Friday, September 16, 2016

Extensive surgical exploration in and around anal canal ought to be avoided

I do come across many patients, who have undergone extensive surgical excisions in and around anal canal and they come with the complaint of stenosis or stricture and hard tissue formation. It is common in cases of surgery of fistula in ano and haemorrhoids. Even after this, the recurrence is seen.

The common complaints are:
1. Difficulty in passing stool in terms of discomfort and holding the urge.
2. Difficulty in sitting for a long period.
3. Lack of natural softness in perianal area.
4. Soiling of clothes.
5. Passing of stool with urge of flatus.
6. Something holds the urge of defecation.
7. Persistence of previous symptoms presented prior to surgery.

My preceptors told me one important thing that complications such as stenosis, stricture and hypertrophic scar. I am fortunate enough that I have not come across a single patient of strciture after following some basic rules.

Results of extensive excisions:

Great degree of tissue loss:

Here you can appreciate the tissue loss and even after that the recurrence of fistula is seen and patient came to our hospital. 
Why perianal fat is important?
The perianal area is very rich in fat particularly the ischiorectal fosse where the abundance of fat is responsible for smooth passage of stool as it gives the space for streching of lumen. The fat is lost after surgery and it hampers the streching which is required during stool movement. 

Why stenosis or stricture?
The incorrectly performed procedure for haemorrhoidectomy or fistulectomy may result in these complications. The extensive excision of skin during these procedure and ligation of internal sphincter may be the cause.

Many alternative therapies are available:

1. Ksharsutra therapy is an alternative. 
2. Medicines in cases of first and second degree piles are suffiecient.
3. Fissure may be managed by anal dilatation and bowel regulation. 

It is my personal advise, that a patient and a doctor should think before advising or performing extensive excisions and jeopardizing precious tissue.

Dr Praveen Choudhary