Anorectal Surgery - Procedure, Indications, and Complications

Introduction:

Anorectal surgery is the treatment modality for specific abnormalities like anal fissure (a small tear in the lining of the anus), anal fistula (an abnormal passage between the skin close to the anus and the last portion of the intestine), anal cancer, etc. They generally cause symptoms like burning sensation, pain, itching, and bleeding. They are then subjected to physical examination and certain diagnostic procedures like anoscopy, biopsy, ultrasound, etc. Afterward, a part of the anus or the rectum is surgically removed.

What is Anorectal surgery?

It is the removal of a part of the anus or the rectum due to a cancerous lesion in the anus or the rectum, anal fissures, or hemorrhoids. The anus is the opening which is the end of the gastrointestinal tract through which the wastes from the digested food are excreted out of the body. The rectum is the last portion of the large intestine that starts from the end part of the colon and extends to the anus.

In What Conditions Anorectal Surgery Is Done?

• Anal Fissure: Anal fissure is a tear in the layer of tissues that line the anus.

  • Causes:

    • The anus consists of a ring of muscles called the sphincter muscles. These muscles help open the anus during the bowel movements for the digested food waste to exit the body. When there is a strain in the anal muscle lining due to hard stools resulting from constipation, pressure is exerted on the thin muscle lining, and there is a tear.

    • Vaginal birth.

    • Anal sex.

    • Very bad diarrhea.

    • A foreign object inserted into the anus.

  • Risky Conditions That Predispose Anal Fissure:

    • Constipation.

    • Low-fiber diet.

    • Severe diarrhea.

    • Infections.

    • HIV(Human immunodeficiency virus).

    • Vaginal childbirth.

    • A minor injury that results due to mountain biking.

    • Inflammatory bowel disease.

    • Surgery.

    • Inflammatory conditions of the anus.

  • Symptoms of Anal Fissure:

    • Pain and discomfort in the anus.

    • Bright bleeding during or after bowel emptying.

    • Visible tear in the anal region.

• Perianal Abscess: Perianal abscess occurs when one of the glands that line the anus is blocked and causes infection, leading to a pus-filled cavity called the abscess.

• Anal Fistula: An anal fistula is an abnormal passage from one structure to another.

  • Causes:

    • The perianal abscess, if left untreated, leads to an anal fistula.

    • It can also occur due to Crohn's disease (it is a type of inflammatory bowel disease that causes inflammation or swelling of the intestines).

    • An anal fistula can also occur after radiation therapy.

    • Any injury to the anal canal.

    • After difficult vaginal childbirth.

    • After surgery.

  • Symptoms:

    • Chills and fever.

    • Pain and swelling around the anus.

    • Feeling weak and tired.

    • Redness and soreness.

    • Itching on the anal region.

    • Draining of pus in the anus.

  • Risk Factors:

    • Ulcerative colitis.

    • Crohn's disease.

    • Severe diarrhea.

    • Radiation therapy for rectal cancer.

• Anal Condyloma: Anal condyloma or anal wart is a small tissue growth on the lining of the anus.

  • Causes:

    • It occurs due to the human papillomavirus (HPV). The human papillomavirus causes cancer. If the wart is left untreated, these warts may develop into anal cancer.

  • Symptoms:

    • Anal warts generally do not cause symptoms. However, a few people experience pain, itching, bleeding and face difficulty in maintaining hygiene.

• Hemorrhoids: Hemorrhoids are enlarged blood vessels around the anus and the bottom part of the rectum.

  • Causes:

    • During pregnancy and childbirth, extra pressure is exerted on the blood vessels in the anus and the skin surrounding the anus. This leads to swollen and irritated blood vessels.

    • It can occur in people of all genders.

    • However, it is common in pregnant females and people aged 50 years and above.

    • It occurs in people who strain during the emptying bowels.

    • People who have constipation or diarrhea for a long time.

    • Family history of hemorrhoids.

  • Symptoms:

    • Pain in the anus and surrounding structures.

    • Bright red blood in stools, tissue paper, or toilet bowls.

    • Swelling or lump around the anus.

    • Irritation around the anus.

    • Itching.

  • Risk Factors:

    • Family history of hemorrhoids.

    • Pregnancy.

    • Sitting in the toilet for a long time.

    • Obesity.

    • Chronic constipation or diarrhea.

    • Older adults between 45 and 65 years.

• Anal Cancer: Anal cancer is abnormal tissue growth in the lining of the anus.

  • Causes:

    • The causes are unclear. However, genetic predisposition plays a role.

    • Cancerous lesions from the gastrointestinal tract spread to the anus.

  • Symptoms:

    • Swelling or lump in the anus.

    • Bleeding or itching in the anus.

    • Leakage of fluid from the anus.

    • Narrow stools.

    • Changes in bowel movements.

    • Pain and pressure in the anus.

    • Swollen lymph nodes in the groin region (the region between the thighs).

