An anal fistula is a condition where abnormally developing tracts occur between the inner and outer surfaces of the anal canal. This condition does not heal on its own and definitely requires surgical intervention.
Fistulotomy is a surgical procedure used in the treatment of anal fistula disease, aimed at cutting open and removing the fistula formed in the anus. This procedure is generally completed within 30 minutes to 1 hour. The recovery process after fistulotomy surgery takes approximately 3-4 weeks when the program recommended by the doctor is followed. However, in some patients, short-term complications such as wound infection or pain may occur.
In this article, we will explain in plain language what a fistulotomy procedure is, how it is performed, the recovery process, and its advantages. You will also learn the differences between perianal fistulotomy and fistulectomy.
What is a fistulotomy?
Fistulas are holes or connections that link two organs or vessels that should not normally be connected. Fistulotomy is a surgical treatment method used in the treatment of anal fistula disease, aimed at cutting open and removing the fistula formed in the anus. This procedure stands out as a preferred and applied method particularly in simply structured fistulas.
What is an anal fistula and how does it form?
An anal fistula is an abnormal connection that develops between the anal canal and the skin surrounding the anus. This connection develops as a narrow tract opening from the terminal part of the large intestine (rectum) or from inside the anus (anal canal) toward the skin near the anus. The part of the fistula opening onto the skin is called the "external opening," and the part opening into the anal canal is called the "internal opening."
Anal fistulas mostly develop following a previously occurred anal abscess. Approximately 50-70% of fistulas occur after a previous abscess. Other causes include:
Chronic bowel diseases such as Crohn's disease
Tuberculosis and other infections
Postoperative complications
Its most common symptoms include itching and burning sensation in the anus, difficulty sitting, a feeling of fullness in the anus, tenderness, and foul-smelling discharge.
What is the difference between fistulotomy and fistulectomy?
Fistulotomy and fistulectomy are two different surgical approaches used in the treatment of anal fistulas. The main differences between them are as follows:
Fistulotomy: The fistula tract is completely opened, the infected tissue inside is cleaned, and the wound is left open. The body is expected to heal this open area through natural ways.
Fistulectomy: It is treated by completely removing the fistula tract. In other words, while the fistula tract is opened and its contents are cleaned in a fistulotomy, the tunnel-like structure is removed as a whole in a fistulectomy.
Fistulotomy shows a high success rate in simple and superficial fistulas, and the recovery process is faster. In contrast, fistulectomy is a more comprehensive procedure and removes the entire fistula tract.
What is perianal fistulotomy or fistulectomy?
A perianal fistula is a chronic and bothersome health problem seen around the anus. Perianal fistulotomy or fistulectomy is applied in the treatment of these fistulas, particularly those formed in the skin around the anus.
Perianal fistulotomy involves opening the skin portion over the fistula tunnel and cutting a small piece of the anal sphincter that connects the external and internal openings of the fistula. Thus, the fistula passage is converted into a wound that will later heal in a controlled manner.
Approximately 70% of anal fistulas are simple fistulas, and fistulotomy provides sufficient and effective treatment for these cases. Following the procedure, patients generally experience recovery within 3-4 weeks with sitz baths. Furthermore, the patient is able to return to normal life in a short time after the operation, and the probability of recovery is high.
One of the important points is that perianal fistulas will not heal on their own. Therefore, surgical intervention is inevitable. Fistulotomy or fistulectomy is preferred by specialist physicians according to the patient's condition and the characteristics of the fistula.
How is fistulotomy surgery performed?
Fistulotomy surgery is a surgical method frequently preferred for simple and low-lying fistulas. This surgery aims to open the fistula tract, clean the infected tissue, and initiate the healing process. So, how is this procedure performed?
Preoperative preparation process
First of all, your doctor will perform a detailed evaluation before the surgery. During this process, your past surgeries, chronic diseases, and health conditions such as bleeding disorders are examined. In addition, you may be asked to stop taking food and fluids 8-12 hours before the surgery.
