Open lateral internal sphincterotomy


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To assess the usefulness of open lateral sphincterotomy for chronic anal fissure.
Review of Literature.

Published in: Health & Medicine
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  • few technical points i would like to add.i do transverse incision-identify internal sphincter and ensure that it is cut completely.throughout the procedure surgeons left hand should be in the anal canal to note the margins.posteriorly till healthy fat seen.laterally only mucosa sholud be left between the operating area and the finger. this plane is a remarkably avascular in sphinterotomy, there should be absolutely no bleeding,presence of bleeding indicates that planes have been transgressed.i prefer to leave the wound open as what is important is healing of sphincter, not skin.sphincter healing takes on average 3 months.and after 1 year the remodelling which occurs by fibrosis is limited to minimum.
    next-any chronic fissure is an indication for surgery. presence of skin tag indicates chronic fissure.
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Open lateral internal sphincterotomy

  1. 1. Open Lateral Internal Sphincterotomy <ul><li>Dr. Dayanand I. Nooli </li></ul><ul><li>Dr. Kalpana D. Nooli </li></ul><ul><li>Dr. Rajendra M. Dixit </li></ul><ul><li>KAMAL HOSPITAL </li></ul><ul><li>CHIKKODI-591201 </li></ul>Indian Health Journal
  2. 2. Indian Health Journal
  3. 3. Anal fissure <ul><li>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 ) </li></ul>Indian Health Journal
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  5. 5. Aetiopathology <ul><li>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 . </li></ul><ul><li>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 ) </li></ul>Indian Health Journal
  6. 6. AIM <ul><li>To assess the usefulness of open lateral sphincterotomy for chronic anal fissure. </li></ul><ul><li>Review of Literature. </li></ul>Indian Health Journal
  7. 7. Factors to assess any method of treatment of chronic fissure in ano <ul><li>Relief of pain. </li></ul><ul><li>Incidence of failure or recurrence. </li></ul><ul><li>Incidence of impairment of normal sphincter control. </li></ul><ul><li>Discomfort experienced by the patient. </li></ul><ul><li>Length of time taken for the fissure wounds to heal. </li></ul><ul><li>Number of visits of the patient to hospital .(Ref. 3) </li></ul>Indian Health Journal
  8. 8. Patients and Methods <ul><li>20 patients diagnosed as chronic fissure in ano. </li></ul><ul><li>Study period- January 2010 to August 2010. </li></ul><ul><li>12 were females and 8 males. </li></ul><ul><li>Common Symptoms- Severe pain during defecation, bleeding P.R., constipation, Skin tag etc. </li></ul>Indian Health Journal
  9. 9. Age-Group Indian Health Journal Age group No. of patients 21-30 06 31-40 12 41-50 02
  10. 10. Examination <ul><li>Inspection of perianal area is confirmatory in diagnosis. </li></ul><ul><li>Digital examination is usually not possible because of severe pain. </li></ul>Indian Health Journal
  11. 11. PROCEDURE <ul><li>All patients were given S.A. </li></ul><ul><li>Patient was given lithotomy position. </li></ul><ul><li>Part painted and draped. </li></ul><ul><li>Proctoscopy done to role out other pathology. </li></ul><ul><li>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) </li></ul><ul><li>A Sim’s speculum was inserted </li></ul>Indian Health Journal
  12. 12. PROCEDURE(Contd.) <ul><li>A radial incision 2.5 cm in length was made at the anal verge at 3 o'clock position. </li></ul><ul><li>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). </li></ul><ul><li>The muscle was divided with cautery. </li></ul><ul><li>All skin tags, sentinel piles excised. </li></ul><ul><li>Anal packing done to control bleeding. (Ref. 8,9 ) </li></ul>Indian Health Journal
  13. 13. PROCEDURE - <ul><li>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. </li></ul><ul><li>Conversely, the upper 1/3 of the sphincter must be left intact to preserve the continence of the patient .(Ref. 2) </li></ul>Indian Health Journal
  14. 14. Procedure (Contd.) <ul><li>Primary closure of the incision after LIS is beneficial to achieve early wound healing. </li></ul><ul><li>(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 </li></ul><ul><li>(ii) Primary closure after LIS obliterates the dead space underneath the sphincterotomy site. By this, bleeding associated complications(ecchymosis, hematoma, bleeding) are reduced. </li></ul>Indian Health Journal
  15. 15. A note- <ul><li>After sphincterotomy, the dead space is created :- </li></ul><ul><li> “ 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) </li></ul>Indian Health Journal
  16. 16. Indian Health Journal
  17. 17. Procedure (Contd.) <ul><li>At the completion of sphincterotomy, the anus is covered with a dressing which is secured by T-bandage. </li></ul><ul><li>The patients are advised to open their bowels as soon as they have the inclination .(Ref. 4) </li></ul>Indian Health Journal
