What Is an Anal Fissure?
An anal fissure is a common benign condition that affects the rectal and anal region in adults and children It is a painful linear tear on the posterior anoderm that extends the cephalad to the dentate line. Pain ranges from mild to severe and pain commonly persists for 15 to 30 minutes. More significant pain is caused b the exposed internal anal sphincter that frequently spasms. In prolonged conditions, tissues become hypertrophied leading to non-healing anal fissures.
There are several medical therapies including slaves, topical nitroglycerine, and fiber that aids in the spontaneous closure of disease. Surgical therapies include fissurectomy, advancement flaps, botulinum toxin injections, and lateral anal sphincterotomy. Surgical intervention is indicated for chronic fissures that fail to heal by medical therapy.
What Are the Symptoms of Anal Fissure?
Anal fissures cause sharp pain during bowel movement. This can last from 15 minutes to several hours. Other symptoms are:
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Painful and visible crack on the skin surrounding the anus.
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Lumps and skin tags on the surface near the anal fissure.
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Bloody painful stools.
What Is Anal Sphincterotomy?
Anal sphincterotomy is also called lateral internal sphincterotomy. It is a type of treatment used to treat individuals who suffer from anal fissures. Anal fissures tears and break the skin of the anal canal. Anal sphincterotomy is the last resort for anal fissures. This is used when the conditions fail to resolve by stool softeners, a high-fiber diet, or botox first. If the symptoms worsen anal sphincterotomy is offered.
What Are the Indications of Anal Sphincterotomy?
Anal sphincterotomy is indicated in individuals who fail at least six weeks of conservative medical management. In most cases, individuals go to medical management for at least one to three months. If this fails, surgery is the only option left. The individuals who are eligible candidates for surgery must have good fecal continence before the procedure so the risk of postoperative fecal incontinence is reduced.
What Are the Contraindications of Anal Sphincterotomy?
Individuals with poor anal incontinence are not appropriate candidates for this procedure. Atypical anal fissure location is fully evaluated before any surgical interventions, any complicated location candidates are not recommended for this surgery.
What Is Done Prior to the Procedure Anal Sphincterotomy?
Sphincterotomy is a minor surgery, individuals need to follow certain instructions that the healthcare provider provides. For administering GA (general anesthesia), restriction on food and drinking is done a night prior to the surgery. Blood thinners and other medications that may affect blood clotting need to be stopped for some days prior to the surgery. It is important to keep the healthcare provider informed about the current medications that are being taken.
Individuals would not be able to drive back home on their own so they need some help to accompany them. A detailed medical history, drugs, supplements, and medication taken are recorded.
What Is the Technique Used in Anal Sphincterotomy?
The individual undergoing the surgery is positioned as per the surgeon's preference. The individual is draped and prepped for the procedure. A Hill- Ferguson retractor or an anoscope is inserted and the canal is inspected for any gross pathology. The fissure or hemorrhoid present is excised and removed. An absorbable suture is then used on reapproximated anal mucosa. The procedure can either be continued by an open fashion or closed fashion technique.
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Open Fashion: Radial-oriented incision over the inter sphincteric groove is made through the anoderm, which exposes internal anal sphincter muscle fibers. A hemostat or similar instrument is used to elevate the external anal sphincter. Using electrocautery to the level of the dentate line this muscle is divided. Adequate hemostasis is used to prevent any postoperative bleeding complications. The site is left open to let it heal by second intention or closed by an absorbable suture.
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Closed Fashion: In this technique, 11- a blade scalpel is inserted in the anal canal is inserted into inter sphincteric plane. The blade is removed medially dividing the internal sphincter. The incision is left open for healing by secondary intention.
How Is It to Recover With Anal Sphincterotomy?
Recovering from this surgery normally takes about six weeks for the anus to fully heal, most individuals can resume their normal activities including work within one to two weeks after surgery. Pain from anal fissures before surgery disappears within a few days of having an anal sphincterotomy. It is normal to experience pain during bowel movements, which reduces to a great extent after the surgery. Things that can help aid in the recovery are:
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Try to walk a little each day after the surgery.
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Eat a high-fiber diet.
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Get plenty of rest.
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Drink plenty of fluids.
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Shower bath, as usual, pat dry anal area after a shower.
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If struggling with constipation the patient must ask the healthcare provider to give a mild laxative and stool softener.
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Instructions as to when to drive again from the healthcare provider have to be followed.
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Take prescribed pain medications.
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Take a sitz bath (sitting around 10 cm of warm water daily and after bowel movements until the pain in the anal area subsides).
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Try passing stools in a squatting position this will help in passing stools easily.
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Instead of toilet paper using baby wipes is recommended to avoid further irritation to the anus.
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Avoid the usage of fragranced soaps.
What Are the Complications Associated With Anal Sphincterotomy?
The main complication associated with anal sphincterotomy is anal incontinence. Around 50 percent of individuals experience transient incontinence, this is the inability to control gas to loss of formed stool resulting in spiling. Anal incontinence resolves in major cases. The rate of major incontinence is an involuntary loss of feces is less than two percent. Experts suggest limiting sphincterotomy to the length of the fissure, which reduces the risk of incontinence. Sometimes other complications associated are an increased risk for non-healing fissures and recurrent fissures. Other minor complications are bleeding, infection, fistula development, pain and discomfort, trouble passing stools, clotting, reduced quality of life, and inability to control gas and bowel movements.
Conclusion
Anal fissures lead to poor quality of life due to inadequate and inappropriate treatment. Primary care is always necessary and the individual should be referred to a colorectal surgeon, because if the condition is left untreated it may lead to enormous morbidity. This condition is together well managed by an interprofessional team including a general surgeon, dietitian, gastroenterologist, and colorectal surgeon. Appropriate treatment is required for anal fissures in adults that would prevent fecal incontinence.