Before the surgery, your doctor will:
Evaluate your clotting, liver, and kidney functions by requesting blood tests
Review your medication use and advise you to discontinue certain medications if necessary
Provide instructions for cleansing your bowels
Showering with antibacterial soap the night or morning before surgery is also recommended to reduce the risk of infection.
Detection of the fistula tract
The most critical step for a successful fistulotomy is the accurate detection of the fistula tract. At this stage, doctors may use the following methods:
A careful physical examination is performed, and examination under anesthesia (EUA) can be carried out. During the examination, the surgeon can follow the inside of the tunnel using a fine probe and map the fistula. Additionally, advanced imaging methods such as pelvic MRI imaging or endoanal ultrasound can also be used for more complex fistulas.
Surgical procedure steps
The basic steps followed in fistulotomy surgery are as follows:
After determining the exact location of the fistula tract, the doctor makes an incision along the fistula tract. This incision completely opens the fistula tract and allows the pus and infected tissue inside to be drained. Then, the fistula and surrounding infected tissues are cleaned. In simple fistulas, the wound is left open, allowing it to heal from the bottom up.
Difference between local and general anesthesia
Fistulotomy surgery can be performed under both local and general anesthesia. While only the surgical area is numbed in local anesthesia, the patient is completely put to sleep in general anesthesia.
It has been observed that fistula maturation times are shortened with regional anesthesia. At the same time, surgeons report higher satisfaction with procedures performed under regional anesthesia. Postoperative pain levels, however, may be higher in the local anesthesia group.
How long does the procedure take?
The duration of a fistulotomy surgery varies depending on the complexity and location of the fistula. Generally, the duration is shorter in simple fistulas, whereas surgical intervention may take longer in complex fistulas.
On average, fistulotomy surgery is completed within 30 minutes to 1 hour. While this duration may be shorter in simple fistulas, the procedure may take longer in complex or deeply located fistulas.
Recovery process after fistulotomy surgery
The most important process for the patient after a fistulotomy is undergoing a proper recovery period. The precautions to be taken and points to consider during this period directly affect the success of the surgery.
How long is the recovery period?
The recovery period varies depending on the type and complexity of the fistula. Generally, recovery takes 1-2 weeks in simple fistulas, while this period can extend up to 4-8 weeks in complex fistulas. It may take 2-4 weeks in superficial fistulas and 6-8 weeks in more complex fistulas. To accelerate the recovery process, it is important to strictly follow your doctor's recommendations.
When you pay attention to patient care and hygiene rules, the recovery process speeds up. Furthermore, if undesirable conditions such as infection develop, the recovery period may be prolonged. In laser-treated procedures, however, the patient can be discharged on the same day and return to normal life faster.
Wound care and hygiene recommendations
Keeping the area clean and dry after surgery is very important. Taking warm sitz baths daily helps clean and soothe the area. It is recommended to apply these baths 3-4 times a day for at least 15 minutes.
Points you should pay attention to after the procedure:
Dry the surgical area by gently dabbing with a soft towel
Apply regular dressings with antiseptic solutions recommended by your doctor
Be sure to clean the area after defecation
A sitz bath prepared with chamomile tea can reduce itching and burning
Nutrition and bowel movement routine
The diet is of critical importance to accelerate the recovery process and prevent constipation. It is recommended to drink at least 2-2.5 liters of water a day and consume fiber-rich foods. Whole grains, fresh vegetables, and fruits regulate your digestive system and prevent straining during bowel movements.
Foods you should avoid:
Hot and spicy foods
Alcoholic beverages
Processed foods
High-caffeine beverages
Constipation can cause pain in the surgical area and damage to the stitches. Therefore, it is important to use fiber-containing products prescribed by your doctor and stool softeners if necessary.
Pain control and medication use
It is normal to feel pain and discomfort in the area after surgery. This pain generally decreases within 5-10 days. Use the painkillers recommended by your doctor regularly. Pain may be severe especially during the first bowel movement; it is beneficial to take a painkiller about half an hour before defecation.
