of severe anal pain. It is equally one of the most common reasons of bleeding per anus in infants and young children. The pain of anal ulcer is intolerable and always disproportionate to the severity of the physical lesion. It may be so severe that patients may avoid defecation for days together until it becomes inevitable. This leads to hardening of the stools, which further tear the anoderm during defecation, setting a vicious cycle.
The fissures can be classified into
The fissures can be classified into
- Acute or superficial
- Chronic fissure in ano.
Acute or superficial fissures are treated with conservative line of treatment like warm water Sitz bath, stool softeners, adequate pain relief and high fiber diet.
Chronic fissures do not yield to these conservative measures.
The fissure is labeled as chronic or complicated if it fulfills the following criteria :
- If not responding to conservative treatment.
- If a fibrous anal polyp is present.
- Presence of an external skin tag is noticed.
- Presence of hemorrhoid is visible.
- Induration is indicated at the edges of fissure.
- If there is exposure of the fibers of the internal sphincter at the floor of the fissure.
- The base of fissure is infected.
Operative treatments of Anal Fissure by Dr. Dinesh Jain :
- Lateral subcutaneous internal sphincterotomy
- Excision of the anal fissure (fissurectomy)
- Stretching of Anal sphincter: Lord’s dilatation
- LASER surgery
After the Operation :
- The patient can be expected to be discharged from the hospital on the same day.
- Medicine for pain relief, antibiotics and stool softeners are given.
- Patient is generally cured of the problem in a week’s time.
Rarely, a few patients may experience a temporary loss of control over the stools that may last for 2-3 weeks.
An anal fistula is an opening in the skin near the anus that leads into a blind pouch or may connect through a tunnel with the rectal canal.
An anal fistula can cause bleeding and discharge when passing stools - and can be painful.
It can occur after surgery to drain an anal abscess.
In some cases, an anal fistula causes persistent drainage. In other cases, where the outside of the channel opening closes, the result may be recurrent anal abscesses. The only cure for an anal fistula is surgery.
Symptoms of anal fistulas :
Possible symptoms include:
- Pain which is usually constant, throbbing and worse when sitting down
- Skin irritation around the anus, including swelling, redness and tenderness
- Discharge of pus or blood
- Constipation or pain associated with bowel movements
Diagnosis of anal fistulas
Usually, a clinical evaluation - including a digital rectal examination - is sufficient to diagnose an anal fistula, but some patients may require additional tests like colonoscopy to screen for :
- Rectal cancer.
- Inflammatory Bowel Disease (Crohn’s disease)
In rare cases, an examination may be done under anaesthesia. The doctor may also ask for an ultrasound or a CT scan or an MRI.
Treatment of anal fistulas by Dr. Dinesh Jain
The type of surgery will depend on the position of the anal fistula. The options include :
- Fistulotomy : This is used in 85-95% of cases and involves cutting open the whole length of the fistula in order for the surgeon to flush out the contents. This heals after one to two months into a flattened scar.
- Fistulectomy : In this method, the entire fistula tract is cored out upto its internal opening. The remaining wound is stitched back completely or partially and allowed to heal.
- VAAFT : Video Assisted Anal Fistula Treatnment: This method is used for complex fistulas with a long tract. An endoscope is passed through the fistula tract to visualize the tract and the internal opening is closed using a stapler. The tract is then electrocauterised after cleaning of all the unhealthy granulation tissue. Finally, a fibrin glue is used to close the tract,
- LASER surgeruy for fistula : Diode LASER probe is used to burn the fistula tract which subsequently closes by 2-3 weeks time.
- Seton techniques : A seton is a piece of thread which is left in the fistula tract. This may be considered if you are at high risk of developing incontinence when the fistula crosses the sphincter muscles. Sometimes several operations are necessary.
PILES ( Mulvyadh/Bavasir ) ( clinically known as hemorrhoids ) basically, is the swelling of blood vessels near the anal opening and a sliding down of the lining of the anal canal. The lumps are formed by increased pressure on blood vessels in the area, causing them to enlarge and swell.
Conventional piles surgery includes cutting the piles from its root and stitching the wound.
Stapler surgery is an advanced technique using the Ethicon stapler equipment. The equipment appears to look like a gun that takes in the loose anal mucosa (inner lining) and cuts a piece in the shape of a doughnut around its periphery. It simultaneously stitches the raw cut edges of the anal mucosa and fixes the pile in its normal position. This action is similar to a stapler; hence it is commonly called stapler surgery. In medical terms it is called MIPH (Minimally Invasive Procedure for Haemorrhoids).
Click here to read more about Piles.
Rectal prolapse occurs when part or all of the wall of the rectum slides out sometimes sticking out of the anus.
There are two types of rectal prolapse.
- Partial prolapse/ Partial thickness rectal wall prolapse (also called mucosal prolapse). The lining (mucous membrane) of the rectum slides out of place and usually sticks out of the anus. This can happen when you strain to have a bowel movement. Partial prolapse is most common in children younger than 2 years.
- Complete prolapse / Full thickness rectal wall prolapse. The entire wall of the rectum slides out of place and usually sticks out of the anus. At first, this may occur only during bowel movements. Eventually, it may occur when you stand or walk. And in some cases, the prolapsed tissue may remain outside your body all the time.
What causes rectal prolapse?
Risk factors for adults include :
- Straining during bowel movements because of constipation.
- Tissue damage caused by surgery or childbirth.
- Weakness of pelvic floor muscles that occurs naturally with age.
Treatment of Rectal Prolapse by Dr. Dinesh Jain
- For partial/ mucosal prolapse: Stapler Anopexy: This is same as the Stapler surgery or MIPH where excess rectal mucosa is cut and stapled simultaneously. If the length of prolapsed rectal mucosa is more, then two staplers may be required to get the desired effect.
- For complete/ full thickness rectal wall prolapse: Laparoscopic abdominal rectopexy: It is a minimally invasive technique, where the rectum is dissected off the sacrum and fixed back using a piece of prolene mesh. This induces fibrosis and keeps the rectum in place. If the conditions are not favorable for a laparoscopic procedure, the same operations can be performed by open surgery through abdomen.
Prevention of rectal prolapse :
- Avoid constipation.
- High fiber diet
- Drink plenty of water (at least 8 glasses a day)
- Maintain regularity and timing of bowel habit.
- Anal sphincter strengthening exercises. Alternate tighting and relaxing of the pelvic floor muscles 2-3 times a day.