Information sheet for patients undergoing anorectal surgery



Professor. IAN T. JONES

FRACS FRCS

COLORECTAL SURGERY

Suite 5, 6 & 7 Telephone: 9347 4077

Private Medical Centre Facsimile: 9348 2075

Royal Melbourne Hospital Royal Parade Pager: 9387 1000

Parkville VIC 3050

INFORMATION SHEET FOR PATIENTS UNDERGOING ANORECTAL SURGERY

INTRODUCTION

Anorectal surgery may be recommended for a variety of anorectal disorders including haemorrhoids, abscess, anal fistula and anal fissure. Usually this surgery is performed under general anaesthetic, is not considered major surgery and is typically performed on a same day, overnight stay basis or longer in certain circumstances.

ANORECTAL CONDITIONS REQUIRING SURGERY

1. Haemorrhoids - consist of engorged blood vessels covered by a lining of the anal canal which typically cause symptoms of protrusion from the anus, bleeding or in some cases severe pain.

2. Perianal Abscess - is a collection of pus developing in the tissues in the area around the anus.

3. Fistula In Ano - a fistula is an abnormal track or tunnel arising between an opening on the inside of the anal canal and extending through the tissues to an opening on the skin outside the anus. These typically develop after drainage of a perianal abscess but may occur spontaneously.

4. Anal Fissure - is a tear or split in the issues of the anal canal and extending out through the anal opening or verge. Anal fissures typically cause pain on bowel movement and rectal bleeding and can be associated with spasm of the anal muscle.

OPERATIONS FOR ANORECTAL CONDITIONS

1. Haemorrhoidectomy - this operation involves surgical removal of the engorged blood vessels which make up the haemorrhoid complex. Typically, three such haemorrhoids are found and removed at operation and the wounds may be closed by dissolving suture material. An alternative surgical procedure is to use a special circular stapler to remove the haemorrhoidal tissue (stapled haemorrhoidectomy).

2. Drainage of Perianal Abscess - this involves incision into the skin over the abscess (lancing) to release pus and other infected material. For small abscesses, this might be performed under local anaesthetic.

3. Surgery for Anal Fistula - one of a range of different surgical procedures may be offered for the treatment of anal fistula and these will be indivualised according to the nature of the particular fistula. The usual procedures undertaken include:

• Insertion of a seton drain tube (which may be left for several weeks prior to further surgery being undertaken)

• Fistulotomy (which involves cutting open or laying open the fistula track)

• Repair of the fistula by a procedure known as rectal advancement flap repair

• Injection of the fistula track using biological fibrin glue to obliterate the track

4. Anal Fissure - the most common operation is called internal sphincterotomy which involves surgical division of a small amount of the inner of the two anal sphincter muscles to release the spasm in the muscle which is the reason that anal fissures have failed to heal spontaneously. On occasion, alternative operations including excision of the fissure (fissurectomy) may be used instead of sphincterotomy.

POSTOPERATIVE COURSE AND INSTRUCTIONS

A degree of anorectal discomfort or pain, swelling in the region of the surgery and some fluid discharge are common after anorectal surgery and typically resolve spontaneously over several days. The following instructions are helpful in recovery from anorectal surgical procedures.

1. Fluid - maintain an adequate fluid intake. Six large glasses of water per day is adequate.

2. Constipation - avoid constipation by taking in an adequate amount of dietary fibre or roughage especially bran containing products such as bran based breakfast cereals, wholemeal bread and bran muffins. Psyllium husks e.g. Metamucil may be helpful.

3. Laxatives - Lactulose 30 ml daily taken by mouth will ensure the adequate return of bowel function and avoid constipation. Once a reasonably normal bowel pattern has resumed, laxatives are usually no longer required and bowel actions can be maintained with an adequate fluid and fibre intake.

4. Painkillers (Analgesics) - depending on the nature of the operation performed and the amount of postoperative discomfort experienced, one or more painkillers will be prescribed. In simple cases with minimal pain, mild painkillers such as paracetamol may be sufficient. Stronger painkillers include Ibuprofen (Nurofen), Panadeine, Panadeine Forte or Tramadol. Whilst very effective, some of the stronger painkillers contain codeine which can increase the tendency to constipation and steps to prevent that occurring with an adequate fluid and fibre intake and the use of laxatives is required as outlined above. Local anaesthetic ointments such as Proctosedyl or Xyloproct may also be helpful in relieving postoperative anal discomfort. These can be gently applied by finger to the external anal area.

