Open lateral internal sphincterotomy

Open Lateral Internal Sphincterotomy

Dr. Dayanand I. NooliDr. Kalpana D. NooliDr. Rajendra M. Dixit

KAMAL HOSPITAL CHIKKODI-591201

Indian Health Journal


Anal fissureIt is an ulcer in the squamous epithelium of

the anus located just distal to the muco-cutaneous junction and usually in the posterior midline.(Ref. 1)



AetiopathologyThe fissure might occur as a result of local

trauma, the initial lesion being a tear in the anoderm caused by the passage of hard stool.

Sphincteric spasm may well be activated by the pain of this overstretching and the spasm may result in tissue ischemia with consequent smooth muscle fibrosis.(Ref. 2)


AIMTo assess the usefulness of open lateral

sphincterotomy for chronic anal fissure.Review of Literature.


Factors to assess any method of treatment of chronic fissure in anoRelief of pain.Incidence of failure or recurrence.Incidence of impairment of normal sphincter

control.Discomfort experienced by the patient.Length of time taken for the fissure wounds

to heal.Number of visits of the patient to hospital.

(Ref. 3)


Patients and Methods20 patients diagnosed as chronic fissure in

ano.Study period- January 2010 to August 2010.12 were females and 8 males.Common Symptoms- Severe pain during

defecation, bleeding P.R., constipation, Skin tag etc.


Age-GroupAge group No. of patients

21-30 06

31-40 12

41-50 02


ExaminationInspection of perianal area is confirmatory in

diagnosis.Digital examination is usually not possible

because of severe pain.


PROCEDUREAll patients were given S.A.Patient was given lithotomy position.Part painted and draped.Proctoscopy done to role out other pathology.Infiltration of a few milliliters of saline containing

1/40,000 adrenaline under the mucosa and between the internal and external sphincter muscles in the left lateral position aided the submucous dissection and also helped to control bleeding (Ref. 3)

A Sim’s speculum was insertedIndian Health Journal

PROCEDURE(Contd.)A radial incision 2.5 cm in length was made

at the anal verge at 3 o'clock position. Intersphincteric groove is felt and a artery

forceps was pushed in the groove, and was delivered out from the medial side of wound, (up to dentate line).

The muscle was divided with cautery.All skin tags, sentinel piles excised.Anal packing done to control bleeding. (Ref.

8,9 )Indian Health Journal

PROCEDURE -The entire thickness of the lower 2/3 of the

internal sphincter must be divided because any fibers left intact would go into intense compensatory spasm, thus leading to recurrence of the fissure.

Conversely, the upper 1/3 of the sphincter must be left intact to preserve the continence of the patient.(Ref. 2)


Procedure (Contd.)Primary closure of the incision after LIS is

beneficial to achieve early wound healing. (i) It is known that wounds primarily closed are healed more quickly than the wounds left to secondary healing, because less granulation tissue is required in primary closure and epithelization is completed earlier

(ii) Primary closure after LIS obliterates the dead space underneath the sphincterotomy site. By this, bleeding associated complications(ecchymosis, hematoma, bleeding) are reduced.


A note-After sphincterotomy, the dead space is

created :- “by the contraction of the

muscular ends in opposite directions that are under high resistance after the incision of sphincter, a dead space reaching to a few cubic centimeters in volume develops underneath the incision” (Ref. 11)



Procedure (Contd.)At the completion of sphincterotomy, the

anus is covered with a dressing which is secured by T-bandage.

The patients are advised to open their bowels as soon as they have the inclination.(Ref. 4)



















Postoperative careNo sitz bath.Routine urinary catheterization.Catheter and pack removed next day.Povidoine-iodine+metronidazole ointment

local application.Oral antibiotics- ofloxacillin+metronidazole.Analgesics, laxatives.


No sitz bath because- Sitz baths improve patient satisfaction in

acute anal fissures. However, the healing and overall pain relief was not significant enough to attract attention. It was also found to be associated with adverse effects in few patients. (Ref. 5)


Postoperative resultsComplete relief of pain.3-6 weeks time all fissures healed.No evidence of incontinence.Follow-up examination- no spasm or stenosis.No recurrence of symptoms or of fissure.


