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Procedures
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Introduction

Below is an introduction to the main procedures carried out on a regular basis, you can find out more information about each procedure in the FAQ section of this website.

Anal Fissure

The treatment of anal fissures range from conservative (non-surgical) to surgical intervention. Treatment options can escalate from dietary manipulation, the use of topical creams and, finally, to surgery.

Once the diagnosis on an anal fissure has been made, the first mode of treatment is dietary manipulation to include more fruit and fibre and to increase daily water intake. The latter measures are often supplemented by the addition of laxatives to keep the stool soft.

Outpatient treatments include the prescription of topical creams which are applied to the anus to help relax the anal sphincter. The cream needs to be applied at regular intervals throughout the day as well as prior to bowels opening. With these conservative managements 75% of patients with an anal fissure are expected to heal.

Botox (botulinum toxin A) is also used to heal anal fissures. A set amount of units of Botox is injected either side of the fissure to produce temporary paralysis to the portion of the sphincter where the fissure overlies. The paralysing effect of Botox can last up to 6 months. As a small portion of the sphincter is affected with this technique, the risk of incontinence is small.

Some anal fissures are resistant to treatments and it is this small group of patients that require a sphincterotomy. This is a surgical procedure where the most superficial fibres of the anal sphincter are divided to relax the sphincter to allow the fissure to heal. This is a permanent procedure and the risk of subsequent incontinence is greater.

Both the Botox injection and sphincterotomy procedures require a general anaesthetic.

Find out more in the Anal Fissure FAQ

Anal fistula

There are several options to the treatment of anal fistulas:

Some patients will have active infection when they present with a fistula and this requires clearing up before definitive treatment can be decided. Antibiotics are usually prescribed in these cases. If the infection has progressed to the formation of a localised abscess then surgery will be required to drain the infection.

For low lying fistulas or fistulas involving the internal part of the anal sphincter then laying open of fistula is the treatment of choice. This option involves an operation to cut the fistula open. Once the fistula has been laid open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. This option leaves behind a scar and is not suitable for fistulas that cross the entire anal sphincter.

For fistulas that involve a great portion of the anal sphincter, treatment is usually in the form a Seton. A seton is a length of soft suture material that is looped through the fistula from the skin to the inside of the bowel. This suture keeps the fistula tract open and allows pus to drain out. In this situation, the seton is referred to as a draining seton. The suture is inserted under a general anaesthetic. This makes further surgery easier in the future.

Fistulotomy is the term given to the procedure of removing that part of the fistula that is found leading up to the anal sphincter. The external portion of the anal sphincter is never cut. This removal of the fistula is where the wound is created and requires regular packing.

Fibrin glue injection is a method explored in recent years with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out and allows it heal naturally.

Fistula plug involves plugging the fistula with a device made from small intestinal submucosa. The fistula plug is positioned from the inside of the anus with suture. Small intestinal submucosa stimulates the body to close the fistula from the inside out. According to some sources, the success rate with this method reaches 60%.

Endorectal advancement flap is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place. The external opening is cleaned and sutured. Success rates are variable and high recurrence rates are directly related to previous attempts to correct the fistula.

Find out more in the Anal Fistula FAQ

Appendicitis

An appendectomy is the surgical removal of the appendix. This procedure is normally performed as an emergency when the patient is suffering from acute appendicitis. Patients are commenced on antibiotics prior to surgery.
The majority of appendectomies are performed laparoscopically (this is called minimally invasive surgery). Some appendicectomies are still performed as an open operation.
Laparoscopy is a very good diagnostic tool if the diagnosis is in doubt. Recovery is quicker with laparoscopic surgery and takes the same time as the open procedure.

Find out more in the Appendicitis FAQ

Bowel Cancer

Large bowel resection is surgery to remove all or part of your large bowel. This surgery is also called a colectomy. The large bowel connects the small intestine to the anus. Normally, stool passes through the large bowel before leaving the body through the anus.

All surgeries are preformed under general anaesthesia. The surgery can be performed laparoscopically or with open surgery depending on the site and stage of the disease.
In a laparoscopic colectomy the surgeon uses a camera to see inside the abdomen and operates using specially designed instruments to remove the affected part of the large bowel. Patients can have three to five small cuts on the abdomen. The surgeon passes the medical instruments through these cuts.

In the majority of cases of patients undergoing a colectomy the bowel is joined back together again. This procedure is called an anastomosis. The anastomosis is always tested before the operation is completed to ensure there is no air leak.

The blood supply towards the end of the large bowel is not as robust as the supply to the rest of the colon. As surgery progresses towards the end of the rectum great care is required to ensure that the anastomosis (join) heals without any complications. In these cases a temporary stoma (bag) is fashioned to protect the anastomosis while it heals. A stoma is the term given to a piece of bowel that is brought through the abdominal wall to divert the flow of faeces. Temporary stomas can usually be reversed after 6-8 weeks.

If the tumour is very close to the exit of the bowel, or even involves the anus, then that segment of bowel is removed, together with the anus, and a permanent stoma is fashioned.
The whole idea of surgery is to remove the affected bowel as well as the surrounding lymph nodes (glands) to allow assessment of the extent of the disease. This will determine the stage of the disease and as to whether or not further treatment with chemotherapy is required.

