EXCISION OF FISTULA IN ANa-EXCISION

Plate CCXVIII
OF FISSURE IN ANa
DETAILS OF PROCEDURE (Continued). All of the superficial tracts ANESTHESIA.
are Local, general, or spinal anesthesia, as acceptable to the
outlined, defined, excised, and saucerized before carrying the dissection into patient,
the is satisfactory.
sphincter (Figures 16 and 17). Usually, only one internal opening is found.
Again, as in a direct fistula, the tissues around the internal opening must POSITION.
be See Plate CCXVI.
carefully excised in order to obliterate the anal glands. The sphincter muscle
may be divided laterally or posteriorly, providing it is cut cleanly at theOPERATIVE
point PREPARATION. The field is prepared as described previously.
where the tract traverses the muscle (Figure 18). The decision to complete the
operation in one or two stages depends solely upon the depth of the tract
traversing the sphincter. No matter how complicated the tract has been orDETAILS how OF PROCEDURE. A self-retaining retractor is introduced into the
many superficial openings have been saucerized and laid open, if the internal anal canal. It will not open widely because of the marked stenosis in the canal.
opening can be reached without dividing the entire anorectal ring, and there Attempting
is to stretch or dilate the canal is very unwise, as it produces trauma
only one mternal opening, a one-stage operation is done. and hemorrhage and may result in recurrent fibrosis. After introduction of the
When the fistula has arisen above the pectinate line, usually because of retractor
the the fibrotic subcutaneous portion of the internal sphincter is identified
presence of a foreign body or some ulcerative process, a two-stage operation by palpation
is as a firm, ringlike contracture of the canal (Figure 23). An incision
done. The dissection is carried down to the external sphincter, but most of is this
made directly over the ring and deepened down to the outer edge of the
is left intact. A small piece of braided silk is pulled through the fistulousmuscle
tract (Figure 24). The incision is placed to the side of the midline to avoid
and loosely tied to act as a seton (Figure 19). This allows the granulations dividing
to the fibrous attachments of the sphincter to the coccyx posteriorly. A
begin to form and the edges of the wound to become somewhat firm before small
the pair of dissecting scissors may be inserted beneath the fibrotic muscle,
sphincter is divided completely. and the muscle may be divided with a knife on top of the scissors (Figure 25).
Theof
It is not division of the sphincter that produces incontinence, but division canal then completely relaxes. The retractor is spread, and the entire canal
the sphincter and then its being allowed to retract widely and fill up withis scarthoroughly inspected. If complete relaxation does not occur, it is because the
tissue. At the second stage, several weeks later, a probe is passed along thesuperficial portion of the sphincter also is involved in the inflammation, and
seton (Figure 20), and the sphincter is divided (Figure 21). The granulations dissection must be made further into the muscle. The process, however, usually
will be firm enough around the wound so that the divided muscle will is not
localized to the subcutaneous or at most the subcutaneous and superficial
retract widely. Rarely, a tract is found that appears to be a simple fistula, portions
in the of the sphincter, so the fibrotic area can be divided with impunity.
sense that there is only one external opening and only one internal opening After the sclerotic portion has been divided, the remainder of the canal is
with a direct tract between the two; yet this may pass at a level above thethoroughly
deep inspected, and any associated pathology, such as cryptitis or papil-
external sphincter anteriorly, or the levator posteriorly, and the operationlitis,
mustis corrected.
be performed in two stages.

D. Excision of Fissure in ADo

CLOSURE. At the completion of the operation the tract is gently packed with
gauze in petrolatum, and a sterile dressing is applied.
INDICATIONS. Fissures are acute or chronic. Acute fissures are superficial
breaks in the anal mucosa. A chronic fissure results from recurrent acute fissures
POSTOPERATIVE CARE. The patient may be out of bed as soon as the
and is accompanied by persistent pain. It is ordinarily associated with pathology
anesthesia has worn off. In most instances it is not necessary to disturb the
such as markedly hypertrophied papillae at the upper edge of the fissure and/or
pack for the first 48 hours. The patient is allowed a light diet, and there is no
a sentinel pile externally. Palpation reveals induration and ulceration of the base
attempt to restrain bowel movements. Hot sitz baths are started on the second
of the fissure. The treatment is total excision, including division of the scarred
day following operation, and daily rectal examination is then performed. The
subcutaneous portion of the external sphincter muscle.
area of the internal opening is gently massaged to prevent the formation of
excessive granulations that protrude into the anal canal. Careful postoperative
dressings and the removal of detritus or slough from the wound surfacePREOPERATIVE
will PREPARATION. No preop.crative preparation is necessary,
The
ensure the development of healthy granulations. Once they begin to form, they cleansing enema, which is such an excruciating procedure to this patient, is
are gently pressed down at each dressing in order to prevent pocketing.omitted.
The
care with which postoperative dressings are performed is as important in the
ANESTHESIA. Spinal, sacral, or local anesthesia is satisfactory.
prevention of a local recurrence as is the operation. Patients may be discharged
from thti hospital in four or five days, but biweekly postoperative examinations
OPERATIVE PREPARATION. The field is prepared with local antiseptic
are continued until healing is complete.
solution. No attempt is made to dilate the canal and irrigate the rectum.

C. Treatment of Fibrotic External Sphincter Ani DETAILS OF PROCEDURE. The self-retaining retractor is inserted into the
canal to permit adequate exposure of the fissure. A triangular incision is made
INDICATIONS. As a result of low-grade chronic cryptitis or papillitis, from com- the outer edge of the fissure down to and including the edge of the
bined with the prolonged use of saline or mineral oil cathartics which make the
pectinate line (Figure 26). The incision is deepened to include all the indurated
stools liquid, the subcutaneous and superficial portions of the external sphinc-
and inflamed scar tissue (Figure 27). The anal skin, the fissure, and a small
ter undergo a progressive contraction m.ul fibrosis (Figure 22, A and B).portionThe of the rectal mucosa are then excised as a large triangular flap (Figure
fibrotic sphincter may be differentiated from a spastic sphincter by the intro-
28). The scarred portion of the internal sphincter will be seen crossing the base
duction of a local anesthetic into the muscle. The sphincter iin spasmofwill the wound (Figure 29). If there are local scarring and contracture, the scars
relax, whereas the fibrosed sphincter will not permit the introduction of moreshould be divided, and the fibrotic edges should be excised (Figure 30). A new
than one finger into the anal canal. Rectal examination or anoscopy may be so
pectinate line is reconstructed by sewing the edge of the rectal mucosa into the
painful as to require postponement until complete anesthesia is induced.lower The edge of the internal sphincter (Figure 31). It is important to place the
operation for correcting this condition is sometimes referred to as pectinotomy,
sutures so that the line of closure is continuous with the adjacent pectinate line.
under the mistaken assumption that the fibrotic area lies at the pectinate line;
however, the fibrotic ring is a portion of the fibrosed internal sphincter (Figure
22, A and B). POSTOPERATIVE CARE. Patients are allowed out of bed and encouraged to
move their bowels as soon as possible after operation. Daily sitz baths and daily
PREOPERATIVE PREPARATION. No special preoperative preparation is examinations are indicated to ensure that granulations do not build up and
rectal
necessary, other than ascertaining that the patient's general condition is good.
protrude into the anal canal. A daily rectal examination keeps the healing
lIt is desirable to give a cleansing enema the night before operation. If there
surface
are firm and encourages epithelialization. The patient should be kept under
sociated spasm and pain, this may be omitted. weekly observation after discharge until healing is complete.