Laser Surgery for Fistula

Procedure Description

1. Surgery for treating anal fistula is performed so that the sphincter muscles of your anus do not get damaged.
2. Laser surgery is one of the newest surgical methods that does not damage your anal sphincter muscles.
3. The procedure for laser surgery is as follows:
4. After you are given anaesthesia, you will be placed in the lithotomy position so that the internal part of the anus is visible and accessible to your surgeon.
5. The surgeon inserts a guidewire in your fistula tunnel over which the surgeon will pass a plastic catheter.
6. After the surgeon successfully places this plastic catheter, the guidewire is removed.
7. The plastic catheter acts as a medium for the laser probe. The laser probe is directed upwards towards the inner end of the fistula.
8. After placing the laser probe at its designated location, the plastic catheter is removed, and the laser is activated.
9. Your surgeon will use a laser probe that emits a laser beam of 1470 nm.
10. The laser energy is passed to the entire fistula tunnel. The process of shrinking damages the inner end of the fistula.
11. A dressing is then applied to your anal area, and you are transferred to the recovery room.

What to Expect Before Surgery?

1. Preoperative preparation: You will have an appointment with your surgeon seven days before surgery.[9] During this appointment, you can expect the following:
2. Your surgeon will conduct a medical check-up to determine which surgery suits you the best. This will include anoscopy and ultrasound of your abdomen, followed by blood and urine tests.[3,5,9]
3. Ensure that you ask them about the risks associated with laser surgery or anything you did not understand.[5]
4. Along with your surgeon, you will also meet your anaesthesiologist (a doctor that will give medicine to numb your body during surgery). The anaesthesiologist will recommend ECG and chest X-ray.[9]
5. As this is an anal surgery, your surgeon will give you certain instructions to cleanse your anal area before surgery.[9,10]

Dietary changes:

1. Do not eat or drink anything (this also includes water and chewing gum) after midnight.[9,11]
2. You may need to stay on a liquid diet the day before your surgery. You can have  beverages, soups or desserts.
3.  Avoid alcohol consumption for at least 48 hours before your surgery.[10]
4. Medications:
5. If your surgeon has allowed you to take your routine medications, take them only with a small sip of water.[9,10]
6. Avoid medicines used for blood thinning, e.g., aspirin or ibuprofen, for a week before surgery.[9]
7. Avoid smoking after midnight before surgery.[9,11]
8. Make a list of your routine medications and allergies. Carry this to the hospital on the day of surgery.[9-11]
9. Other:
10. Do not wear make-up, nail polish, or artificial nails on the day of surgery.[9,10]
11. Avoid wearing contact lenses. Use glasses instead.[10,11]
12. Do not carry jewellery to the hospital as you will need to remove it before the surgery.[10]
13. Wear clothes that are loosely fit and comfortable.[10,11]
14. Try to remain active before surgery. You can walk or do mini squats or heel raises.[11]
15. If your health deteriorates before surgery, e.g., fever, vomiting, throat soreness, etc., contact your surgeon immediately.[9,11]

What to Expect on the Day of Surgery?

1. When you reach the hospital on the day of surgery, you will experience the following:
2. You will be asked to remove your clothes and wear a hospital gown.
3. The healthcare staff will provide a consent form that you need to sign before undergoing surgery.
4. You may be given an enema to remove bowels from your anus. An enema is a liquid administered into the large intestine via the anus to remove any stools trapped in the intestines.
5. If someone from your family has accompanied you on the day of surgery, they will be asked to stay in the waiting room. Meanwhile, the healthcare staff will direct you towards the pre-operative room.
6. The healthcare staff will check your vitals like body temperature, blood pressure, and pulse rate.
7. They will also attach a thin tube called an intravenous line by inserting a needle into your arm or hand vein.

What to Expect During Surgery?

1. The healthcare staff will take you from the pre-operative room to the operative room. Here you will meet your anesthesiologist, who will administer medication for anaesthesia.
2. You may receive local, epidural or general anaesthesia for this type of surgery. Epidural anaesthesia will only numb the lower body, and local anaesthesia will only numb your anal area, while you will be asleep during the surgery if you receive general anaesthesia
3. For laser surgery to remove the fistula, your surgeon will keep you in a lithotomy position. After your anal region is numbed, the surgeon will begin the surgery.
4. Your surgeon will insert a laser probe in the fistula with the help of a plastic catheter.
5. After placing the laser probe at its designated location, your surgeon will remove the plastic catheter and activate the laser.
6. The laser energy is passed to the entire fistula tunnel, and your fistula will shrink.
7. After successfully applying laser energy, a dressing will be applied to your anal area, and you will be transferred to the recovery room.
8. The surgery will take approximately 20 minutes.

What to Expect After Surgery?

At the hospital:

1. After the surgery, the healthcare staff will shift you from the operative room to the recovery room. Here they will observe your condition.
2. You are likely to remain in the recovery room for two hours after surgery. After that, the healthcare staff will shift you to the hospital room.
3. Your surgeon will meet your family members and discuss how the surgery went and your condition.
4. You might feel pain after laser surgery. To get relief from it, your surgeon will administer you a local anaesthetic (e.g., lidocaine). A local anaesthetic will numb your anal region. Your surgeon may also recommend painkillers for reducing pain.
5. Your healthcare staff will provide you with a liquid diet after surgery. You can slowly shift to soft foods and your regular diet unless the surgeon has instructed you differently.
6. Try to stay active after surgery, as this will speed up your recovery.
7. If you had surgery on an outer fistula, you would get discharged on the same day; however, if surgery was performed on the deep fistula (fistula present in the inner region of your anus), your surgeon will recommend an overnight stay in the hospital.
8. You cannot drive post-surgery; hence you will need to ask your friend or family member to drive you home.

Medications:

1. A small amount of pain is quite normal after laser surgery, and it will decrease as you recover. Meanwhile, you can try out different pain relief methods listed in the table below:
2. At home:
3. There are no restrictions on walking but avoid lifting anything heavy for four weeks.
4. Do not drive for a week.
5. Try to rest or nap as much as possible because surgery can make you feel tired.

Diet: 

1. You should resume your regular diet; however, avoid overeating to prevent bloating. Instead, eat small and frequent meals in a day.
2. Include foods rich in fibre that will help to prevent constipation.
3. Drink plenty of water (minimum eight to ten glasses in a day).

Risks:

1. Laser surgery for fistula can possess risks like:
2. You may get an infection at the surgical site. For this, your surgeon will prescribe you a course of antibiotics to help you get rid of your condition.
3. The fistula can recur after surgery.
4. As mentioned earlier, you may lose bowel control if your sphincter muscles get damaged during the surgery. However, this is extremely rare, so there is not much to worry about it.

When to See a Doctor?

Follow-up:

1. Your surgeon will recommend a follow-up three to four weeks or a month after surgery. The time between the surgery and follow-up is more so that you do not feel pain or discomfort while your surgeon is examining the anal region.
2. You should visit your colon and rectal surgeon right away if the following symptoms occur after the laser surgery:
3. Pain, swelling, or redness in your anal region
4. High body temperature (more than 101 degrees).
5. Pain while passing bowel.
6. Pus, blood, or mucous in your bowels.
7. Bowel incontinence (difficulty to control bowel movements).
8. Persistent vomiting.
9. Pain or swelling in your abdomen that does not go away within a few hours.
10. Unable to pass urine after eight hours post-surgery.
11. Feeling dizzy or extremely tired.