Introduction
Lateral internal sphincterotomy is an operation for chronic anal fissures. The internal sphincter refers to a group of muscles in the anal region. The term ‘sphincterotomy’ describes a cut made in the muscle to relieve pressure. After trying all other remedies, the surgical procedure is taken as a last resort.
What Is an Anal Fissure?
An anal fissure is formed when there is a sudden involuntary contraction of the internal sphincter muscle (a muscle around the anus). The contraction lowers the blood flow, and healing is delayed. The recovery of the anal fissure is promoted by making a cut on the sphincter muscle that increases the blood supply to that region.
What Are the Causes of Anal Fissures?
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Passing dry and hard stools can tear the lining of the anus leading to fissures.
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Tight internal sphincter muscle has an increased risk of forming fissures.
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Inflammatory bowel diseases cause inflammation and ulcers in the digestive tract.
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Trauma to the anal region.
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Tumors.
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Infections.
What Are the Symptoms of Anal Fissures?
Anal fissures usually cause symptoms that are not tolerable. They include:
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Sharp pain that can last for fifteen minutes to several hours or days.
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Bleeding from the fissures.
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A lump may develop near the anal fissure.
When Is Lateral Internal Sphincterotomy Recommended?
The surgery is suggested as a treatment modality for:
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Patients with symptomatic anal fissures for more than eight weeks.
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Patients undergoing any other surgery in the anal region.
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Anal fissures that are untreatable by other conservative methods.
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Patients with severe muscle contraction in the internal sphincter.
In general, medical treatment is first tried for three months. If there is no relief, then a surgical procedure is recommended.
When Is Lateral Internal Sphincterotomy Not Recommended?
Patients who cannot control the urge to pass out stools are not advised for surgery as it may further complicate the condition.
What Are the Benefits of Lateral Internal Sphincterotomy?
The patient has many benefits from the surgery.
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The surgical option has a higher success rate than the conservative treatment.
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The recovery is faster.
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The recurrence rate is low.
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The surgery is not very technique sensitive.
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When other methods have failed to work, surgery is used as an alternative treatment which is found to be successful.
How to Prepare the Patient for the Surgery?
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First, a written consent form is obtained from the patient.
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The patient is advised to avoid eating food the night before surgery and to drink water before reaching the hospital.
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If the patient is under any other medications like blood thinners and vitamin E, they are advised to stop it a week before surgery with the physician’s consent.
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A complete medical history of the patient is taken.
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Allergies to anesthesia or any medication are noted to avoid any complications.
How Is Lateral Internal Sphincterotomy Done?
The surgery takes only about fifteen to thirty minutes to complete.
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Local anesthesia is sufficient. General anesthesia can be used if the patient is uncooperative or anxious.
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The patient is positioned with the knee and chest down with the buttocks exposed.
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The surgery is of two types - open and closed.
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In the open type, an anoscope (a small plastic or metal tube slightly larger than the finger) is inserted into the anal sphincter. A skin incision is made, and the internal sphincter muscle is exposed and divided.
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In the closed type, the incision is made between the inner and outer sphincter muscles. Then a scalpel is introduced through the incision, and a cut is made to divide the internal sphincter muscle.
The cut in the internal sphincter muscle will increase the blood supply, lower the pressure, and relieve spasms.
What Are All Non-surgical Treatment Options Available?
Apart from the surgical treatment, which is the last resort, all other non-surgical options are first tried. They are:
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Stay hydrated by drinking plenty of water.
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Eating fiber-rich foods.
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Exercise regularly.
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When there is an urge to pass out stool, do not try to control it. The stool must be passed out as and when required.
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Avoid using wet wipes with fragrances as they may irritate the skin.
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After passing out the stool, the back region can be soaked in warm water for some time to relax the muscles involved.
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Laxatives (drugs to treat hard stools) are prescribed to make the stool soft and easy to pass. The medication is started at a low dose and then increased gradually.
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If there is severe pain, painkillers can be given to provide symptomatic relief.
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Glyceryl trinitrate, an ointment, is used for at least six weeks. It improves blood flow and decreases the pressure within the anal canal. This helps to ease the symptoms, and healing occurs faster. The ointment is not recommended for pregnant or breastfeeding women and children.
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Botulinum toxin is a poison but is medically effective in many treatments at small doses. It is given as an injection and works by paralyzing the muscles around the anus. Paralysis helps in preventing muscle spasms and lowers the pain. The patient injected with botulinum toxin will have its effect for about three months, by which the fissures will also heal by that time.
What Are the Complications Involved With Lateral Internal Sphincterotomy?
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The general complications associated with the surgery like bleeding, allergic reactions, pain, and infection.
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The complications of this surgery include the inability to control the urge to pass out stool, farting, and difficulty in passing urine.
How Is the Recovery After the Surgery?
The pain decreases gradually after the surgery. The complete recovery usually happens in about six weeks. Some instructions to be followed after discharge include
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Maintaining a high-fiber-rich diet and drinking plenty of water.
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Avoid heavy exercises.
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Soak the back region in warm water for a few minutes and then dry the area with a towel.
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In about one to two weeks, the patient can resume normal activities.
Conclusion
Lateral internal sphincterotomy is a simple outpatient procedure to treat patients with anal fissures that are unresolved even after medical therapy, like ointments and Botox. Proper health maintenance and follow-up are necessary for sound healing and resume normal functioning. Hence, the surgery is safe, effective, and has a good success rate postoperatively.
