Fistulotomy

Fistulotomy is a surgical technique to cut open an entire fistula so that it heals as a flat scar. 

Fistulas are small channels formed between two regions of the body such as between blood vessels, organs like intestines and skin, and other structures like the aorta and urinary tract. They may develop due to surgery, infection, injury, or inflammation.

Fistulotomy is commonly used for the treatment of anal fistulas. An anal fistula is an abnormal connection formed between the skin around the anus and the anal canal. It occurs because of an infection in the anal region that causes an abscess (accumulation of pus) in the surrounding area, The fistula is formed when the pus drains out.

The food we eat gets digested in the gastrointestinal tract, leaving behind solid waste. This waste is stored in the rectum till the time it is excreted out of the anus as stools. Anus is made up of the anal sphincter complex, which is a group of muscles that includes the external anal sphincters. Muscles on the outer side of the anus are under voluntary control and muscles on the inner side of the anal canal that are involuntary. 

The area and size of fistula vary depending on the region through which it passes. It may be a deep fistula (more than 30% of the external sphincter is included) or superficial fistula (less than 30% of the external sphincter is included). 

Fistulotomy is performed only in cases of superficial fistulas because if more than 30% of the external sphincter is cut, the person will lose control over their bowel movements.

Fistulotomy is recommended to treat anal fistulas. Symptoms of the condition include:

• Pain around the anus
• Abscesses forming around the anus frequently
• Blood in stool or pus in stools
• Fatigue, chills, and fever
• Redness and swelling around the anus
• Skin irritation around the anus
• Bowel incontinence

People who have complex fistulas may not be eligible for fistulotomy. A complex fistula has at least one of the following features:

• Multiple branches
• Near the vagina in women 
• Recurring fistulas
• Includes more than 30% to 50% of the external sphincter
• The individual has had radiation therapy in the anal region
• Individual with Crohn’s disease
• Individual with faecal incontinence

Relative contraindications (surgery can be performed but with caution) include the following:

• Short anal canal
• Diarrhoea
• Women who have fistulas in the anterior wall of the anal canal
• A history of faecal incontinence

The following preparations are needed before a fistulotomy:

• Your doctor will conduct a physical examination and order a few tests, including:
  • Ultrasound
  • Magnetic resonance imaging (MRI)
  • Proctoscopy (a device with a light is inserted to see inside the anus)
  • Rectal exam (a finger is inserted into the anus for rectal examination)
  • Blood tests
• You will need to share the following with your doctor:
  • Your medical history
  • Pregnancy status
  • A list of medicines that you take, including supplements and vitamins
• Arrange for a friend, family member, or responsible adult to drive you home after the surgery.
• You may be advised to stop smoking prior to the surgery. This helps promote quick healing afterwards and reduces the risk of complications associated with the procedure. Read more: How to quit smoking 
• Your doctor will tell you to discontinue blood thinners like warfarin, ibuprofen, and aspirin a few days before the surgery. 
• You will be asked to fast from the midnight prior to the surgery.
• If you agree to the procedure, the medical staff will ask you to sign an approval/consent form.

After you arrive at the hospital, the hospital staff will provide you with a hospital gown. You may need to put on special stockings to prevent the formation of blood clots, or a medicine will be given for it. They will also insert an intravenous line in your arm to administer fluids and medications during the surgery. 

In the operation theatre, different devices will be attached to your body to measure your blood pressure, heart rate, and oxygen level.

Fistulotomy is performed under general anaesthesia (medicine given to make you fall asleep). Local anaesthesia (a numbing medicine) will also be administered to you to reduce the pain after the surgery.

The procedure for the fistulotomy is as follows:

• You will be made to lie on your back with your legs raised.
• The surgeon will insert an anoscope (a device that helps to see inside the anus) into the anus. 
• To confirm the internal opening, the liquid will be injected through the external opening of the fistula, and its departure is observed via the internal opening inside the anus.
• The surgeon will then cut open the fistula through its length.
• Then, he/she will trim any extra tissue around the fistula to form a wound with sloping ends from the original slit and cover the area with an antiseptic gauze for three hours. 
• Finally, the surgeon will send any of the tissue (pus or fistula) obtained after scraping for an examination.

Fistulotomy takes about an hour. The medical staff will shift you to a recovery room after the surgery. A nurse may note your temperature and blood pressure. You will be asked to move around after the surgery to prevent blood clot formation in your legs.

You would be given a discharge once you are awake and can drink fluids.

You can take care of yourself in the following manner after the surgery:

• You can have your regular diet after the surgery, but you should include foods rich in fibre in your diet and drink lots of water. 
• Your doctor will suggest you to take over-the-counter pain medications like paracetamol or ibuprofen to control the pain. 
• You may be able to continue your regular activities including bathing without any restrictions.
• If the surgeon has placed a dressing on the anal incision, you will be told when to remove it. However, if it falls off before that time, you should not replace it. The incision will heal on its own in a week or two. Do not worry about having an infection due to bowel movements.
• You can resume driving when you can sit without any discomfort for a long duration and you have stopped taking painkillers.
• You will be able to resume work in about seven to 14 days. 
• You may need to use a gauze or sanitary napkin to absorb the discharge from the fistula.  
• If you have pain, you may take a sitz bath for about 10 to 15 minutes. A sitz bath involves sitting in a small tub or vessel filled with warm water. Once you are done, pat the anal region dry. Covering ice in a thin cloth and applying it on the operated area for 10 to 20 minutes may also help reduce the discomfort.
• Use a small stool under your feet when you wish to pass bowels. This will reduce the strain on your pelvic muscles.

When to see the doctor?

Visit or call your doctor if you observe the following symptoms:

• Fever
• Pain, swelling, and redness in your leg
• Pain at the site of the surgery 
• Pus from the incision
• Inability to pass bowels or gas
• Excessive bleeding at the incision site

The surgery carries the following risks:

• Bowel incontinence
• Infection
• The fistula may recur 
• Obstruction in bowels
• Reaction from anaesthesia

A follow-up visit may not be required if everything is alright. However, after about four months, your surgeon may perform a physical examination to check the healing of the incision.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.