Why the Thiersch Operation is Outmoded

Historically, the attempt to improve quality of life for those suffering from fecal incontinence has led to frequent interest and disinterest in various surgical approaches. One such is Thiersch’s operation, formerly the favored treatment for anal pain and bleeding or prolapse. While it did have some uses as a surgical tool, it is mostly obsolete. Why? With developments in medical technology, particularly neuromodulation, it is now an outmoded, and often less effective or problematic, intervention compared to the contemporary technique, SNS.

What Problem was the Thiersch Procedure Attempting to Cure?

TheThiersch operation was designed to correct rectal prolapse or severe fecal incontinence, by encircling the hemorrhoids and anal fissures with a synthetic or biologic sling (often a net-like material). It was to physically support the anus and narrow the opening just slightly enough to assist the patient in stool holding. In essence, it formed an artificial sphincter to compensate for what the body couldn’t do naturally.

Why Did It Fall Out of Favor?

The approach was a last-ditch therapy for patients who were too frail or too ill from other medical conditions for more invasive surgery. But it also came with a series of caveats. Erosion, secondary to surrounding tissue, infection, and faecal seepage, were the most common complications. And in some cases, the tightening went too far — leading to continuous leakage — or too soft, resulting in constipation and pain. The process also didn’t address the root cause — whether related to a neurologic issue, a pelvic muscle problem or something else — that caused someone to be incontinent, so results were unpredictable, and the fix was temporary.

Why SNS Is Really Any Better?

The latest therapies, such as sacral nerve neuromodulation, address the cause of incontinence, including the faulty nerve signals between the brain, spinal cord, and the pelvic floor. Instead of squeezing the anus, SNS relies on a tiny implanted device that delivers mild electrical signals to the sacral nerves. These are the nerves that control the bladder and bowels. By altering the nature of firing of such nerves, patients usually are able to resume voluntary control of their bowel movements.

During clinical trials of SNS, greater than 90% of patient’s experienced relief of their symptoms during the testing period. That is a whole different ballgame than the hit-or-miss outcome of the Thiersch approach. The SNS trial phase is very low-impact, providing patients with a sneak peek of how effectively therapy will work for them before making the more permanent decision to have it implanted. If the patient has greater than 50% relief during the trial, they will elect for implantation.

What Are the Dangers of Each Procedure?

There are no truly ‘risk-free’ surgeries; however, complication rates with SNS are much lower than with the Thiersch technique. Erosion, infection and pain were common with the mesh utilized in the Thiersch sling. In contrast, the SNS system is implanted far from the pain in rectum after pooping, and adjustment or the cessation of stimulation does not require further operations. And if the patient knows right away that it’s not right for them, if it is ineffective or uncomfortable, it’s completely reversible — a safety net that just didn’t exist with the older methods.

Managing SNS as A Lay Person

Patients who are implanted with the SNS device report that it is a convenient and life-changing option. The feeling is often described as a fine tapping or pulsing, and settings can be easily adjusted via a handheld remote. It,’s not just about skirting embarrassing accidents; many also get fewer infections and cleaning is more straightforward when your bowels listen. It is the latter which works with the Thiersch because in the few cases, where a cure has been effected, namely through SNS, natural function follows unlike in Thersch, which was frequently nothing more than a mechanical bypass.

Why Do Most Colles’ Fracture Now Treated by SNS Instead of Thiersch?

The reason behind moving away from the Thiersch is simple: it just works. Whereas the Thiersch sling attempted to overcome a physical weakness with a mechanical remedy, SNS seeks to address this failure on a functional, biologic basis. It is about the way the nerves talk to muscles, returning control from inside rather than attempting to brace the anatomy from the outside.

Secondly, SNS can be attempted temporarily prior to definitive implant to assure the patient and physician that the outcome be favorable. The results of the Thiersch procedure were permanent — and when they didn’t work, the patient was frequently left with painful complications and few options.

A Shift in Surgical Philosophy

The cessation of the Thiersch flap is also a reflection of a broader change of surgical philosophy. Contemporary medicine prefers reversible and adjustable treatments that aim to restore physiology rather than crude anatomical immobilisation. The better we understand the neurology involved in continence, the clearer it is that it’s better to address nerve signaling than to try to physically “tighten up” the anus.

Conclusion

The Thiersch and similar operations are no longer popular because they do not treat the cause of the fecal incontinence, produce frequent complications, and produce very inconsistent results. The current standard of care, sacral nerve stimulation, is a safe, effective, and reversible therapeutic solution that complements rather than opposes the body’s natural activity.