Anal surgery

Surgical treatment of haemorrhoids is indicated if they cause severe, recurring complains and cannot be adequately treated with conservative therapy. In the past, haemorrhoids were often completely removed; nowadays, the procedure is rarely undertaken due to the severe post-operative pain. Smaller haemorrhoids can be ablated or ligated with a rubber band. The stapled haemorrhoidopexy surgical method is preferred for larger haemorrhoids. It causes almost no postoperative pain when the haemorrhoids are removed early.

Anal cancer, a rare tumour of the digestive tract, is a further indication for anal surgery. The surgical treatment consists of the localised removal of the tumour. Where possible, the sphincter muscle is preserved.

Anal fistulae (external protuberances), anal fissures (tears in the anus) or anal skin tags (mucous membrane folds on the anus) can be further reasons for smaller surgical procedures on the anus.

Procedures to remedy a colon prolapse or a disorder of the sphincter muscle are described in the chapter entitled surgery for faecal incontinence.

What preparations are carried out before the procedure?

Different examinations are carried out to clarify diseases of the anus. They usually include palpation and an anoscopy. Sometimes an ultrasound or a CT examination are also carried out.

All the usual pre-operative assessments are required, such as a blood test, blood pressure measurement and an ECG. All blood-thinning medication must be discontinued before the procedure takes place. The colon is usually cleaned out before the procedure. The patient should have an empty stomach as well. Depending on the surgery used, the procedure will either be undertaken under general or regional anaesthetic (spinal anaesthesia).

How is the operation carried out?

Haemorrhoid surgery

The most frequent and easiest treatment for smaller haemorrhoids is rubber band ligature. This involves tying the haemorrhoids with a rubber band. In the process, the blood flow is cut off and the haemorrhoids die off. The procedure can be carried out on an outpatient basis and there is virtually no pain.

Another method is ablation. This involves destroying the haemorrhoid nodes either with heat (infra-red) or a special ablation fluid is injected into the haemorrhoids. Several partial treatments are usually required for this almost painless treatment method: they can be carried out on an outpatient basis.

Nowadays, stapled haemorrhoidopexy surgery is preferred for larger or prolapsed haemorrhoids. It is carried out under general anaesthetic or with spinal anaesthesia. The procedure does not take place directly on the pain-sensitive haemorrhoids but rather above the haemorrhoids in the almost pain-insensitive rectum. A circular strip of the mucous membrane above the haemorrhoids is removed with a stapler and the wound is immediately resutured within the same step. This tightens and fixes the mucous membrane above the haemorrhoids. The haemorrhoids are then pulled up into the body and the nodules shrink due to the restricted blood supply.

During a standard procedure to remove haemorrhoids, known as a haemorrhoidectomy, the haemorrhoids are removed. This causes a wound on the rectum which cannot be sutured. Instead, it must be mended during an open wound treatment, which is painful and uncomfortable. This procedure is therefore only used in exceptional circumstances, in particular if stapled haemorrhoidopexy surgery cannot be carried out.

Surgery for patients with anal cancer

The location of the tumour and the stage of the disease determines the type of surgical treatment used for patients with anal cancer. Where possible, localised rather than radical surgery is carried out nowadays, and the sphincter is preserved in the process. In this way, a stoma can be avoided in many cases. Moreover, the prognosis is just as good as for a radical removal of the anus.

Surgery for fistulas, fissures and anal skin tags

Smaller surgical procedures are sometimes required for these diseases. However, they can often be carried out under local anaesthesia. Fissures are surgically cleaned and covered with a skin flap where necessary. In the case of anal skin tags, the annoying skin folds are removed. Fistulas can be ablated with a laser or with the natural tissue binder, Fibrin.

What is the success rate of this procedure?

The success rates after surgery on the anus depend on the underlying disease. Stapled haemorrhoidopexy surgery has the best success rates of approx. 90% for haemorrhoids. After ablation, the skin tags recur relatively often.

If a patient has anal cancer, the stage of the disease will determine the prognosis. Surgical treatment is highly successful for localised tumours.

What are the possible complications and risks of this procedure?

As with all surgery, the operation may occasionally lead to post-operative bleeding, nerve damage or infections. Patients who undergo anal surgery may need to defecate more frequently, but this is only temporary. In extremely rare cases, they can experience faecal incontinence.

What happens after the operation?

The follow-up treatment is based on the type of disease and the surgical procedure carried out. After haemorrhoid surgery, the amount of time you take off work and the healing time will vary, depending on the procedure you have undergone. For example, around a week for stapled haemorrhoidopexy surgery and up to three weeks for classic haemorrhoid removal.

If the surgery was due to anal cancer, additional [radiotherapy] or [chemotherapy] is often carried out afterwards.