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What is Anal Fissure Surgery?
An anal fissure is a tear in the lining of the anus which is called the mucosa. These affect about 1 in 10 people of all ages.
Your doctor may recommend a Botox injection and this is typically given under general anaesthetic. It works by paralysing one of the muscles in the bottom, which eases spasm and promotes blood flow to the injured area. The medicine lasts for three to four months and then wears off. It is safe, with limited side effects. However, Botox will only work in about 50% of cases and there is a risk of temporary incontinence or infection or the need for further treatment.
Surgery is reserved for patients in whom these simple measures don’t work. This is known as a “lateral sphincterotomy”. The aim is to cut one of the muscles in the bottom and to permanently reduce the spasm in the anal sphincter muscles. It works in about 90% of patients. This is performed under general anaesthetic as a day case procedure. Most patients will recover in about two to four weeks. Although effective, 1 in 20 patients will experience some symptoms of incontinence. This is usually to wind or liquid motions and in most cases this is temporary.
Very resistant or chronic fissures may require more complex treatment with surgery called “advancement flaps”. This procedure creates a flap of healthy tissue which is taken from the skin around the bottom which is then stitched over the area of the fissure. This is a complex procedure which requires discussion with your surgeon.
Why are they treated?
Typically because the fissure causes symptoms which cannot be controlled with topical therapy.
What are the benefits?
The main benefit is that the diagnosis is confirmed and that your symptoms are treated. Most surgical treatments are effective.
What are the risks?
This is a safe procedure and the likelihood is that you will make a good recovery. However, all surgical procedures have some risks.
1. Incontinence: If you are treated with botox therapy this is very unlikely to occur. If it does, then it will be temporary as the botox will wear off after about three months. If you have had a lateral sphincterotomy, then around 10% of patients will suffer from incontinence to flatus or liquid faeces and they may experience soiling. Although this can be improved with biofeedback, it may be permanent.
2. Infection: If this happens the wound will become red and painful, and you may have a temperature. You should seek further help from your doctor as you may require antibiotics. If you smoke, you have diabetes or you are obese you are at an increased risk of wound infection.
3. Bleeding: If this happens, it typically causes a haematoma (a collection of blood) in the tissues. It increases the appearance of bruising. Swelling can slow down healing and it may spoil the cosmetic appearance of the final result. A large bleed is unlikely to occur but very rarely it may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin).
4. Failure of therapy: If you have had botox there is a 1 in 2 chance you will require another injection. The failure rate with lateral sphincterotomy is much lower, and it is nearer 2%. If you have had an advancement flap, your doctor will describe this with you in person, but there is change that the blood supply to the flap fails and that the fissure recurs.
What are the alternatives?
A change in lifestyle and toilet habit may help. Certainly, treating any underlying cause such as constipation is critical. Patients may choose to continue taking topical therapy.
What is the recovery like?
If you have surgery at OneWelbeck you will go home on the same day. If you have had a procedure under local anaesthetic you will be able to leave straight away. If you have had a general anaesthetic you will need to rest until the effects have passed (usually a few hours). If you have had a general anaesthetic you will also need to arrange for someone to escort you home. Try to have a friend or relative with you for the first 24 hours after your surgery.
You will need pain relief to help with any discomfort as the anaesthetic wears off. Pain after this is variable depending on the specific treatment you have had. Botox treatment does not causes significant pain and it can be controlled with paracetamol and ibuprofen.
Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice. Your surgeon will also give you a short supply of stronger painkillers when you’re discharged from hospital along with other medicines, such as laxatives, anti-inflammatories and occasionally antibiotics or medicines to protect your stomach lining from the stress of surgery and the side effect of the anti-inflammatories. These will be issued with instructions.
If you have had a lateral sphincterotomy you will have an open wound on the bottom. This should be irrigated with fresh water in the shower once a day. You will be given a dry dressing to place over this which must also be changed daily. If you have had an advancement flap your surgeon will issue you with specific instructions.
If there is any doubt as to the nature of the tissue removed then the sample will be sent to the laboratory for analysis to ensure there is no malignancy. It may take a week or so for the results of the biopsy to be ready. A follow-up appointment, to give you the results, may be arranged before you go home
Frequently Asked Questions
1. What do I need to do before surgery?
If you smoke, you will need to stop as this increases your risk of getting a chest and wound infection, which can slow your recovery. Stay as active as you can. If you are having a general anaesthetic please stop eating or drinking anything EXCEPT WATER for six hours before your surgery and stop drinking WATER at two hours before your surgery. If you are having local anaesthetic, you can eat and drink as normal.
2. What will happen when I am admitted for surgery?
When you arrive at hospital, the nurse will check your heart rate, blood pressure and test your urine. You will be asked to put on a gown and to wear compression stockings to help prevent blood clots forming in the veins in your legs.
Your doctor will complete the consent process started in the clinic, by signing, or re-signing, with you the Consent Form. The doctor will discuss with you what will happen before, during and after your procedure.
You may be asked to have an enema on your arrival at the hospital.
3. How do I go to the toilet?
As you would normally go. However, instead of wiping the bottom with tissue paper, use cotton wool and some fresh water. Irrigate the wound daily in a shower or a shallow bath.
If you are experiencing discomfort, try taking your pain relief half an hour or so before you visit the toilet. Also take regular laxatives to avoid constipation which can sometimes be caused by the pain killers.
At around two weeks after the surgery, the pain in the bottom should begin to improve and you can return to swimming and bathing. There will be no sutures to remove.
4. When can I drive or use machinery?
General anaesthesia temporarily affects your co-ordination and reasoning skills, so you must not drive, drink alcohol, operate machinery or sign legal documents for 24 hours afterwards. There is no exact timing restriction on your driving. You must be able to perform an emergency stop and be free of any physical restrictions due to your operation, be comfortable in the driving position and be able to safely control your car. Broadly speaking, you will most likely need to refrain from driving for at least a week and often closer to ten days. You should be free from the distracting effect of pain or the sedative or other effects of any pain relief medication you are taking. You should inform your motor insurer of your operation so that you’re aware of their recommendations and any restrictions.
5. When can I return to normal activity levels?
Following minor surgery you may need to refrain from any exercise for two weeks. After this point the wound will be well healed. This includes swimming, gym work, running or strenuous gardening. Your surgeon will usually review you around 2-3 weeks after the surgery and will then allow a graduated return to activity, initially avoiding heavy lifting and very strenuous activity for a further two weeks. By four to six weeks post operatively, you can do whatever you wish, including high intensity training, weight training and vigorous cardiovascular activity.
6. When can I go back to work?
If you have a desk job or work from home then whenever you are able to manage this is up to you. If you do more manual work or have to travel a lot then most people take one week off work.
7. When can I fly?
If you have had local anaesthesis, this can be done straight away. For a general anaesthetic, then you can fly 2-3 days after your surgery as long as it was uncomplicated and you feel comfortable to travel. It does depend slightly where you are going, and on individual patient factors.
8. What should I eat and drink after the operation?
Eat sensibly as the anaesthesia, painkillers and surgery may make you feel slightly nauseated – so have small light meals. Avoid rich, spicy or fatty foods and alcohol for 48 hours after the surgery but after this you should be able to return to a normal diet.