Open lateral internal sphincterotomy

Open Lateral Internal Sphincterotomy Dr. Dayanand I. Nooli Dr. Kalpana D. Nooli Dr. Rajendra M. Dixit KAMAL HOSPITAL CHIKKODI-591201 Indian Health Journal

Anal fissure It 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 ) Indian Health Journal

Aetiopathology The 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 ) Indian Health Journal

AIM To assess the usefulness of open lateral sphincterotomy for chronic anal fissure. Review of Literature. Indian Health Journal

Factors to assess any method of treatment of chronic fissure in ano Relief 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) Indian Health Journal

Patients and Methods 20 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. Indian Health Journal

Age-Group Indian Health Journal Age group No. of patients 21-30 06 31-40 12 41-50 02

Examination Inspection of perianal area is confirmatory in diagnosis. Digital examination is usually not possible because of severe pain. Indian Health Journal

PROCEDURE All 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 inserted Indian 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) Indian Health Journal

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. Indian Health Journal

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) Indian Health Journal

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) Indian Health Journal

Postoperative care No sitz bath. Routine urinary catheterization. Catheter and pack removed next day. Povidoine-iodine+metronidazole ointment local application. Oral antibiotics- ofloxacillin+metronidazole. Analgesics, laxatives. Indian Health Journal

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) Indian Health Journal

Postoperative results Complete 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. Indian Health Journal

Complications MINOR Wound dehiscense o Perianal hematoma 0 Itching/pruritus 1 Mucous discharge 1 Fecal soiling 0 Transient gas incontinence 0 MAJOR Abscess 0 Long 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) Indian Health Journal

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) Indian Health Journal

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. Indian Health Journal

Operative Techniques Anal stretch. Open lateral sphincterotomy. Closed lateral sphincterotomy. Posterior midline sphincterotomy. Dermal flap coverage. Anterior levatoroplasty. Fissurectomy. Indian Health Journal

Anal dilatation-12 pts. Presenting with fecal incontinence- NATURE OF STRUCTURAL INJURY Using 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) Indian Health Journal

Normal Internal Sphincter Indian Health Journal

Single Break after anal stretch Indian Health Journal

Fragmentation of IS after anal stretch Indian Health Journal

IS appearance after LIS Indian Health Journal

Author’s Conclusions Anal 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. Indian Health Journal

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. Indian Health Journal

CONCLUSIONS Open 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) Indian Health Journal

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 Indian Health Journal

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 Indian Health Journal

Open lateral internal sphincterotomy

More Related Content

What's hot

Viewers also liked

Similar to Open lateral internal sphincterotomy

More from Indian Health Journal

Recently uploaded

In this document

Open lateral internal sphincterotomy