Lateral Anal Sphincterotomy

Lateral anal sphincterotomy is an operation to treat an anal fissure. An anal fissure is a tear or split in the skin lining of the anus, just inside the back passage.

Is the operation necessary?

Sometimes an anal fissure will not heal, even if you are using the medicated creams and stool softeners recommended by your doctor. You may continue to have uncomfortable symptoms. If this is the case, surgery can help. Your surgeon will discuss this choice with you.

What happens during the operation?

The operation is done under a general anaesthetic. This means you will be asleep during the procedure and will feel no pain. Your surgeon will first make a small cut in the skin of your anal canal (back passage) to reach the anal sphincter (the muscle around your anal canal). This ring of muscle controls the opening and closing of the anus. The surgeon will then make a small cut in the sphincter to relax it and stop it going into spasm. This will allow the fissure to heal.

The small skin wound may be stitched or left open to heal naturally. Afterwards a pad or dressing will be put onto your anus to help stop the bleeding. Usually you will feel well enough to return home the same day, but sometimes you may need to stay in hospital overnight.

Are there any risks associated with cutting the sphincter muscle?

The cut in the sphincter muscle should not mean that the anus opens too easily, but very rarely the cut may affect your ability to control your bladder and bowels. The effects are usually minor and do not need to be treated.

If the sphincter muscle is damaged during the operation, you may need to have more surgery to correct the problem. This is very rare.

What can I expect after my operation?

You will have some discomfort after the operation. This can be eased using simple pain relievers which you will be given to take home when you leave hospital. You should have a bath the day after your operation – this will help to soak away any dressing. You may bleed a little in the bath. It is important to keep the anus area clean.

For the first few days after your operation try to take a bath or shower, or use the bidet (if you have one), after each time you open your bowels. Once the first few days have passed and you are back to normal activities, you can wipe your anal area using damp cotton wool. You may see a little blood with your stools (poo) or on the toilet paper, usually for seven to 10 days after the operation. If you are a woman, you should remember to wipe the anus area from front to back, away from the vagina.

It will be more comfortable for you to go to the toilet if the stool is soft. Make sure you drink plenty of fluids and eat a high-fibre diet (containing things like vegetables, pulses and bran). You may be given a stool softener (a laxative that makes your stools softer) to take home from hospital.

There may be a small amount of mucous discharge (slime) from your back passage for a few days after the operation. A small pad or panty liner will prevent stains on your underwear. Cotton underwear will be most comfortable.

When can I return to work?

The recovery time will vary but you should feel well enough to return to work after a few days.

If, after you leave hospital, you have any new concerns or problems (for example, severe pain around the anus, a raised temperature or bleeding from the anus) you must contact your own doctor (GP) or the hospital. You will be given contact numbers in case this happens.

Examination under anaesthesia (EUA) and Injection of Botulinum Toxin A (Botox or Dysport)

There are a number of treatments your doctor would have tried before suggesting an EUA and injection of Botox/Dysport to treat your anal fissure.

These include:

• Dietary advice and laxatives to keep your stool soft to prevent irritation of the fissure;
  
• Or GTN or Diltiazem cream to apply around your bottom for 6 weeks. This is used to relax the muscles around your bottom to help allow your fissure to heal.

Reasons for having an EUA and injection of Botox/Dysport.

If the initial treatments (listed in the alternative treatments section) have not helped then your doctor may suggest having an EUA and injection of Botox/Dysport.

What does the procedure involve?

You will be brought in to hospital and be given a general anaesthetic. Once you are asleep your doctor/practitioner will examine your bottom to assess the severity of the fissure and then inject the Botox/Dysport into your sphincter muscles (muscles that open and close when passing a stool) this will relax the muscles to help reduce the pain you are experiencing and to allow the fissure to heal.

You may require a further injection at a later date if your fissure is particularly severe, or the fissure returns.

What happens before the operation?

1-2 weeks before: You will be given an appointment to attend a preoperative assessment. During this appointment you will be examined, you will discuss your medical history and fitness levels and have a number of tests done. This is done to ensure that you are fit for an anaesthetic. A blood test may also be taken. Please bring a list of medications that you are taking along with their doses to this appointment.