ComplicationsMINOR

Wound dehiscense oPerianal hematoma 0Itching/pruritus 1Mucous discharge 1Fecal soiling 0Transient gas incontinence 0

MAJORAbscess 0Long term occasional impaired continence 0

(Ref. 2)Indian Health Journal

A note-Association of LIS with Hemorrhoidectomy

frequently resulted in defects of continence. (17%) –(Ref. 6)


Sphincterotomy should not be performed for-Superficial fissures.Minimal stenosis.Minimally symptomatic chronic fissures.Ultralow Hirschsprung’s or Chron’s disease.Refractory constipation.Complex anal fistulas. (Ref. 2)


Review of Literature(Nelson RL)Operative procedures for fissure in ano(1)Objectives- To determine the best technique

for fissure surgery.Search strategy-The Cochrane Central

Register of Controlled Trials and MEDLINE(1965-2008). 23 publications. (1650 patients)

Data collection and Analysis- The two most commonly used end points were persistence of fissure and postoperative incontinence of flatus.


Operative TechniquesAnal stretch.Open lateral sphincterotomy.Closed lateral sphincterotomy.Posterior midline sphincterotomy.Dermal flap coverage.Anterior levatoroplasty.Fissurectomy.


Anal dilatation-12 pts. Presenting with fecal incontinence- NATURE OF STRUCTURAL INJURYUsing anorectal physiology and anal

endosonography after anal dilatation, there was a disruption (11) and extensive fragmentation (10) of internal anal sphincter.

3 pts had defects of the external anal sphincter.

“Thus anal endosonography has demonstrated, extensive damage to delicate sphincter mechanism in patients who developed incontinence after anal dilatation” (Ref. 7)


Normal Internal Sphincter


Single Break after anal stretch


Fragmentation of IS after anal stretch


IS appearance after LIS


Author’s ConclusionsAnal stretch and posterior midline internal

sphincterotomy should probably be abandoned.

Open and closed lateral internal sphincterotomy appear to be equally efficacious.

More data needed for- posterior internal sphincterotomy, anterior levatoroplasty, wound suture.


Author’s Conclusions(Contd.)The sphincterotomy should be performed to

the level of dentate line or to achieve an anal canal aperture of 30 mm.

The issue of incontinence after fissure surgery, could be resolved by more rigorous pre-surgical continence assessment.


CONCLUSIONSOpen lateral internal sphincterotomy is

treatment of choice for chronic anal fissure and can be done effectively and safely with acceptable low rate of complications. (Ref.10)


References 1. Nelson RL. Operative procedures for fissure in ano(Review) The

Cochrane Library 2010, Issue 1 2. Romano G., Rotandano G., Santangelo M., Esercizio L. A critical

appraisal of pathogenesis and morbidity of surgical treatment of chronic anal fissure. J Am Coll Surg 1994; 178:600-604

3.Hawley P.R. The treatment of chronic fissure in ano. Br J Surg 1969;56:915-918

4. Notaras M.J. The treatment of anal fissure by lateral subcutaneous internal sphincterotomy- a technique and results. Br J Surg 1971;58:96-100

5. Gupta P.J. Randomized controlled study comparing sitz bath and no sitz bath treatments with acute anal fissure. ANZ J Surg 2006;76:718-21

6. Walker W.A., Rothenberger D.A. Goldberg S. M. Morbidity of internal sphincterotomy for anal fissure and stenosis. Dis. Colon Rectum, 1985;28:832-835


References 7. Speakman C.T.M., Burnett M.A., Kamm M.A. and Batram C.I. Sphincter injury after anal

dilatation demonstrated by anal endosonography. Br J Surg 1991;78:1429-1430 8. Jensen S.L.,Lund F.,Nielsen O.V. and Tange G. Lateral sucutaneous sphincterotomy versus

anal dilatation in the treatment of fissure in ano in outpatients: a prospective randomised study. B M J 1984;289:528-530

9 Arroyo A., Perez F.,Serrano P., Candela F., Calpena R. Open versus closed sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: Prospective randomized study of clinical and manometric longterm results. Am J Surg 2004;199:361-367

10. Liratzopoulos N., Efremidou E. I., Papageorgiou M.S., Kouklakis G., Moschos J., Manolas J., Minopoulos G. J. Lateral subcutaneous internal sphincterotomy in the treatment of chronic anal fissure in ano: our experience in 246 patients. J Gastrointestin Liver Dis 2006;15:143-147

11. Aysan E., Aren A., Ayar E., A preospective ,randomized, controlled trial po primary wound closure after lateral sphincterotomy. Am J Surg 2004; 187:291-294



Health & Medicine

Open lateral internal sphincterotomy