Creams containing lidocaine provide relief when used before and after defecation. In addition, warm sitz baths help alleviate the pain.
Doctor check-ups and follow-up process
Regular doctor check-ups are very important in terms of monitoring the recovery process. During these check-ups, your doctor evaluates the healing of the wound and can recommend additional treatments if necessary.
You should contact your doctor immediately in the following situations:
Severe pain that does not go away
Excessive amount of bleeding (active bleeding 3-4 times in a row)
Inability to defecate for more than 3 days
Watery stooling more than 5 times a day
Fever above 38 degrees Celsius
Difficulty in urination
Remember that for a successful recovery process, you must strictly follow your doctor's advice, use prescribed medications regularly, and take post-surgery recommendations into account.
Advantages and disadvantages of fistulotomy
When choosing the fistulotomy method for anal fistula treatment, it is important to know the pros and cons of this procedure. Like every surgical procedure, fistulotomy has its own specific advantages and risks.
Advantages: Success rate and rapid recovery
Fistulotomy is the best treatment option for simple perianal fistulas. When appropriate patient selection is made, success rates are quite high, and a success rate of 92-97% can be achieved. This means a more reliable outcome compared to other treatment methods.
The hospital stay duration has been determined as an average of 1.3 days. This means patients can rapidly return to their daily lives. In addition, the recovery process after the procedure can be completed in about 3-4 weeks when the program recommended by the doctor is followed.
Other advantages:
High recovery rate in simply structured fistulas
The patient can return to normal life in a short time after the procedure
The potential of offering a definitive solution is high
Disadvantages: Risk of complications
Like every surgical procedure, fistulotomy also carries some risk of complications. Research has revealed that local infection is seen in 4.4% of patients. In addition, the problem of urinary incontinence after the procedure has been observed in 5.9% of patients.
The risk of recurrence (relapse) is also a factor that must be considered. Recurrence can be seen in 17.8% of all patients. Especially in patients with a long fistula tract, the risk of recurrence is higher.
Besides these, a long recovery period, postoperative pain, and the necessity of dressings can be counted among other disadvantages.
Is there a risk of fecal incontinence?
One of the most serious potential complications of fistulotomy is the risk of fecal incontinence, which may arise as a result of damage to the sphincter muscles. However, research shows that fecal incontinence problems are not experienced in correctly performed procedures.
In particular, in the event of the internal sphincter muscle being affected, control problems such as stool or gas leakage may occur. Therefore, it is of great importance that sphincter-sparing techniques are preferred in surgical planning and that it is performed by experienced surgeons.
For which patients is it more suitable?
Fistulotomy is generally preferred in the treatment of simple and straight-line anal fistulas. It is ideal especially for cases where the fistula tract carries the potential to cause minimal damage to the sphincter muscles.
This treatment approach is suitable:
In superficial fistulas (success rate as high as 98.2%)
In uncomplicated fistula structures
In fistulas located far from the sphincter muscles
However, if the fistula tract passes through important muscles or exhibits a complex structure, alternative treatment methods should be preferred to reduce the risk of fecal incontinence.
Alternative treatment methods to fistulotomy
In some cases, a fistulotomy may not be a suitable treatment option. Alternative treatment methods have been developed especially for patients whose sphincter muscles need to be preserved. These methods aim to minimize the risk of fecal incontinence.
Laser fistula treatment
Laser anal fistula treatment is a minimally invasive method. In this treatment, the fistula tract is closed by burning it with laser energy. The procedure is generally performed under local anesthesia and takes about 10-15 minutes. The biggest advantage of laser treatment is that it does not damage the sphincter muscles.
Patients can be discharged on the same day after treatment. Less pain is felt compared to other methods, and the recovery process is faster. It is particularly suitable for patients with chronic diseases and those who cannot receive general anesthesia.
