Fistulotomy

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Preoperative Care

Most patients who undergo a fistulotomy can go home frome the hospital the same day. If a patient must remain in the hospital, he or she is usually discharged the following day.

As with any surgical procedure, certain preoperative tests are ordered. Blood and urine tests, a chest x-ray, and an EKG may be required. The need for additional tests depends on the patient's health and if general anesthesia is going to be utilized. These tests are normally done a few days prior to the surgery.

Medications that "thin" the blood,

including aspirin, are usually discontinued several days before scheduled surgery. On the day of surgery, other prescription drugs may also be held. The need for discontinuing medications must be discussed with the physician before the operation.

If general anesthesia is going to be used, nothing can be eaten from midnight on the evening before surgery until after the procedure. This includes all food, water, chewing gum, and candy. This precaution decreases the possibility of vomiting during and after surgery.

For local and spinal anesthesia, dietary restrictions vary. Some doctors require their patients to follow the guidelines for general anesthesia in case it becomes necessary to switch to general anesthesia during the procedure. Dietary restrictions should be discussed with the physician in advance.

Check-in is usually the same day as the surgery. An informed consent form must be signed acknowledging that the patient understands the procedure, the potential risks, and that they will receive certain medications.

The anesthesiologist (doctor who administers the anesthesia) performs a brief physical examination and takes a patient history. It is important that the anesthesiologist is aware of all medications that the patient is taking, any allergies, and if there has been a prior adverse reaction to anesthesia. This information helps the anesthesiologist select the most suitable anesthetic agents and dosages and avoid possible complications.

Hospitals usually have an area reserved for same day or ambulatory surgical patients. Instead of checking into a room, same day patients go to this unit before and after the procedure. In preparation for surgery, patients have an intravenous line put in to receive fluids and medication during and after surgery. They may be given a sedative by injection or through the intravenous line to help them relax.

Same day surgical patients may go from this area to the operating room or may be taken to the preoperative or holding area, for a short time. Sometimes the intravenous is started here, depending on hospital protocol. The anesthesia is administered in the operating room.

After surgery, the patient is taken to the recovery room or post anesthesia recovery unit (PACU) and is closely monitored by the nursing staff until they are stable. The amount of time spent in the PACU depends on the patient's progress and the type of anesthesia used. Patients who received local anesthesia generally recover more quickly and leave the PACU faster. Those who received general anesthesia must be awake and coherent before they are transferred.

Ice chips are offered to the patient, and if those are tolerated, water is given. The intravenous line remains in until clear liquids are taken and tolerated. This may occur almost immediately following surgery, especially if local anesthesia was used. Sometimes general anesthesia causes nausea, which may delay taking oral fluids. Once clear liquids are tolerated, the diet quickly progresses to solid foods.

From the PACU, the patient is transferred back to the outpatient or ambulatory unit, where recovery is completed. Inpatients are transferred to their room. Most patients can go home within a few hours, once they are up and walking around. Even though the anesthesia has worn off, most patients remain groggy for the rest of the day. This is true for patients who received local anesthesia as well, because of the sedative that was given. A family member or friend should be present upon discharge, if it is the same day as the surgery.

Spinal anesthesia usually wears off within a few hours. In the first hour following surgery, patients lie flat on their back to decrease the chance of an anesthetic-induced headache, which can be painful and prolonged. Before being discharged, a patient must have full sensation in the region of their body that was numbed.

Unfortunately, most patients experience mild to moderate pain following these procedures, and the first few postoperative days can be quite uncomfortable. Medication is prescribed to help cope with the first few days. If the pain is mild, an over-the-counter remedy may be sufficient. All pain medication should be taken according to instructions.

In addition to medication, other measures can be taken to reduce discomfort and speed healing. The bandage or dressing should be kept on for at least several hours after discharge, but sitz baths can be taken the evening of the operation or the following morning. A sitz bath is a shallow bath filled with warm water, and is very helpful in keeping the area clean and easing pain. They should be taken at least twice a day, for 10 to 15 minutes. The surgeon may or may not recommend adding Epsom salts.

The pain usually disappears within a few days, but complete healing takes a few weeks. The time lost from work or school is generally minimal.

The healing fistula may have some normal drainage. A gauze pad or sanitary napkin can prevent it from soiling clothes.

Many patients dread having their first bowel movement following anal surgery, and it can be uncomfortable. However, a bowel movement does not affect healing, and it is much worse to become constipated. Eating a high fiber diet and drinking six to eight glasses of water a day can help prevent constipation. Stool softeners may also be helpful.

There may be some bleeding, especially when having a bowel movement. Using moistened toilet paper or baby wipes reduces irritation and keeps the area clean. Some doctors may prescribe an ointment to reduce infection and assist in healing. If so, this should be applied after a bowel movement, sitz bath, and/or as directed.

Sitting upright in a chair can be painful. Using a donut ring, a cushion with a hole in the middle, can make this position more comfortable. Normal activities can be resumed when it feels comfortable to do so.

Complications from this procedure are rare and include:

• Excessive bleeding
• Fecal incontinence, which is the loss of the ability to control bowel movements
• Inability to urinate
• Infection
• Problems resulting from anesthesia

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