Sphincterotomy

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Preoperative Care

Most fissure repairs are same day surgeries, meaning that the patient can go home the same day. If a patient needs to remain in the hospital, they are usually discharged the following day.

Preoperative tests including blood and urine tests, a chest x-ray, and an EKG may be performed. Additional tests depend on the patient's health and if general anesthesia is going to be utilized. These tests are normally done a few days prior to surgery.

Medications that "thin" the blood,

including aspirin, are usually discontinued several days before a scheduled surgery. On the day of surgery, other prescription drugs may also be withheld. 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 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, regardless of the type of anesthesia to be used, because it may be necessary to switch to a general anesthetic 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. The anesthesiologist must be aware of all medication 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, 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 to help them relax.

Same day surgical patients are taken from this area to the operating room or 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 postanesthesia 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 recovery and the type of anesthesia used. Patients who received local anesthesia generally recover more quickly. 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 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 food.

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. A family member or friend must accompany the patient if discharge 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 risk for an anesthetic-induced headache, which can be painful and prolonged. Before being discharged, the patient must regain full sensation in the region of the body that was numbed.

Most patients experience mild to moderate pain following these procedures and the first few postoperative days can be quite uncomfortable. Pain medication may be prescribed and should be taken as directed. If the pain is mild, an over-the-counter remedy may be sufficient.

In addition to medication, other measures can be taken to reduce discomfort and promote healing. The bandage or dressing should be kept on for several hours after discharge, and 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 helps keep the area clean and decreases 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. Time lost from work or school is generally minimal.

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 prescribe an ointment to reduce infection and assist in healing. If so, this should be applied after a bowel movement or sitz bath, and as directed.

Using a donut ring, a cushion with a hole in the middle, can make sitting upright more comfortable. Normal activities can be resumed when it is comfortable to do so.

The risk of complications from this procedure is very low, but they do develop occasionally. Most common are:

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

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