90% effective - Side effects - incontinence
Preparation
None No enema due to pain
Anaesthesia
Spinal, epidural, LA or GA
Position
Jack knife or lithotomy
Operative preparation
None
Procedure
Place gauze to keep faecal matter away
Fissure treatment
- Hill-Ferguson’s retractor - inspected
- Fissure is excised and dissolvable suture used to close anoderm
Lateral sphincterotomy
- Incision made in the left lateral position (often a haemorrhoid in this location needs to be excised)
- Exposure of the hypertrophied internal sphincter
- Note the cranial limit of the fissure as this will be the superior extent of the sphincterotomy
- 1/3 to 1/2 should be cut
Closed technique (Notaras)
- The intersphincteric groove is found with a finger
- An 11-blade is inserted vertically into the intersphincteric groove
- The blade is rotate medially
- A finger is placed over the mucosa and the knife pushed up to cut the sphincter
- A finger can then be used to check the depression and check the anal tone. Further cutting can be performed if inadequate
Open technique (Eisenhammer)
- 1cm incision in the line of the IS plane along lower border of internal sphincter
- Gentle dissection of the lower sphincter border and into the intersphincteric plane
- Aim to dissect deep to the level of the proximal extent of the fissure only and superficial to IS to separate from mucosa, aiming to keep mucosa intact
- Usual artery forceps rotate towards canal through level of sphincter to be incised whilist retracting back the mucosa
- Divided sohincter fibres with diathermy
- LA to intersincteric plane
- Closure of incison with 3/0 vicryl suture
- Spongostan dressing