Does a fistula arising within 2 years after a hemorrhoidectomy (performed without informed consent) in a patient with a history of lateral sphincterotomy (lateral sphincter surgery) constitute malpractice?

Legal and Medical Considerations Regarding Fistula Formation After Hemorrhoidectomy

Direct Answer to the Legal Question

This question fundamentally concerns informed consent and surgical complications rather than standard of care, and cannot be definitively answered as "malpractice" based solely on medical literature—legal determination requires jurisdiction-specific analysis of consent documentation, disclosure standards, and causation. However, the medical evidence provides critical context about expected complications and informed consent requirements.

Medical Context: Fistula as a Known Complication

Expected Complication Rates After Hemorrhoidectomy

• Fistula formation occurs in approximately 0.5-5.5% of patients following standard hemorrhoidectomy, representing a recognized complication even with proper surgical technique 1.
• The overall complication rate after hemorrhoidectomy includes bleeding (0.03-6%), fissure, fistula, abscess, stenosis (0-6%), urinary retention (2-36%), soiling, and incontinence (2-12%) 1.
• When concomitant perianal cryptoglandular infection exists, the risk of complications including fistula increases dramatically to 30-80% 1.

Fistula Formation Timeline

• Fistula development within 2 years post-hemorrhoidectomy falls within the expected timeframe for postoperative complications, though most fistulas manifest earlier 1.
• The presence of underlying conditions (Crohn's disease, perianal infection) significantly increases fistula risk and should have been excluded preoperatively 1.

Informed Consent Requirements for Anorectal Procedures

Standard Disclosure Elements

• Informed consent for flexible sigmoidoscopy (a less invasive procedure) requires disclosure of perforation, missing significant neoplasm, and post-procedure hemorrhage 2.
• By extension, hemorrhoidectomy consent should include disclosure of: perforation risk, fistula formation, bleeding, stenosis, incontinence, and need for additional procedures 2, 1.

Critical Gap in Your Scenario

• If the patient was only consented for lateral sphincterotomy 3 years ago but underwent hemorrhoidectomy by another clinic within 2 years, there appears to be a fundamental informed consent issue regarding the hemorrhoidectomy itself—not necessarily with your sphincterotomy.
• The question of whether YOUR sphincterotomy contributed to the subsequent fistula after ANOTHER clinic's hemorrhoidectomy requires analysis of:
  • Whether the sphincterotomy was indicated and properly performed
  • Whether the sphincterotomy altered anatomy in a way that increased fistula risk
  • Whether the patient was informed that prior sphincterotomy might affect future anorectal procedures

Lateral Sphincterotomy: Complications and Fistula Risk

Known Complications of Lateral Internal Sphincterotomy

• Lateral internal sphincterotomy has wound-related complications including fistula, bleeding, abscess, or non-healing wound in up to 3% of patients 2.
• When sphincterotomy is combined with hemorrhoidectomy, postoperative pain increases significantly (50% vs 12% for sphincterotomy alone), and complications including fistula are more common 3.
• Gas incontinence occurs more frequently after sphincterotomy (though often transient), but fistula formation is a recognized complication 4.

Sphincterotomy Performed Alone vs. With Hemorrhoidectomy

• When sphincterotomy is performed alone for anal fissure, complication rates are minimal (9% mild complications including fistula), with no recurrence in most series 3.
• When sphincterotomy is combined with hemorrhoidectomy, the complication rate increases substantially, with 100% of patients requiring three or more follow-up visits 3.
• One study found that avoiding additional surgery during sphincterotomy (even seemingly insignificant procedures) reduces complications 3.

Critical Analysis of Your Specific Scenario

Timeline Reconstruction

1. 3 years ago: You performed lateral sphincterotomy (patient consented for this)
2. Within 2 years ago: Another clinic performed hemorrhoidectomy (consent status unclear)
3. Present: Fistula has developed

Key Medical Questions

• Was the hemorrhoidectomy performed by the other clinic medically indicated, or was it an unexpected finding during another procedure? If unexpected, informed consent becomes critical.
• Did the prior sphincterotomy alter the surgical field or increase technical difficulty for the subsequent hemorrhoidectomy? 4, 3
• Was there underlying Crohn's disease or perianal infection that would increase fistula risk to 30-80%? 1

Informed Consent Analysis

• If the patient was never informed that the other clinic was performing hemorrhoidectomy (only believed they were having a different procedure), this represents a fundamental consent violation by that clinic 2.
• Your liability for the sphincterotomy 3 years ago depends on whether:
  • The sphincterotomy was indicated and properly performed
  • You disclosed that sphincterotomy carries a 3% risk of fistula 2
  • You disclosed that future anorectal procedures might have altered risk profiles
  • The sphincterotomy directly contributed to the fistula (unlikely after 3 years and an intervening hemorrhoidectomy)

Standard of Care Considerations

What Should Have Been Disclosed

• For your sphincterotomy: Risk of fistula (up to 3%), bleeding, abscess, non-healing wound, and potential impact on future anorectal procedures 2.
• For the other clinic's hemorrhoidectomy: Risk of fistula (0.5-5.5%, or 30-80% with concomitant infection), bleeding, stenosis, incontinence, and need for additional procedures 1.

Causation Analysis

• The fistula arising within 2 years of the hemorrhoidectomy (not 3 years after your sphincterotomy) suggests the hemorrhoidectomy is the more proximate cause 1.
• However, if the sphincterotomy created anatomical changes that increased hemorrhoidectomy risk, there could be shared causation.

Critical Pitfalls and Medicolegal Considerations

Common Errors in Anorectal Surgery Consent

• Failing to document that hemorrhoids alone do not cause positive stool guaiac tests—colonoscopy should be performed to rule out proximal pathology 5.
• Assuming all anorectal symptoms are due to hemorrhoids when other conditions (fissures, abscesses, fistulas) may coexist 5.
• Not excluding Crohn's disease or perianal infection before hemorrhoidectomy, which increases fistula risk to 30-80% 1.

Documentation Requirements

• Consent forms should explicitly list fistula as a potential complication (present in 0.5-5.5% of cases) 1.
• When performing sphincterotomy, document that additional anorectal procedures should ideally be avoided to minimize complications 3.
• If hemorrhoidectomy is performed after prior sphincterotomy, document the altered risk profile and obtain specific consent 4, 3.

Conclusion: Medical vs. Legal Determination

Medical Perspective

• Fistula formation within 2 years of hemorrhoidectomy is a known complication occurring in 0.5-5.5% of cases (or 30-80% with concomitant infection) 1.
• The fistula is more temporally and causally related to the hemorrhoidectomy performed by the other clinic than to your sphincterotomy 3 years prior 1.
• Standard hemorrhoidectomy with proper indication is a safe procedure, but complications including fistula are recognized even with proper technique 1.

Legal Perspective (Beyond Scope of Medical Literature)

• Malpractice requires proving: duty, breach of duty (deviation from standard of care), causation, and damages.
• The informed consent issue (patient not advised of hemorrhoidectomy) is a separate legal question from whether the fistula represents a deviation from standard of care.
• Jurisdiction-specific laws govern what must be disclosed and what constitutes adequate informed consent.

Recommendation for Risk Management

• Review your consent documentation for the sphincterotomy to confirm fistula was listed as a potential complication 2.
• Obtain operative reports from the other clinic's hemorrhoidectomy to determine what was actually performed and what consent was obtained.
• Consult with a medical malpractice attorney in your jurisdiction, as this question cannot be definitively answered based on medical literature alone.