SURGERY FOR ANAL
FISSURES
UNIVERSITY OF HULL
ACADEMIC SURGICAL UNIT
CASTLE HILL HOSPITAL

SURGICAL OPTIONS

ANAL STRETCH

LATERAL SPHINCTEROTOMY

EXCISION

ISLAND FLAP

ROTATION FLAP

AIM OF TREATMENT

HEALING OF THE FISSURE
– RESTORE NORMAL PRESSURE
– RESTORE BLOOD FLOW

MAINTAIN CONTINENCE
– ONLY SURGEONS MAKE PATIENTS
INCONTINENT

ANAL STRETCH
PLEASE
DO NOT DO
(? Balloon dilatation)

ANAL STRETCH

EXCISION +/- SUTURE



UNCOMMON PROCEDURE
FRESHEN EDGES
CLEAN FISSURE BASE

MAY SUTURE CLOSED

DOES NOT TREAT THE CAUSE

? COMBINE WITH BOTOX

LATERAL ANAL
SPHINCTEROTOMY

OPEN TECHNIQUE MOST ACCURATE

IAS ONLY 2mm ACROSS

CUT NO FURTHER THAN DENTATE
LINE

GREAT CARE IN WOMEN

SCAN IF POSSIBLE

LATERAL ANAL
SPHINCTEROTOMY

LATERAL ANAL
SPHINCTEROTOMY

RESULTS

ANAL STRETCH 80 – 90 %

LATERAL SPHINCTEROTOMY
80 – 90 %

EXCISION ?

PROBLEMS

FAECAL INCONTINENCE

INCONTINENCE

INCONTINENCE

ISLAND / V-Y FLAPS
 “ARE NON DESTRUCTIVE”

NEW, VASCULARISED TISSUE

PROMOTE HEALING

ISLAND FLAPS

ISLAND FLAPS

ISLAND FLAPS

ROTATIONAL FLAPS

USING LATERAL SIDE AS A FULCRUM

AIM TO AVOID DONOR SITE
INFECTIONS

Operative technique

Operative technique

Proposed flap

Proposed flap

Rotation and tension free closure

Sutured flap

Questionnaire data
Incontinence Gas
Liquid Stool 1
Solid 0
Before
Surgery
0
Pain
Functional outcome/overall satisfaction
None
Severe
Mild
None
Good
Fair
Poor
4
0
20
17
5
1
4
16
15
1
0
20
1
After
Surgery
0

Fissure/donor site
YES
HEALED
FISSURE
18
HEALTHY
DONOR SITE
19
NO
3
2

Fissure/donor site

Complete resolution 16 patients

No new continence defects

Three recurrent fissures

Two donor site dehiscence
– Fissure fistula complex
– Haemorrhoidectomy and advancement flap

Conclusions

Use of rotation flap is simple, safe and successful

Fewer problems than island flaps

Potential procedure of choice for chronic anal fissures particularly in patients with risk of incontinence

CONCLUSIONS

WARN ABOUT INCONTINENCE

USE LEAST DESTRUCTIVE METHOD

NO LAS IN WOMEN

ROTATIONAL FLAPS ARE LEAST
RISKY

ACTION PLAN FOR
FISSURES

DIETARY CHANGE

CHEMICAL SPHINCTEROTOMY

STILL A PLACE FOR LIS!

ASSESS INCLUDING USS

ROTATION / ISLAND FLAP

? HYPERBARIC OXYGEN

Operative technique

No bowel prep

GA

Single dose of prophylactic antibiotics

Jack-knife position

Edges of fissure lifted

Proposed flap marked

Results

Median hospital stay 2 days (range 1-4)

No post-operative morbidity

Post-operative questionnaire