Anal canal Surgeries
Anal Canal
The anal canal is the last or exit portion of the digestive tube, measuring about 4 cm. Diseases affecting this portion of the system are common, ranging from infection and pus formation (abscesses) to cancers. These can be debilitating, hampering routine activities. Diseases affecting this portion are related to lifestyle habits, largely due to less consumption of fiber & water in the diet.
Symptoms:
- Pain, swelling, mass from or around the anus
- Bleeding – mostly fresh blood, either mixed with stools or separately
- Additional openings around the anus discharging pus, blood, or feces
- Constipation
These symptoms can be continuous or intermittent.
Diagnosis:
- Routine blood investigations
- Proctoscopy
- Video proctoscopy
- Sigmoidoscopy
- Trans-rectal ultrasound
- MRI
Treatment:
A) Conservative: Dietary modifications, medications for local application, and laxatives.
B) Surgery: Different modalities are available, and the choice of procedure is chosen based on patient factors.
1. Piles
Piles are normal anal cushions that become abnormally enlarged. They can be internal, external, or both and are graded from I to IV. Various treatment modalities exist, and some situations may require a hybrid approach for optimal results.
- Open Haemorrhoidectomy: The gold standard technique where the entire pile mass is removed, especially useful for large-grade internal and external piles.
- Stapler Haemorrhoidopexy: Used in selected cases and is less painful. A stapler instrument is used to resect the portion of the anal canal with piles.
- Laser Haemorrhoidectomy: Indicated in certain cases and is largely painless. Laser energy is used to burn the pile mass, allowing it to shrink.
2. Fissure
A cut at the anus is called a fissure. This cut leads to involuntary spasm of the inner muscles of the anal canal, resulting in severe pain. It usually arises due to excessive straining or passing very hard stools. Relieving the muscle spasm through relaxants or dividing the tightened inner muscle forms the core principle of treatment.
- Lateral Sphincterotomy: Using a small cut, the inner muscle is identified and divided.
- Fissurectomy: The fissure, along with the abnormally enlarged surrounding skin called ‘sentinel pile,’ is removed and combined with releasing the tightened inner muscle.
- Laser Sphincterotomy: Releasing the tightened inner muscle can be achieved using lasers.
3. Fistula
An abnormal communication between the inside of the anal canal and the outer surrounding skin is called a fistula. These can be simple or complex and classified as high or low. In complex cases, conditions like Crohn’s disease and tuberculosis need to be ruled out. A biopsy will be sent in all suspected cases. The choice of treatment modality is based on clinical examination and scan reports.
- Fistulotomy: A standard procedure that involves laying open the fistula route.
- Fistulectomy: Complete removal of the tract from end to end.
- LIFT Procedure: Identifying & isolating the tract and closing it on either side with or without removal of the intervening segment.
- Seton Insertions: Used when the fistulous tract traverses through a significant portion of a muscle bundle. A seton or thread is placed along the tract & across this muscle. Seton may also be used when there is excessive pus. The seton will be removed once the fistula is healed or when all collections are drained.
- Laser Fistula Surgeries: In select cases, lasers have shown benefit, especially in long single tracts with no significant collections. Less pain and no wound are its USP.
4. Anal Sphincter Repair and Reconstructions:
Anal sphincter repair involves surgical procedures aimed at restoring the function of the anal sphincter muscle. This procedure is often indicated for patients suffering from fecal incontinence due to childbirth, trauma, or other underlying conditions. The goal is to reconstruct the sphincter to improve control over bowel movements and enhance quality of life.
- Sphincter Injuries: Muscle injuries around the anus can happen after delivery, trauma, or unnatural or violent sexual activity. Based on the clinical presentation & MRI findings, these can be repaired in either single or multiple stages.
- Incontinence: Can be due to multiple reasons. After thorough evaluation and failure of biofeedback, surgery is considered.
5. Perianal & Ischiorectal Abscess:
Pus collection around the anus is a common clinical presentation. These are usually a consequence of constipation, where a blocked mucus gland with piled-up secretion gets infected. Pus collections can be at one position or more than half the circumference (Horse-shoe abscess). These pus collections tend to develop into a fistula later.
- Drainage of Pus Collections Around Anal Canal: An incision is made over the pus collection, and the pus is let out. The cavity is opened up completely and allowed to heal.
