What is involved in anorectal surgery?

Anorectal Surgery: Comprehensive Overview

What Anorectal Surgery Encompasses

Anorectal surgery addresses a spectrum of conditions ranging from elective outpatient procedures for benign diseases to emergency interventions for life-threatening complications. The field includes management of hemorrhoids, anal fissures, anorectal abscesses, rectal prolapse, anorectal foreign bodies, anorectal varices, and Fournier's gangrene 1.

Common Anorectal Surgical Conditions

Elective/Ambulatory Procedures

• Most anorectal pathology can be managed on an ambulatory basis with excellent safety profiles, reduced costs, and high patient satisfaction 2.
• Ambulatory procedures include hemorrhoidectomy, fissurectomy, fistulotomy for small fistulas, excision of anal warts, and polypectomy 3.
• These procedures typically utilize multimodal pain regimens and restricted intravenous fluids to minimize urinary retention 2.

Emergency Anorectal Conditions

Anorectal Foreign Bodies

• For low-lying foreign bodies without perforation, attempt bedside transanal extraction first 1.
• If bedside extraction fails, use pudendal nerve block, spinal anesthesia, intravenous conscious sedation, or general anesthesia to improve retrieval success 1.
• For high-lying foreign bodies (above rectosigmoid junction), attempt endoscopic extraction as first-line therapy 1.
• Perform proctoscopy or flexible sigmoidoscopy after foreign body removal to evaluate bowel wall integrity 1.
• In patients with hemodynamic instability or perforation, proceed directly to emergent laparotomy with damage control surgery—do not attempt transanal extraction 1.
• For stable patients with perforation and limited contamination, primary suture is appropriate only for small, recent perforations with healthy, well-vascularized tissue 1.
• In critically ill patients with perforation or extensive contamination, perform Hartmann's procedure 1.

Acute Anal Fissures

• Surgical treatment is contraindicated in the acute phase 1.
• Surgery should only be considered for chronic fissures (>8 weeks) that fail non-operative management 1.
• For acute fissures, integrate topical anesthetics and common pain medications for inadequate pain control 1.
• Topical antibiotics may be used when therapeutic compliance is reduced or genital hygiene is poor 1.

Complicated Rectal Prolapse

• For incarcerated rectal prolapse without ischemia or perforation, attempt gentle manual reduction under mild sedation or anesthesia 1.
• In hemodynamically stable patients, perform urgent contrast-enhanced abdomino-pelvic CT scan to detect complications and assess for colorectal cancer, but do not delay treatment 1.
• In hemodynamically unstable patients, do not delay surgical management to perform imaging or attempt conservative reduction 1.
• Request complete blood count, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin, lactates) to assess patient status 1.

Bleeding Anorectal Varices

• Maintain hemoglobin >7 g/dL and mean arterial pressure >65 mmHg during resuscitation, but avoid fluid overload 1.
• Provide intravenous fluid replacement, blood transfusion if necessary, and correction of coagulopathy 1.
• Administer a short course of prophylactic antibiotics (strong recommendation) 1.
• Consider vasoactive drugs (terlipressin or octreotide) to reduce splanchnic blood flow and portal pressure 1.
• Temporarily suspend beta-blockers during acute bleeding, though they are recommended for prevention of recurrent bleeding 1.
• Use a stepwise approach: medical management → local procedures → interventional radiology (embolization or TIPS) → surgical procedures 1.
• Avoid "per anal" suture ligation after failure of medical and radiological treatments 1.

Anesthetic Considerations

• Anorectal surgery requires deep levels of anesthesia 4.
• Options include regional blocks (spinal anesthesia, caudal blockade, posterior perineal blockade, local anesthesia) alone or combined with monitored anesthesia care, or deep general anesthesia with muscle relaxants and tracheal intubation 4.
• Modern general anesthetics provide smooth, quickly adjustable anesthesia and are preferred for ambulatory surgery 4.
• The trend in regional anesthesia is toward lower doses of local anesthetic with selective segmental blocks and adjuvants for potentiated analgesia 4.

Common Complications

Acute Complications

• Minor complications are relatively common, but major complications are rare 5.
• The most frequent acute complications include bleeding, infection, and urinary retention 5, 4.
• Pelvic sepsis, while rare, can result in dramatic morbidity and mortality 5.
• Urinary retention occurs due to common nerve supply between the anorectal region and bladder 4.

Long-Term Complications

• The most feared long-term complications include fecal incontinence, anal stenosis, and chronic pelvic pain 5.
• Anal canal stenosis with altered sensory continence or mucosal ectropion may occur after anorectal operations 6.
• Island flaps with perianal skin or VY-anoplasty are effective plastic methods to reconstruct the anorectal region and treat anal strictures or mucosal ectropion 6.

Critical Pitfalls to Avoid

• Never delay surgical intervention to perform imaging in hemodynamically unstable patients 1.
• Never attempt transanal extraction in patients with signs of perforation or hemodynamic instability 1.
• Do not disrupt drug packages in suspected "body packers"—avoid endoscopic retrieval in these cases 1.
• Do not routinely use antibiotics for uncomplicated anorectal foreign body removal without signs of infection or perforation 1.
• Extensive fistulas, unusually large hemorrhoids with generalized mucosal prolapse, and disorders in poor-risk patients should be managed in the hospital, not as outpatient procedures 3.