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  35. 35. Postoperative care <ul><li>No sitz bath. </li></ul><ul><li>Routine urinary catheterization. </li></ul><ul><li>Catheter and pack removed next day. </li></ul><ul><li>Povidoine-iodine+metronidazole ointment local application. </li></ul><ul><li>Oral antibiotics- ofloxacillin+metronidazole. </li></ul><ul><li>Analgesics, laxatives. </li></ul>Indian Health Journal
  36. 36. No sitz bath because- <ul><li>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) </li></ul>Indian Health Journal
  37. 37. Postoperative results <ul><li>Complete relief of pain. </li></ul><ul><li>3-6 weeks time all fissures healed. </li></ul><ul><li>No evidence of incontinence. </li></ul><ul><li>Follow-up examination- no spasm or stenosis. </li></ul><ul><li>No recurrence of symptoms or of fissure. </li></ul>Indian Health Journal
  38. 38. Complications <ul><li>MINOR </li></ul><ul><ul><li>Wound dehiscense o </li></ul></ul><ul><ul><li>Perianal hematoma 0 </li></ul></ul><ul><ul><li>Itching/pruritus 1 </li></ul></ul><ul><ul><li>Mucous discharge 1 </li></ul></ul><ul><ul><li>Fecal soiling 0 </li></ul></ul><ul><ul><li>Transient gas incontinence 0 </li></ul></ul><ul><li>MAJOR </li></ul><ul><ul><li>Abscess 0 </li></ul></ul><ul><ul><li>Long term occasional impaired continence 0 (Ref. 2) </li></ul></ul>Indian Health Journal
  39. 39. A note- <ul><li>Association of LIS with Hemorrhoidectomy frequently resulted in defects of continence. (17%) –(Ref. 6) </li></ul>Indian Health Journal
  40. 40. Sphincterotomy should not be performed for- <ul><li>Superficial fissures. </li></ul><ul><li>Minimal stenosis. </li></ul><ul><li>Minimally symptomatic chronic fissures. </li></ul><ul><li>Ultralow Hirschsprung’s or Chron’s disease. </li></ul><ul><li>Refractory constipation. </li></ul><ul><li>Complex anal fistulas. (Ref. 2) </li></ul>Indian Health Journal
  41. 41. Review of Literature(Nelson RL) Operative procedures for fissure in ano(1) <ul><li>Objectives- To determine the best technique for fissure surgery. </li></ul><ul><li>Search strategy-The Cochrane Central Register of Controlled Trials and MEDLINE(1965-2008). 23 publications. (1650 patients) </li></ul><ul><li>Data collection and Analysis- The two most commonly used end points were persistence of fissure and postoperative incontinence of flatus. </li></ul>Indian Health Journal
  42. 42. Operative Techniques <ul><li>Anal stretch. </li></ul><ul><li>Open lateral sphincterotomy. </li></ul><ul><li>Closed lateral sphincterotomy. </li></ul><ul><li>Posterior midline sphincterotomy. </li></ul><ul><li>Dermal flap coverage. </li></ul><ul><li>Anterior levatoroplasty. </li></ul><ul><li>Fissurectomy. </li></ul>Indian Health Journal
  43. 43. Anal dilatation-12 pts. Presenting with fecal incontinence- NATURE OF STRUCTURAL INJURY <ul><li>Using anorectal physiology and anal endosonography after anal dilatation, there was a disruption (11) and extensive fragmentation (10) of internal anal sphincter. </li></ul><ul><li>3 pts had defects of the external anal sphincter. </li></ul><ul><li>“ Thus anal endosonography has demonstrated, extensive damage to delicate sphincter mechanism in patients who developed incontinence after anal dilatation” (Ref. 7) </li></ul>Indian Health Journal
  44. 44. Normal Internal Sphincter Indian Health Journal
  45. 45. Single Break after anal stretch Indian Health Journal
  46. 46. Fragmentation of IS after anal stretch Indian Health Journal
  47. 47. IS appearance after LIS Indian Health Journal
  48. 48. Author’s Conclusions <ul><li>Anal stretch and posterior midline internal sphincterotomy should probably be abandoned. </li></ul><ul><li>Open and closed lateral internal sphincterotomy appear to be equally efficacious. </li></ul><ul><li>More data needed for- posterior internal sphincterotomy, anterior levatoroplasty, wound suture. </li></ul>Indian Health Journal
  49. 49. Author’s Conclusions(Contd.) <ul><li>The sphincterotomy should be performed to the level of dentate line or to achieve an anal canal aperture of 30 mm. </li></ul><ul><li>The issue of incontinence after fissure surgery, could be resolved by more rigorous pre-surgical continence assessment. </li></ul>Indian Health Journal
  50. 50. CONCLUSIONS <ul><li>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) </li></ul>Indian Health Journal
  51. 51. References <ul><li>1. Nelson RL. Operative procedures for fissure in ano(Review) The Cochrane Library 2010, Issue 1 </li></ul><ul><li>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 </li></ul><ul><li>3.Hawley P.R. The treatment of chronic fissure in ano. Br J Surg 1969;56:915-918 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>Indian Health Journal
  52. 52. References <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>Indian Health Journal
  53. 53. Indian Health Journal