Anal Surgery

An anal fistula represents a connection between the perianal skin and the internal area of the anal canal, and is due to an infection starting in an internal anal gland which causes an abscess, which then spreads out through the perianal area, sometimes involving the anal sphincter muscles, to the skin on the external surface.  These will therefore present with an abscess sometimes and then drainage of pus with or without a small amount of blood. 

• Perianal abscesses can be drained simply, sometimes under local anaesthetic in the rooms and often needing a general anaesthetic in the operating theatre. If there is persisting discharge as an anal fistula then this needs surgical treatment in its own right. 

• Perianal abscesses will settle completely with surgical drainage in 50%.  In 50% they will persist as an anal fistula.
• Anal fistulae can be simple, and treated and cured with simple excision, but can be complex if involving the anal sphincters and require second stage operations, after insertion of soft silastic ties called “Setons”.
• If anal fistulae are not operated on and cured then they can present an ongoing septic problem which leads to greater complications, including anal strictures.  

An anal fissure is commonly termed a “split” or “tear” in the lining of the anal canal.  It is often quite acutely and significantly painful, and the pain will often be accompanied by some bright blood.

• Anal fissures are common.  They often occur at the time of straining, or when someone has constipation. 
• Anal fissures, because of the resultant pain, lead to a reflex tightening of the anal sphincter muscles so the person will feel as though they are “passing their motions through a tight anal ring”. 
• Anal fissures are treated by one of three methods to relax the anal sphincter tightness back to a normal tone.  This can involve the use of ointments such as Rectogesic, or Botox injection, in specific cases, and by anal sphincterotomy operation.
• Anal fissures can be cured, but cure also involves having normal and good bowel evacuation, with high fibre diet, fibre supplements and high fluid intake.
• All of the treatments for anal fissure are extremely safe and, a selection of the most appropriate one for each particular case allows cure of fissures in almost all cases. 

• Cancers of the anal canal are less common than cancers of the bowel itself, but are seen reasonably regularly. 

• Squamous cell cancer of the anal canal is oftentimes secondary to previous genital warts.  Adenocarcinoma of the anal  canal is another less common type.
• Anal canal cancers can be cured, sometimes in an early stage by local excision only, but often requiring radiotherapy and chemotherapy as well.  

Rectal prolapse is a protrusion of the lower bowel (rectum) through the anus to form a protruding lump of reddened tissue which is most uncomfortable for the patients involved.  The prolapsed bowel can be pushed back into place but inevitably the process will be recurring.  This occurs when the lower bowel or rectum is relatively loose on a mesentery inside the pelvis to allow the prolapse to occur.  Definitive surgery in younger people is conducted by laparoscopic techniques in most cases, and involves anchoring the rectum back into position in the sacral curve at the back of the pelvis internally.

In older patients a much simpler procedure – The De Lormé procedure – Can be conducted as a per-anal procedure as a day case, or with a single overnight stay in hospital, without incisions externally at all.  This allows the rectum to be concertinaed back into the pelvic area but with surgery conducted through the anus itself.  This procedure is very simple from a patient’s point of view in terms of easy recovery, and can be extremely effective, particularly in situations where a patient has limited mobility due to age and infirmity.