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Fissure Surgery

Anal fissure tears or ulcers develop in the opening skin of the anus. The tear is in the squamous epithelium extending into the anal verge from the dentate line. Bowel movements involve severe, sharp, searing pains around the anus. The pain lasts for several hours after the bowel movement. The internal and external anal sphincter muscles control the opening and closing of the anus. External anal sphincters can be relaxed and tensed but the internal anal sphincters tend to go into a spasm due to the pain in the fissure. This increases the pressure around the anus. Quality of life is affected due to the pain.

Generally a lateral internal sphincterotomy is done for anal fissures. The hypertrophied internal sphincter is cut to release the tension and allow the fissure to heal on its own. Elective fissurectomy is performed along with the lateral sphincterotomy. In such cases the portion of the internal sphincter is not included along with the excision. Prior to the procedure, the colon, rectum and anus are inspected completely with a proctosigmoidoscopy.

Technique

Lateral internal sphincterotomy

  • Local anaesthesia is administered using 0.5% bupivacaine with epinephrine

  • Positioning of the patient – prone jackknife

  • The buttocks are strapped apart for visualization

  • Preparation of the surgical field – with betadine or chlorhexidine solution

  • Visual field will include the anus after draping

  • The anus and anoderm are inspected using an anoscope

  • A Pratt bivalve speculum is used to examine the anal pathology

  • The valve is rotated to the left lateral position

  • A scalpel is used to make a linear incision from the dentate line

  • The dissection exposes the internal sphincter and part of the external sphincter

  • Hemostasis is achieved with electrocautery

  • The full thickness of the internal sphincter is divided distally from the level of the dentate line

  • The incision is closed using 3-0 chromic catgut running sutures

Closed lateral internal sphincterotomy – This procedure involves the usage of a no.11 scalpel. The intershpinteric groove is palpated manually and a blind lateral subcutaneous internal anal sphincterotomy is carried out. The blade is rotated medially and drawn out cutting the internal anal sphincter. Care is taken to preserve the anal mucosa overlying the sphincterotomy. The anal mucosa is palpated after the knife is removed.

Lateral sphincterotomies are complex procedures which require advanced knowledge of the anorectal anatomy. Dr. Deepak is an experienced surgeon performing such surgeries for over a decade now.

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