Anal Fistula Surgery

Anal fistula surgery removes abnormal tunnels (fistulas) that form between the anal canal and the skin near the anus. These fistulas typically arise from an infection in an anal gland, allowing stool particles and bacteria to spread, causing recurring infections and discharge. The surgery aims to remove the entire fistula tract while preserving anal muscle function and preventing recurrence.

Dr. Chok Aik Yong

Colorectal Surgeon & General Surgeon

MBBS | MRCS (UK) | MMed (Surgery) | FRCS (UK)

Indications Benefits Techniques Preparation Procedure Recovery FAQ

When is Anal Fistual Surgery Necessary?

Surgical intervention is often required in the following scenarios:

Persistent Anal Drainage: The presence of continuous pus or blood-stained discharge from an opening near the anus indicates an active fistula requiring surgical intervention.
Recurrent Anal Abscesses: Multiple episodes of painful swelling and infection near the anus suggest an underlying fistula that needs surgical treatment.
Failed Conservative Treatment: Patients who have not responded to antibiotics and other non-surgical treatments over 4-6 weeks may need surgery.
Pain and Discomfort: Ongoing pain during bowel movements or while sitting, accompanied by skin irritation around the anal area, signals the need for surgical evaluation.

Benefits of Anal Fistula Surgery

Undergoing surgery for an anal fistula offers several advantages, addressing both immediate symptom relief and long-term outcomes.

Infection Resolution

Surgery removes infected tissue and closes abnormal passages, preventing further bacterial spread and lowering the risk of future infections.
Symptom Relief

The procedure stops persistent drainage and reduces local pain and discomfort associated with the fistula.
Prevention of Complications

Timely surgical intervention helps prevent potential complications such as abscess formation and the spread of infection to surrounding tissues.
Long-term Outcome

Successful surgery provides a permanent solution, significantly reducing the likelihood of recurrence compared to non-surgical approaches.

Surgical Techniques

Fistulotomy

This technique involves opening the entire fistula tract. The surgeon cuts along the length of the fistula, removes infected tissue, and allows the wound to heal from the inside out. This method works best for simple, low fistulas that involve minimal sphincter muscle.

Seton Placement

A soft surgical thread (seton) is placed within the fistula and secured on the skin surface outside the anus. This technique facilitates drainage, reduces infection, and allows the fistula to heal gradually while minimising damage to surrounding tissue. The process typically takes several weeks and is particularly useful for preserving sphincter function in more complex cases.

LIFT (Ligation of Intersphincteric Fistula Tract)

This technique involves tying off and removing the fistula tract while preserving the sphincter muscles. This technique preserves the anal sphincter muscles and reduces healing time compared to traditional methods.

Rectal Advancement Flap

The surgeon creates a flap of healthy tissue from the rectum or anal canal. After removing the internal opening of a fistula, the flap is pulled down to cover the repair site. This method suits complex fistulas and helps maintain muscle integrity.

Video Assisted Anal Fistula Treatment (VAAFT)

VAAFT is a modern and advanced minimally invasive approach for managing complex anal fistulas. This technique uses a video scope to visually examine the entire fistula tract, from the external opening to its internal origin. Once the internal opening is located, it is sealed, and the fistula tract is thoroughly cleaned with specialised tools, such as a brush and probe, under direct visualisation. One of the key advantages of VAAFT is that it eliminates the need for a large incision on the skin, resulting in a less invasive procedure and potentially quicker recovery.

Preparing for Surgery

Medical Assessment: Includes physical examination, imaging (e.g., MRI or ultrasound), and blood tests.
Medication Adjustments: Blood thinners may need to be stopped, and antibiotics prescribed for active infections. The doctor will review the current medications and advise accordingly.
Bowel Preparation: Patients follow a clear liquid diet 24 hours before surgery and cleanse the lower bowel with a bowel preparation kit or enema. No food or drink is allowed for 6–8 hours before the procedure to ensure an empty stomach and reduce surgical risks.