Find out more in the Bowel Cancer FAQ

Crohn's Disease

The strategy for surgery for Crohn’s disease is completely different from that of ulcerative colitis. As Crohn’s disease can affect any part of the gastrointestinal tract, surgery is focused on removing the affected segment of bowel in an attempt to preserve as much healthy bowel as possible.
The majority of surgeries involve removal of diseased segments of bowel and joining the remaining healthy bowel together. This is known as limited or segmental resections.

Find out more in the Chron's Disease FAQ

Diverticular disease

A mild attack of diverticulitis can be treated at home with adequate pain relief and antibiotics.

If symptoms and signs progress then a hospital admission is required. As well as blood investigations a CT scan will be performed to assess the severity of the diverticulitis. The majority can be treated as an inpatient without surgery. This will include intravenous antibiotics and painkillers.

All patients who have had an attack of diverticulitis should undergo a full colonoscopy once the diverticulitis has been treated. This is to assess the area of bowel involved and to ensure the rest of the colon is normal.

Patients with sever diverticulitis or complications of diverticulitis may need the segment of affected bowel removing. In a controlled situation, this can be done laparoscopically (key hole surgery).

Find out more in the Diverticular Disease FAQ

Endoscopy

This will mainly focus on colonoscopy.

A colonoscopy is an internal examination of the colon (large intestine) and rectum, using an instrument called a colonoscope.

The colonoscope has a small camera attached to a flexible tube. Unlike sigmoidoscopy, which can only reach the lower third of the colon, colonoscopy examines the entire length of the colon.

The patient will lie on their left side with knees drawn up toward their chest. The procedure is carried out under conscious sedation. A painkiller is also used in conjunction to the sedative. The colonoscope is inserted through the anus and gently guided through the whole of the colon and sometimes into the lowest part of the small intestine.

Air will be inserted through the scope to provide a better view. Suction may be used to remove any residual fluid or stool.
A better view of the large bowel is obtained as the colonoscope is pulled back out and a more careful examination is done while the scope is being pulled out. Tissue samples may be taken with tiny biopsy forceps inserted through the scope. Polyps may also be removed and photographs may be taken.

The colon will need to be completely clean prior to the procedure. This is achieved by being prescribed a special diet, bowel cleansing agents which will produce diarrhoea and being nil by mouth for six hours prior to the procedure. Certain drugs, especially blood thinning drugs, need to be stopped prior to the procedure.
Outpatients must plan to have someone take them home after the test because they may be drowsy and unable to drive.

The combination of a sedative and pain medication will relax you and make you feel drowsy. Many patients do not remember having the colonoscopy. A rectal examination is performed before the test to make sure there are no major blockages. You may have the urge to have a bowel movement when the rectal exam is performed or as the colonoscope is inserted.

You may feel pressure as the scope moves inside. You may feel brief cramping and gas pains as air is inserted or the scope advances. Passing gas is necessary and should be expected.
You can reduce discomfort by taking slow, deep breaths. This will also help relax your abdominal muscles. You may have mild abdominal cramping, colic, and pass a lot of gas after the exam.
The sedation should wear off in a few hours. Because of the sedation you may not feel any discomfort and may have no memory of the test.

Find out more in the Endoscopy FAQ

Faecal Incontinence

People who have bowel incontinence that continues even with medical treatment may benefit from surgery to correct the problem. Several different options exist. The choice of surgery is based on the cause of the bowel incontinence and the person's general health.


RECTAL SPHINCTER REPAIR
Sphincter repair is performed on people whose anal muscle ring (sphincter) is not functioning well due to injury. The procedure consists of re-modelling the anal muscles to tighten the sphincter and helping the anus close more completely.


SACRAL NERVE STIMULATOR

If faecal incontinence is due to nerve damage/ dysfunction and the anal sphincter is intact, then patient’s can be offered sacral nerve stimulation (SNS) as treatment. Sacral nerve stimulation, also known as sacral neuromodulation, is a procedure where the sacral nerves at the base of the spine are stimulated by a mild electrical current from an implanted device.
Sacral nerve stimulation is conducted through an implanted device that includes a thin insulated wire, called a lead, and a neurostimulator much like a cardiac pacemaker. SNS is first tried with the implantation of a test lead. If the trial treatment is successful, the patient is scheduled for a permanent device.
Permanent surgical implantation involves the introduction of an implant, the neurostimulator, which is about the size of a pocket stopwatch, under the skin of the patient's upper buttock. Thin wires, or leads, running from the stimulator carry electrical pulses from the stimulator to the sacral nerves located in the lower back. This is a permanent device, the presence of which, the patient is unaware of. The stimulator functions continuously to provide continence and can be turned off for defaecation.


GRACILIS MUSCLE TRANSPLANT
In people who have a loss of nerve function in the anal sphincter, A gracilis muscle transplants may be performed to restore bowel control. The gracilis muscle is taken from the inner thigh with it’s intact blood and nerve supply and is wrapped around the anal sphincter to provide sphincter muscle tone.


ARTIFICIAL BOWEL SPHINCTER
Some patients may be treated with an artificial bowel sphincter. The artificial sphincter consists of three parts: a cuff that fits around the anus, a pressure-regulating balloon, and a pump that inflates the cuff.
The artificial sphincter is surgically implanted around the anal sphincter. The cuff remains inflated to maintain continence. You have a bowel movement by deflating the cuff.

Find out more in the Faecal Incontinence FAQ

Find out more

This page is designed to give you a short break-down for each procedure, more informatino can be found on our 'Super FAQ'

If you have more questions please get in touch with us to book a consultation.


Read more about Anthony's inclusion in the Tatler Doctors Guide 2013