Fistula Surgery (LIFT / Laser)

Medically reviewed by Dr Murlidhar Boob, MS, FAIS, DLS, FMAS - Laparoscopic Surgeon & Surgical Gastroenterologist

What it is

An anal fistula is a small abnormal tunnel running between the inside of the anal canal and the skin near the back passage. It nearly always begins as an infection in one of the tiny glands that sit inside the anal canal. The gland blocks, an abscess forms, and when that abscess drains - whether a surgeon opens it or it bursts on its own - a track is left behind. That track is the fistula, and it does not close by itself.

Fistula surgery means finding that tunnel, identifying the internal opening where it began, and closing it without damaging the muscle that keeps you continent. Two sphincter-sparing techniques do most of that work today: LIFT, which stands for ligation of the intersphincteric fistula tract, and laser closure, in which a fine laser fibre seals the tunnel from within. Both were developed for the same reason - to cure the fistula while leaving the sphincter alone.

Who needs it

You probably need this operation if you recognise yourself in some of this:

• A small opening near the anus that keeps discharging pus, blood or a yellowish fluid, staining your underclothes, settling for a while and then starting again.
• You had an abscess drained weeks or months ago and the wound never properly closed.
• Recurring swelling and pain in the same spot, often building over a few days and then relieving itself when it discharges.
• Itching, dampness and an odour around the back passage that no amount of washing fixes.
• You have already had a fistula operation elsewhere and the problem has returned.
• You have Crohn disease or a history of tuberculosis and have developed a fistula - the treatment in that situation is different, and the underlying disease must be treated alongside.

“It only discharges now and then. Can I just leave it?” I am asked this often, usually by people who have lived with it for two or three years. Leaving it means accepting repeated abscesses, and every abscess adds inflammation and sometimes a new branch. A simple fistula that would have taken one straightforward operation can, given enough time, turn into a complex one. Very rarely, a long-neglected fistula undergoes malignant change. Waiting almost never makes the surgery smaller.

How it is done

The principle is the same whichever technique is used: find the internal opening, deal with the tract, protect the muscle.

Assessment first. Under anaesthesia the tract is gently probed, and dye or hydrogen peroxide may be used to confirm where the internal opening lies. For complex or recurrent fistulas, an MRI fistulogram done beforehand maps the tunnel and its branches.

LIFT. A small cut is made in the groove between the internal and external sphincter muscles - the intersphincteric plane. The fistula tract is isolated where it passes through that plane, tied off on both sides, and divided in the middle. The outer part of the tract is cleaned out and left to drain. Nothing of the sphincter is cut. The internal opening is now sealed off from the rest of the tunnel, and the tract has nothing feeding it.

Laser closure. A thin laser fibre is passed along the tract from the outside. As it is withdrawn, controlled energy is delivered circumferentially, so the lining of the tunnel shrinks and collapses. The internal opening is usually closed with a stitch or a small mucosal flap at the same sitting. There is no external wound to speak of beyond the original opening.

Seton, when it is needed. If the fistula is inflamed, abscessed or very complex, a soft draining thread is placed through the tract first and left in for several weeks. It controls infection and matures the tract so that the definitive repair, done later, has a much better chance of holding.

Anaesthesia, duration and hospital stay

The operation is done under spinal anaesthesia in most cases, and under general anaesthesia where that suits you better or where the fistula is complex. Either way you feel nothing during the procedure.

Most procedures take 30 to 60 minutes. A branching or recurrent fistula takes longer.

This is usually a day-care or single-night admission. You are walking within a few hours, eating normally the same day, and home the next morning at the latest.

Recovery

Day 1. Expect a dull ache rather than sharp pain, and some discharge or spotting on the dressing. You will be asked to start warm sitz baths - a shallow warm-water soak for ten minutes, two or three times a day. Eat normally and drink plenty; a soft first motion is far better than a delayed hard one.

The first week. Dressings and sitz baths continue. A stool softener keeps things comfortable. Discharge from the outer opening is expected and does not mean the operation has failed. Desk work is usually possible within four to seven days.

Weeks 2 to 4. The external wound is closing, the discharge is tailing off, and sitting for long periods becomes comfortable again. Avoid heavy lifting and long two-wheeler rides. Keep up the fibre and the water.

By 6 weeks. In most people the tract has healed and normal life, including exercise, has resumed. I like to review patients around this point, because healing that stalls is much easier to deal with early.

“There is still some discharge at three weeks. Has it failed?” Almost certainly not. A tract that has been tied off or lasered takes time to dry up, and a little serous discharge in the first month is part of normal healing. What worries me is discharge that is increasing, pain that is building, or a swelling that returns - tell us about those rather than waiting for the review date.

