Professor. IAN T. JONES
FRACS FRCS
COLORECTAL SURGERY
Suite 5, 6 & 7
Private Medical Centre
Royal Melbourne Hospital Royal Parade
Parkville VIC 3050
Telephone: 9347 4077
Facsimile: 9348 2075
Pager:
9387 1000
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
around the anus.
- is a collection of pus developing in the tissues in the area
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.
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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
per day is adequate.
- maintain an adequate fluid intake. Six large glasses of water
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.
b.
c.
d.
Severe postoperative pain
Excessive bleeding (more then half a cup full of blood per day)
Fever above 38 degrees centigrade or shivering and chills (rigors)
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.
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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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