Step-by-Step Procedure

1. Anaesthesia Administration

The anaesthetist administers either spinal or general anaesthesia based on the surgical requirements. Vital signs are continuously monitored during the procedure. The patient is positioned to provide the surgeon with optimal access to the surgical site.

2. Fistula Tract Identification

The surgeon examines the anal area and locates both the internal and external openings of the fistula. A probe gently explores the tract to determine its path and any branches. A special dye may be injected to highlight the tract.

3. Surgical Removal

The surgeon removes or treats the fistula tract using the selected technique and clears any infected tissue. If required, muscle repair or flap creation is performed during this stage. Depending on the procedure and individual case, the wound is left open to heal naturally or closed with sutures.

4. Wound Management

The surgical site is cleaned and dressed. For a seton placement, it should be secured comfortably. The surgeon checks for bleeding and ensures proper wound drainage before completing the procedure.

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Post-Surgical Care and Recovery

Immediate Post-operative Care

Pain medication and antibiotics are prescribed to manage discomfort and prevent infection. Vital signs and wound drainage are closely monitored. Most patients are discharged on the same day unless complications occur, or the surgery is extensive.
Wound Management

Daily sitz baths help keep the area clean and promote healing. Dressings must be changed after each bowel movement, as the surgeon advises. The frequency of dressing changes decreases as healing progresses over 4-6 weeks.
Activity Restrictions

Light activities can resume within 1-2 days, but heavy lifting and strenuous exercise should wait 2-4 weeks. Most patients return to work within 1-2 weeks, depending on their job requirements and healing progress.
Follow-up Care

The first follow-up visit occurs 1-2 weeks after surgery. The surgeon checks wound healing and adjusts treatment if needed. Additional visits may be scheduled every 2-4 weeks until complete healing occurs.

Frequently Asked Questions (FAQ)

Can anal fistulas heal without surgery?

Simple, superficial fistulas occasionally heal with antibiotics and proper wound care. However, most fistulas require surgical intervention for complete resolution and to prevent recurrence.

What dietary changes are needed after surgery?

A high-fibre diet and adequate fluid intake help prevent constipation and reduce strain during bowel movements. Stool softeners may be recommended for the first few weeks of recovery.

How can I prevent anal fistulas from recurring?

Regular hygiene, proper wound care during healing, and treating underlying conditions like Crohn’s disease reduce recurrence risk. Early attention to anal abscesses and prompt medical evaluation of symptoms also help prevent fistula formation.

Are there any risks or complications for anal fistula surgery?

Anal fistula surgery carries certain risks, including infection at the surgical sites, and temporary difficulty controlling gas or liquid stool due to the involvement of sphincter muscles during the procedure. Scarring from surgery can sometimes result in mild anal stricture, causing a narrowing of the anal canal. Recurrence of the fistula is possible, particularly in complex cases or those involving substantial portions of the sphincter muscle. Careful post-operative care and monitoring can help mitigate these risks and support recovery.

Dr. Chok Aik Yong

Colorectal Surgeon & General Surgeon

MBBS|MRCS (UK)|MMed (Surgery)|FRCS (UK)

Expertise lies in managing colorectal diseases, particularly advanced colorectal cancer and inflammatory bowel disease.

Dr Chok graduated with degrees in Bachelor of Medicine and Surgery from the National University of Singapore. He was conferred the Master of Medicine (Surgery) in Edinburgh (UK) and a member of the Royal College of Surgeons, UK. He subsequently completed his specialist training in colorectal surgery and became a Fellow of the royal college of Surgeons in Edinburgh in 2016.
Dr Chok was awarded the Health Manpower Development Plan (HMDP) award in 2019 to further advance his colorectal training at Royal Marsden Hospital, one of the top 5 cancer centres in the world. While in London, Dr Chok trained with pioneers in the surgical management of advanced colorectal cancer and inflammatory bowel disease (IBD) and gained extensive experience while appraising the latest clinical and research evidence.

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