Anal Fistula Surgery - Types, Symptoms, Risks & Complications

1. What is an Anal Fissure?
2. Types of Anal Fissure
3. Why is anal fissure surgery required? 
4. Preoperative tests and diagnostics
5. Procedure day
6. Post operative care and recovery
7. Risks and Complications

What is an Anal Fissure?

An anal fissure is a small tear or cut in the thin, moist tissue that lines the anus. Anal fissures are one of the most common anorectal conditions and can be quite painful as the damage in the skin can often pull apart and even worsen the situation. Bowel conditions like chronic diarrhoea or constipation can also make an anal fissure worse. 

Some of the most common causes of an anal fissure include, constipation, persistent diarrhoea, passing large or hard stools during bowel movement and inflammatory bowel diseases (IBD) such as Crohn’s disease or ulcerative colitis. 

Types of Anal Fissure

There are primarily 2 types of anal fissures: 

Acute anal fissure: An acute anal fissure is one of the most common types of fissures and looks very fresh and similar to a paper cut. Most acute fissures heal on their own within 5-6 weeks and do not require surgical intervention but if the condition persists, your surgeon may recommend a surgery.

Chronic anal fissure: In comparison to acute anal fissures, chronic fissures look more old, likely have a deeper cut and may have internal fleshy growths. A fissure is also considered to be chronic if it persists for more than 8 weeks. Surgery is almost always necessary in case of a chronic fissure.

After a thorough diagnosis, your proctologist can easily tell the difference between the two and recommend a suitable surgery for you. 

Why is anal fissure surgery required? 

While acute anal fissures can heal on their own, chances of recurrence in such cases are very high. For example, if fissure is caused by constipation, fissure may reoccur if constipation remains untreated. Your doctor may recommend some non-surgical treatments for your fissure but if the condition persists for more than 8 weeks, in which case the fissure is considered chronic, a surgery is almost always necessary.

If you suffer from a fissure that has persisted for more than 8 weeks, it is recommended to contact your healthcare provider for a thorough diagnosis and treatment. Delaying the surgery or allowing a fissure to persist can cause the fissure to worsen overtime and lead to serious complications. The fissure may even extend and start affecting the sphincter muscles in which case surgery becomes more complicated. 

Preoperative tests and diagnostics

Tests and diagnostics: Before surgery, your doctor will likely ask about your medical history and perform some general tests and diagnostics including a gentle inspection of the anal region. Most anal fissures are visible and once they’re located, do not require further diagnostics but if your doctor suspects an underlying condition such as Crohn’s disease or ulcerative colitis to be the reason behind your fissure, he or she may recommend additional imaging tests such as: 

• Anoscopy: Anoscopy is a procedure that uses a tubular device called an anoscope to view the lining of your anus and rectum.
• Flexible sigmoidoscopy: For this test, your doctor will insert a thin and flexible tube, that has a tiny camera attached to it, inside your rectum. This provides the surgeon with a detailed view of the lining in your anus and rectum. 
• Colonoscopy: This procedure involves inserting a thin, flexible tube into your rectum to inspect the entire colon. 

Food and medications: Your doctor may instruct you not to eat or drink anything for the last 12 hours before surgery. If you take any blood thinning medications, your doctor may also advise you to temporarily stop taking them to reduce chances of excessive bleeding during surgery as much as possible. 

Procedure day

Sphincterotomy procedures do not require any special pre-operative procedures such as bowel prep. The field is typically prepared using a local antiseptic solution and does not require any intravenous antibiotics. A sphincterotomy is generally performed under local anaesthesia but depending on your overall health, your surgeon may prefer using general anaesthesia. Take your normal medications as usual unless you are directed otherwise by your doctor.
Methods of anal fissure surgery

There are primarily 2 ways to treat an anal fissure: 

Lateral Internal Sphincterotomy: Often referred to as LIS or an open surgery, lateral internal sphincterotomy is one of the most common methods of anal fissure treatment. This method is often preferred by surgeons to treat both an acute and chronic fissure but being an open surgery, it has its own set of potential complications. In a LIS procedure, the surgeon makes a small incision in the internal anal sphincter. The aim here is to reduce the tension on the sphincter as when the tension is too high, fissures are unable to heal. Once the incision has been made, and the anal muscles are allowed to relax, the fissure can heal on its own. An LIS procedure can be performed under local or general anaesthesia and is generally performed on an outpatient basis meaning, you can go home on the same day of the surgery. 

Laser sphincterotomy: Laser sphincterotomy or laser treatment for anal fissure is often the preferred method of surgery by doctors when the patient suffers from a chronic fissure. In a laser sphincterotomy, a laser probe is used to emit infrared radiation at the site of fissure and make a small incision similar to the one made in LIS. This incision allows the tight sphincter muscles to relax and reduce some tension. Once the tension is reduced, the fissure can heal on its own. The high energy laser beam also increases the blood flow to the affected area and promotes faster healing of the fissure as compared to open surgery. Laser sphincterotomy is a minimally invasive procedure and the chances of fissure recurrence after laser surgery are significantly low as well. The procedure is generally performed under local anaesthesia but your surgeon may use general anaesthesia meaning you won't be awake during the procedure. 

Post operative care and recovery

The healing capacity of every person is different and hence, recovery rate after your anal fissure surgery may vary. In most cases, a complete recovery takes about 1-3 months. Most people can return to work and continue their normal routine after 1-2 weeks of surgery. To promote faster recovery and reduce chances of any complications, your doctor may recommend some temporary changes in your daily lifestyle such as:

• Taking adequate rest and plentiful sleep to help in boosting your recovery.
• Spicy or oily foods are to be avoided for some time. Fibre-rich foods such as watermelon, bananas, brown rice or cauliflower reduce chances of constipation and help in softening up the stools. 
• Alongside a fibre-rich diet, about 2-3 litres of water is also needed to keep the stools soft and avoid constipation.
• Perform a sitz bath 2-3 times a day for at least the first couple months after surgery. 
• Performing simple and easy exercises daily for at least 20-30 minutes. Sedentary lifestyle can lead to straining during bowel movements and cause the fissure to reoccur. 

Risks and complications

Complications of any kind after an anal fissure surgery are very rare but as is the case with any other surgery, they can still happen. Some of the most common complications that occur after a fissure surgery are given below: 

• Bowel incontinence: Bowel incontinence is one of the most common complications that occur after a anal fissure surgery. During the surgery, sphincter muscles that are responsible for controlling bowel movement, may get damaged and as a result, you may lose some control over your bowel. 
• Bleeding: Although very uncommon, there is a slight chance that heavy bleeding or haemorrhage could occur during an anal fissure surgery. If unexpected heavy bleeding occurs, your doctor may need to perform additional procedures to control it.  
• Failure of the fissure to heal: Even after a sphincterotomy procedure, the fissure may not respond well and in such cases should be re-examined. Conditions such as constipation or persistent large and hard stool can also cause the healing process to be slow or absent. 
• Fissure recurrence: Chances of recurrence in case of an anal fissure are generally high if conditions like constipation or persistent diarrhoea was the reason behind your fissure and remains untreated.
• Infection: While rare, infections after your fissure surgery can occur. If you exhibit symptoms such as fever, chills or pain that continues to grow after bowel movement, it is best to contact your doctor as soon as possible.