The day of the procedure:
You will be given a time to come in to hospital. Once you arrive you will be shown where you can sit. Please be aware that there will be periods of waiting depending where you have been placed on the list. During this time you will be seen by a number of people including a nurse, an anaesthetist and a surgeon prior to having your procedure. You will also be asked to change into a theatre gown (please remember to remove your underwear), and remove any jewellery and make up/nail varnish.

Time of the procedure:
You will be collected by a nurse and walked to the anaesthetic room (if you are able), you will then be asked to remove your dressing gown and shoes then get onto the theatre bed (trolley). Once on the trolley you will have a cannula put into the back of your hand or the inside of your elbow so that the anaesthetic drugs can be given, you will have stickers placed onto your chest to monitor your heart rate, a cuff placed on your arm to measure your blood pressure, a probe will be placed on your finger to monitor your oxygen levels and a mask supplying oxygen will be placed on your face.

The Anaesthetic:
You will be given a short acting general anaesthetic. This will ensure that you are asleep and are comfortable for the procedure, but should allow you to wake up quickly after the procedure without feeling too ‘groggy’. You will be able to eat and drink straight away upon waking.

You must ensure that you have somebody to collect you from hospital and have somebody to stay with you overnight as you maybe still experiencing the effects of the anaesthetic.

The risks of a general anaesthetic

General anaesthetics have some risks, which may be increased if you have chronic medical conditions, but in general they are as follows:

Common temporary side effects (risk of 1 in 10 to 1 in 100) include bruising or pain in the area of injections, blurred vision and sickness, these can usually be treated and pass off quickly.

Infrequent complications (risk of 1 in 100 to 1 in 10,000) include temporary breathing difficulties, muscle pains, headaches, damage to teeth, lip or tongue, sore throat and temporary problems with speaking.

Extremely rare and serious complications (risk of less than 1 in 10,000). These include severe allergic reactions and death, brain damage, kidney and liver failure, lung damage, permanent nerve or blood vessel damage, eye injury, and damage to the voice box. These are very rare and may depend on whether you have other serious medical conditions.

What happens after the operation?

When you wake up you will be asked about your comfort levels – a small amount of discomfort should be expected. Simple analgesia such as paracetamol can be taken to help with this. A nurse will take your blood pressure, oxygen levels and heart rate. You will also be offered something to eat and drink and encouraged to mobilise

Once you feel ready to leave – generally within 1-2 hours after the operation, a nurse will remove the cannula from your hand or arm, go through your medications to take home and any follow up appointments (if required). Once somebody has arrived to take you home you will be free to leave.

We expect you to make a rapid recovery after your operation and to experience no serious problems. However, it is important that you should know about minor problems, which are common after this operation, and also about more serious problems that can occasionally occur.

What problems can occur after the operation?

Every operation carries a risk – this can be increased by pre-existing health conditions and general poor fitness of the patient. This is relatively low risk surgery. Most people will not experience any serious complications from their surgery, but risks do increase with age, and for those with heart, chest or other medical conditions, such as diabetes, obesity, or if you smoke.

Generalised operative risks include:

Bleeding:
you can expect very little bleeding with this procedure, this is rarely a major problem.

Wound infection:
You are very unlikely to develop an infection from this procedure, however, If you notice redness, swelling, discharge from your wounds, tell your nurse, or contact your GP if you have gone home.

Chest infection:
To try and prevent this it is important you practice deep breathing, as explained below. Stopping smoking as long as possible before your operation will also help.

Thrombosis (blood clot):
Deep vein thrombosis is a possible problem, but is uncommon. If you are at particular risk then special precautions will be taken to reduce the risk. Moving your legs and feet as soon as you can after the operation and walking about early, all help to stop thrombosis occurring

Procedure specific risks include:

Flu like symptoms - following your procedure; these generally last a few days and will resolve without any need for treatment.

Non resolution of symptoms – there are times when unfortunately the treatment does not help your symptoms, your doctor will discuss with you further options.

Faecal Incontinence – this is very rare, you may experience problems controlling flatus (wind), liquid or solid stool. This is usually temporary and generally resolves in approximately 12 weeks.

What should you do if you develop problems?

If you are worried about any symptoms following your procedure then please contact your GP.

Do you need to return to hospital for a check?

You will given a follow up appointment approximately 6 weeks following your procedure to re assess your symptoms.

Who should you contact in an emergency?

Immediately after surgery you may contact the ward where you had your procedure, otherwise please contact your GP or Emergency Department.