Fistulotomy
A fistulotomy is an outpatient surgical procedure designed to repair an anal fistula. An anal fistula is an abnormal tunnel that forms in the anorectal area, typically running from the anal canal to an irregular hole in the perineum, the area between the anus and the genitals. While some fistulas may resolve with antibiotic and anti-inflammatory treatment, many require surgical intervention.
Most often, the procedure performed is a fistulotomy, during which the fistula is opened and drained, rather than a fistulectomy, during which the entire fistula is removed. Unless the fistula is located deeply in the body, the fistulotomy is considered the safer alternative since it is less invasive and has a shorter recovery period. A relatively new version of the fistulotomy procedure known as a ligation of the intersphincteric fistula tract (LIFT) has been found to be advantageous in preserving the anal sphincters and preventing fecal incontinence when a deeper fistula is present.
The Fistulotomy Procedure
Most anal fistulas are intersphincteric, following a path between two sphincter muscles. The surgical goal is to close the fistula while protecting the sphincter muscles. A fistulotomy is typically performed under general anesthesia, but local anesthesia with an intravenous sedative, or a regional block, such as an epidural, can also be used.
During the procedure, an incision is made along the entire length of the fistula. The contents of the fistula are then flushed out, flattening the tunnel. The fistula tract is then merged with sutures to the anal canal. It will eventually heal into a flat scar.
Because of the extremely sensitive anatomy of the area, patients undergoing a fistulotomy procedure are normally injected with a local anesthetic at the end of the procedure to ease postoperative pain. Also, because of the proximity of the region to intestinal waste, special care must be taken to keep the incision clean and free of bacterial contamination. For this reason, antibiotics are prescribed before, during and after the procedure.
Recovery from a Fistulotomy
Pain medication is prescribed during recovery because the region is still sore and because the first few bowel movements can be quite painful. Immediately following the operation, patients should expect to use gauze pads or sanitary napkins to absorb drainage from the wound. Moistened towelettes should be used to cleanse the area after bowel movements. Patients are also advised to take sitz baths for comfort and cleanliness.
After surgery, the patient must maintain regular bowel movements that pass as easily as possible. This is because straining during defecation may interfere with suture stability. In order to keep bowel movements as regular and comfortable as possible, patients are encouraged to eat a high-fiber diet and often advised to take fiber supplements as well. Drinking water and taking stool softeners may also be helpful. Because sitting in a chair may be painful, patients often find it helpful to sit on a donut ring until the discomfort subsides. Post-operative pain should lessen within a few days, although complete healing may take 6 weeks. In most cases, patients are able to return to a normal routine before healing is fully complete.
Risks of Fistulotomy
While a fistulotomy is a safe surgical procedure, patients should be aware that any surgery involves an element of risk. The risks, though minimal, include:
- Excessive bleeding
- Adverse reactions to anesthesia or medication
- Postsurgical infection
- Breathing problems
- Blood clots
Because of the proximity to the sphincter muscles, a fistulotomy involves a small risk of fecal incontinence.