Why LIFT or laser rather than a conventional fistulotomy

Fistulotomy - laying the whole tract open and letting it heal from the bottom up - has the highest cure rate of any fistula operation, and for a genuinely low, simple fistula it remains an excellent choice. The difficulty is that it works by cutting through whatever muscle lies over the tract. For a high tract, that means dividing a meaningful part of the sphincter, and the price can be permanent difficulty controlling wind or motion.

LIFT and laser exist to avoid that trade:

• No sphincter muscle is divided, so the risk to continence is very low.
• The wound is small, so healing is quicker and dressings are needed for weeks rather than months.
• Pain is less, and most people are back at work within a week.
• They can be repeated if the fistula recurs, and they do not burn any bridges for a future operation.

The honest counterpoint is that recurrence is more likely than after a fistulotomy. If a sphincter-sparing repair fails, you can be treated again. If your continence is damaged, that is much harder to put right. That is the reasoning behind the choice, and it is the conversation I have with every patient before we decide.

Risks and complications

• Recurrence of the fistula - the commonest problem, and the one to understand before you consent.
• Incomplete healing of the external wound, needing longer dressings or a second look.
• Infection or an abscess forming during healing.
• Bleeding, usually minor.
• Some change in control of wind, which is uncommon with sphincter-sparing techniques and usually temporary when it does occur.
• Pain on passing motion in the first week or two.
• Missed branches of the tract, which can present later as a persistent discharge - a reason MRI matters in complex cases.
• The usual risks of spinal or general anaesthesia, which the anaesthetist will discuss with you.

Alternatives

Seton alone. In some people - particularly those with Crohn disease or a very complex tract - a long-term draining seton is a legitimate treatment in itself rather than a step towards something else. It controls the symptoms without risking the sphincter.

Fistulotomy. The right operation for a low, simple, first-time fistula, with the highest cure rate of all.

Advancement flap. A flap of healthy rectal lining is raised and stitched over the internal opening. Useful for high fistulas and in selected recurrent cases.

Fistula plug or glue. Sphincter-safe and simple, but the results have not been durable enough for these to be a first choice.

Medical treatment of the underlying disease. Where the fistula is due to Crohn disease or tuberculosis, treating that condition is the main work; surgery is limited and carefully timed.

One thing worth saying plainly: a great many people arrive convinced they have piles, because bleeding and discomfort around the back passage feel much the same from the outside. They are different conditions with different treatments - this may help you tell them apart: laser and stapler piles surgery, and when piles are serious enough to see a surgeon. Our general surgery and gastroenterology team will examine you and tell you which it is. You can also see all the procedures we perform.

What it costs

We have not published a fixed price for fistula surgery, because no two fistulas cost the same to treat. What moves the figure is:

• Whether the tract is simple or complex - a single low tract and a branching horseshoe fistula are very different operations.
• Which technique is used - LIFT, laser, flap repair, or a staged seton followed by definitive surgery.
• How long the procedure takes, and whether it is a first operation or a repeat.
• Whether an MRI fistulogram is needed before surgery.
• The type of anaesthesia and the length of your stay.
• Your room category, and whether it is a day-care case or an overnight admission.
• Consumables - the laser fibre, sutures, energy devices and dressings.
• Whether another procedure is done at the same sitting, such as treatment for piles or a fissure.
• Your insurance or TPA cover, and whether the admission is pre-authorised.

Call us on +91-8668954915 and we will give you a written, itemised estimate for your own case before you commit to anything.

Preparing for your surgery

• Bring your old records - the details of any abscess that was drained, previous operation notes, and any scans you have had. These change the plan more than anything else.
• Have the MRI done in advance if it has been advised, and bring the films, not just the report.
• Tell us about bowel symptoms - chronic diarrhoea, blood, weight loss or mouth ulcers may point to Crohn disease, which alters the whole approach.
• Blood thinners need to be discussed well before the date; never stop a heart medicine on your own.
• Stop smoking. Healing in this area is noticeably worse in smokers, and this is one of the few things entirely within your control.
• Fasting. Nothing to eat for six hours and nothing to drink for two hours before surgery, or as the anaesthetist instructs.
• Get the bathroom ready - a small tub or basin for sitz baths, loose cotton underclothes, and a supply of dressings and pads.
• Start the fibre and water now, before the operation, so your first motion afterwards is an easy one.

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A fistula is not a dangerous condition, but it is a wearing one, and people put up with it for far longer than they should out of embarrassment. The surgical gastroenterology team at Shubham Hi-Tech Hospital and Test Tube Baby Centre, Amravati, will examine you properly, tell you whether your fistula is simple or complex, and explain which operation suits it and why. Call +91-8668954915 or get in touch here.

Disclaimer: This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor for guidance specific to your situation.