  • Risk Factors:

    • Multiple sex partners.

    • Anal sex.

    • History of anal warts.

    • History of organ transplantation.

    • HPV (human papillomavirus) infection.

    • Weak immune system.

    • HIV (human immunodeficiency virus).

• Rectal Prolapse: Rectal prolapse is the outward bulging of the rectum through the anus. The rectum being the last part of the large intestine, stores the fecal waste before passing out through the anus.

  • The rectum pushes the waste to the anus through the rectal muscles, and the rectum is pulled back.

  • The rectum sometimes does not go back to its original position and is found hanging from the anus.

  • Causes:

    • The muscles around the rectum weaken and do not support the rectum.

    • Constipation.

    • Damage to the rectal muscles after challenging childbirth.

    • Abnormality in the pelvis or lower gastrointestinal tract.

  • Symptoms:

    • A bulge felt in the anus after a sneeze, cough, or while lifting something.

    • Presence of mucus in the stool.

    • Straining while starting or finishing a bowel movement.

    • Abdominal pain or discomfort.

    • Incomplete bowel emptying.

    • Bleeding from the rectum.

    • Bleeding from the anus.

    • Pain in the anus.

    • Constipation.

    • A pressure felt in the rectum.

  • Risk Factors:

    • History of chronic constipation.

    • Strained bowel movements.

    • Overuse of laxatives.

    • Chronic diarrhea.

    • Spinal cord problems.

    • Cystic fibrosis.

    • Dementia.

    • Childbirth.

What Tests Are Performed Before Anorectal Surgery?

• Physical Examination: The physicianinspects the anus and the rectum with a gloved hand to look for abnormalities.

• Anoscopy: Anoscopy is a diagnostic method that involves using a tube-like structure with a light attached to one end of the tube. It helps view the last portion of the anus anal canal and the rectum.

• Colonoscopy: In a colonoscopy, a tubular structure with a light and a camera attached to the end is inserted into the rectum through the anus. The internal part of the anal canal, rectum, and colon are viewed on a screen outside with the colonoscpy.

• Biopsy: In a biopsy, a small tissue of the organ or the lesion is removed and viewed at a microscopic level to detect abnormalities.

• Flexible Sigmoidoscopy: Flexible sigmoidoscopy is a diagnostic method to look for internal parts of the rectum and lower parts of the large intestine. It consists of a tubular structure that has a light, a lens, a portal for irrigation purposes, and an instrument portal. The last segment of the large intestine just before the rectum is called the sigmoid colon. This technique is used to view the rectum and the sigmoid colon for any abnormalities.

• Digital Rectal Exam: The physician, with a gloved hand and a lubricant, checks for any abnormalities in the rectum, anus, pelvis, and prostate in males. The fingers on the gloved hand are lubricated with a lubricant and inserted into the anus for further examination.

• Ultrasound: An ultrasound uses high-frequency sound waves to capture internal organs' images to detect abnormalities.

• Magnetic Resonance Imaging (MRI): Magnetic resonance imaging technique uses high-frequency sound waves in a radio magnetic field to capture images of the internal organs and structures. Pictures of the targeted organs, surrounding soft tissues, and structures are generated.

How Is Anorectal Surgery Performed?

• A part of the anus or rectum is removed. Sometimes a part of the sigmoid colon is also removed. It is the last part of the large intestine just before the rectum. It is “S” in shape.

• The surgeon who performs the surgery makes a few incisions or cuts in the abdomen or the belly and a cut in the rectum.

• The surgeon then removes the anus, rectum, and the muscles surrounding them.

• The surgery is done under general anesthesia, where the patient is put to sleep with medications and is not conscious of the surroundings.

What Are the Complications of Anorectal Surgery?

• Urinary Retention: Urinary retention is a condition where the urine is not completely emptied from the bladder.

• Postoperative Hemorrhage: Minor postoperative bleeding is common after anorectal surgery.

• Anal Stricture: The abnormal narrowing of the anal canal is called an anal stricture. It causes difficulty in passing stools.

• Fecal Incontinence: Fecal incontinence is a condition when the bowel movements are not under control, and they leak from the rectum spontaneously.

• Chronic Pain: Acute (short-term) anal pain after anorectal surgery is common and resolves in two to three weeks. However, a few people experience chronic (long-term) pain and need medical attention.

Conclusion:

Anorectal surgery is performed for certain abnormal medical conditions which cannot be treated with medications. For example, rectal prolapse, anal fissure, and anal cancer need surgical intervention. These conditions cause a few symptoms like pain in the anus and the rectum, bleeding from the anus, swelling around the anus, etc. Therefore, anorectal surgery is the only option for these conditions. However, there are a few complications like minor bleeding and acute pain that resolve over time, but chronic pain and major bleeding need medical intervention. However, this does not happen in all cases, and it improves the patient's life quality in most cases.