Seton placement method
A seton is a surgical thread or rubber material passed through the fistula tract. It is preferred especially in fistulas passing through the sphincter muscles. With this method, the inflammation inside the fistula is drained, ensuring that the infection is brought under control.
The seton helps the fistula heal by being tightened gradually during regular check-ups. This process generally takes several weeks or months. The biggest advantage is the preservation of the sphincter muscles, but the treatment process is longer.
Fibrin glues
Fibrin glue is a biocompatible material that mimics the body's natural clotting process. It is injected into the fistula tract to ensure the closure of the tract. It is preferred especially in patients for whom surgical intervention is risky.
This method is generally a procedure that takes a short time and does not require hospitalization. The risk of sphincter damage is minimal, therefore the risk of fecal incontinence is low. However, the success rate is between 40-60%.
Fistula plugs
Fistula plugs are products made of biocompatible materials used to close the fistula tract. The plug is placed into the fistula tract and is absorbed by the body over time.
This method is minimally invasive and preserves the function of the sphincter muscles. Pain and discomfort after treatment are at a minimum level. The success rate varies between 60-80%.
VAAFT method
VAAFT (Video-Assisted Anal Fistula Treatment) is the visualization and treatment of the fistula from the inside using a special camera system. In this method, the external opening of the fistula is entered, the internal opening is identified, and the fistula is burned from the inside with a laser.
Important advantages of the VAAFT method:
The anal muscles are not touched at all and are 100% preserved
No surgical incision or scar is formed
Postoperative pain is minimal
The recovery process is fast, and patients can return to their normal lives within a few days
This method yields successful results especially in complex and high fistulas. The recovery process takes about 3-5 weeks.
Fistulotomy in Summary
In conclusion, fistulotomy is a surgical procedure with a high success rate in the treatment of simple anal fistulas. Preferred especially for superficial fistulas, this method provides over 90% recovery when the patient is correctly selected.
Nevertheless, every patient's condition is different, and the treatment plan must be personalized. In some cases, particularly in complex fistulas or in patients where muscles need to be preserved, alternative methods such as laser treatment, seton placement, or VAAFT may be more appropriate.
Following your doctor's recommendations during the recovery process is of great importance. Regular cleaning, warm sitz baths, and proper nutrition will accelerate your recovery. Recovery is generally observed within 2-4 weeks in simple fistulas and 6-8-weeks in complex ones.
However, do not forget that an anal fistula does not heal on its own. When you notice symptoms such as pain, discharge, or swelling in the anus, you must definitely consult a specialist. Thanks to early diagnosis and appropriate treatment, your chance of getting rid of this condition permanently is very high.
For detailed information about fistulotomy and other treatment options, be sure to consult a specialist physician. You can return to your normal life in a short time with the right treatment method.
Frequently Asked Questions
What happens if an anal fistula is not treated? An anal fistula does not heal on its own. If left untreated, it can grow over time, causing continuous infection and new abscesses. In some cases, there is also a risk of turning into cancer in later periods.
Which doctor should be visited for an anal fistula? You should apply to a general surgery specialist for anal fistula complaints.
Does an anal fistula recur? Yes, fistulas can recur. Approximately 50% of abscesses can recur in the form of a second abscess or fistula. The risk of recurrence increases especially if there are underlying diseases such as Crohn's.
How long does recovery take after a fistulotomy? It generally takes 4-8 weeks. Daily dressings are required throughout this period.
Is a fistulotomy suitable for every patient? No, it is risky to perform it especially in fistulas close to muscle tissue or in horseshoe fistulas. Non-surgical methods may be safer in these situations.
What are the risks of fistulotomy? There are risks of bleeding, infection, a long recovery period, and gas-stool leakage in some patients.
Are there alternative treatments to fistulotomy? Yes. There are alternative treatments such as laser treatment, seton placement, fibrin glues, and the VAAFT method.
Fistulotomy is a surgical method used in the treatment of anal fistula. The procedure ensures the opening, cleaning, and healing of the fistula tract. Learn information about its advantages and recovery process.
