Fistulotomy Surgeryin Tiruvannamalai: Procedure, Types, Benefits & More

A Fistula is an abnormal connection formed between two tracts or organs, and the surgical procedure used to treat it is called Fistulotomy. Uncomplicated perianal fistulas (around the anus) are the most commonly treated fistulas by fistulotomy. These are usually complications of an untreated abscess that develops in the perianal area and breaks through the walls of adjacent structures as it grows. Fistulotomy can effectively open and drain the pus and other fluids to facilitate tissue healing and closure of the abnormal passage. This article will discuss fistulotomy, the procedure involved, and the possible complications that may occur post-surgery

Anal fistulas are abnormal connections that form a passage between the anus internally and the skin externally. These could occur as a complication of untreated perianal abscess or could also develop due to trauma or severe inflammation. It may cause various symptoms like

• Pain and discomfort that aggravates while coughing or moving around.
• Bowel incontinence (difficulty controlling bowel movements that may result in accidental fecal discharge).
• Pruritus (a condition that causes severe skin irritation and itching).
• Redness, swelling, and purulent discharge (pus) around the anus.
• Fever caused due to pus.

Fistulotomy treats anal fistulas by opening the passage (fistula) and draining the pus and other fluids to promote healing. It is usually an outpatient procedure performed under general anesthesia (GA). Fistulotomy and fistulectomy are procedures to treat a fistula - the difference from fistulectomy is that in fistulotomy, the surgeon will not remove any tissue, and the two ends of the fistula will be closed and remain attached to the organs, whereas in fistulectomy, the surgeon removes the entire fistula tract. 

The purpose of fistulotomy is to drain the pus and the other infected fluids from small and simple fistulas 
while keeping them open to promote optimal healing. After a few days, the abnormal passage or 
connection between the tracts is closed. Fistulotomy is also recommended to prevent injury to the anal sphincter.
Fistulotomy effectively provides symptomatic relief from pain, bowel incontinence, pus discharge, and other infection-related symptoms (fever, swelling, redness, etc.), thus improving your quality of life. It is further recommended to prevent the progression of malignancy (cancer-forming property) in the existing fistula if left untreated. 

Your surgeon will take your history and perform a physical examination. Your medical history will be reviewed to rule out diseases like diabetes (increased blood sugar levels), and heart and lung abnormalities. 

• Your surgeon will examine your fistula through a digital rectal exam to determine the size and location of the fistula. Further diagnostic tests will be performed to determine the fistula's path.:
  • X-ray with barium contrast- A barium solution will be given orally or as an enema to identify the fistula tract on the X-ray.
  • Magnetic resonance imaging (MRI)- This test uses strong magnetic and radio waves to identify the exact position and path of the fistula.
  • Endoscopic ultrasound- An endoscope will be inserted into the anus and rectum to generate images of the internal structures.
  • Fistulography- A contrast medium will be introduced into the fistula to visualize its size on X-ray.
  • Lower endoscopy- An endoscope (a device with a camera and light source) will be inserted into the anus and bowel to capture images. 
• You will be advised to discontinue medications like blood thinners and other herbal supplements 2 weeks before the procedure, as they can delay wound healing.
• Smoking should be discontinued 2 weeks prior to surgery since it can narrow the blood vessels and delay healing.
• Fasting 6 to 8 hours before the procedure is important if the procedure is performed under general anesthesia to prevent aspiration of food and liquids.

A fistulotomy is a minimally invasive (does not involve extensive incisions, bleeding, or trauma to the surrounding structures), and an outpatient procedure (does not require hospitalization). Once you are prepped for the surgery, you will likely be given general anesthesia that will put you to sleep during the entire procedure. Local anesthesia may be used if the fistula is small and just beneath the anal skin. Another form of sedation called MAC (Monitored Anesthesia Care) may be used to induce “twilight sleep" (a condition characterized by insensitivity to pain without the loss of consciousness).

• Preoperative antibiotics will be introduced through IV (intravenous) lines to prevent post-op infections.
• You may be placed in one of the three positions before the surgery begins:
  • Prone position: Facing down on a flat table
  • Kraske position: Facing down on an inverted "V" shaped table 
  • Lithotomy position: Lying on your back with your knees and calves raised to an angle of 90 degrees.
• Once the effect of anesthesia sets in, your surgeon will insert an anal retractor to open the anus slowly. The fistula is reached and gently cut with a scalpel (surgical blade).
• The base of the fistula is scraped with an instrument, and the wound is left open to heal. 
• If necessary, the cutting edges of the wound may be stitched (marsupialization).
• The wound will be packed with an antiseptic gauze or surgical dressing.
• The fistulotomy procedure may take around 30 minutes to 1 hour, depending on the size of the fistula.

Once the procedure is completed, you will be taken to the recovery room, and your vitals (blood pressure, pulse, heart rate, and urine output) will be monitored until you are fully awake.

• You may experience mild pain and discomfort, which is normal after a fistulotomy and will resolve gradually through the painkillers prescribed. 
• You will be given sips of water once the effect of anesthesia wears off. You may be given juices or semi-solid food if you do not feel nauseated. 
• Once you can walk on your own, you will be sent home the same evening.
• You will be abstained from driving for the initial few days, so arrange for someone to drive you back home. 
• You will be prescribed antibiotics and painkillers for at least 5 days to prevent infections and promote healing.
• Once you are back home, rest for the day and avoid bathing or showering for 1 to 2 days post-procedure.
• Try to lie down on your side and wear loose-fitting cotton underwear with sanitary pads or adult diapers to manage any bleeding or wound discharge.
• Consume easily digestible foods to prevent constipation and laxatives (stool softeners) if needed.
• Drink plenty of water to improve hydration and wound healing.
• Avoid lifting heavy objects and strenuous activities until your wound heals.
• A Sitz bath (submerging your anus and genital area in warm water) is vital for quick healing. This should be done 3 to 4 times for 15 to 20 minutes daily.
• Proper care and management will take 2 to 6 weeks to recover, depending upon the size and location of the fistula. 

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