5. Hygiene and Baths - in the early postoperative period, toilet paper may be uncomfortable to use after a bowel movement. Nappy wipes available from a pharmacist or supermarket are more soothing and lubricating. In the first few days after surgery, a warm bath taken after bowel movements is particularly comforting and ensures the surgical area remains clean.

6. Dressings - only very simple dressings are used after anorectal surgery. Some of these may lie in the anal canal such as Vaseline coated gauze or the biodegradable (dissolving) dressing known as Spongistan. The remnants of these dressings may be passed by the patient after the first bowel movement and should not cause alarm. They do not need to be replaced. Whilst not essential, a pad placed within the underwear over the anal area will protect clothing from any minor discharge or bleeding from the anal wounds.

ABNORMAL SYMPTOMS AFTER ANORECTAL SURGERY

The following should be reported.

a. Severe postoperative pain

b. Excessive bleeding (more then half a cup full of blood per day)

c. Fever above 38 degrees centigrade or shivering and chills (rigors)

d. Difficulty in passing urine

ADVERSE CONSEQUENCES OF COMPLICATIONS OF ANORECTAL SURGERY

1. Excessive Bleeding - this is more common after haemorrhoidectomy than other anorectal surgical procedures. This can occur within hours after surgery or be delayed for up to fourteen (14) days or more. If excessive (more then half a cup full in a day), further treatment might be required including readmission to hospital or even operation to control the bleeding point.

2. Infection - despite involving the anal region, it is uncommon for infections to occur after anorectal operations. However occasionally quite severe infections can develop. These are most common in immuno-compromised patients (e.g. diabetics, patients on chemotherapy or medication to prevent transplant rejection and HIV positive patients). In serious infections, aggressive treatment including antibiotics and surgery might be required. Rarely these infections are life threatening.

3. Difficulty in Passing Urine – this is more common in men and might need to be treated by the temporary passing of a urinary catheter. Occasionally it is found that the main cause of difficulty in passing urine after an anorectal surgery operation is due to enlargement of the prostate and treatment by a specialist urologist might be required.

4. Excessive Pain - the degree of pain depends primarily on the nature of the surgical operation but also on the patient’s own perception. In some cases, the level of pain may be such that discharge from hospital needs to be delayed to allow continued administration of strong painkillers. Occasionally, excessive anorectal pain after surgery is a sign of postoperative infection.

5. Swelling in the Surgical Area – early in the postoperative period, some patients notice swelling in the anal region. This is usually due to fluid accumulation in the tissues around the surgical wounds (oedema) and typically resolves over a period of three or four weeks. Some patients are left with small permanent tags of skin in the anal area. These are not serious and simply represent redundant folds of skin remaining after postoperative swelling.

6. Weakness of Bowel Control (Incontinence) – weakness for bowel control after haemorrhoidectomy is rare and is reported quite infrequently after that operation. Incontinence occasionally occurs after internal sphincterotomy (performed for anal fissure, incidence around 3%) or after fistulotomy for anal fistula. In many cases, such weakness is temporary and minor (e.g. loss of control for flatus or wind). Occasionally it can be more significant than this. Whilst it is impossible to predict which patients might experience this problem, the issue will be discussed before surgery in patients requiring the operations of internal sphincterotomy or fistulotomy in particular.

7. Delayed Wound Healing - because the wounds created by anorectal surgery are exposed to the continued passage of bowel movements on a regular basis, wound healing may be delayed in some patients particularly of haemorrhoidectomy. In most cases, the anorectal wounds will have healed by four weeks after surgery. Sometimes healing is delayed or painful and on occasion further surgery might be required to achieve complete wound healing.

CONTACT

For questions or concerns after anorectal surgery performed by Professor Jones, please call him during office hours on 03 9347 4077 or after hours on 03 9387 1000.

Professor Ian T Jones

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