Hofer - Liebl - Specialists in Visceral Surgery and Proctology

Anal fissure surgery

When ointment no longer helps

Anal fissure: When does surgery have to be performed?

Have you had recurrent pain or bleeding during bowel movements for years? You can literally feel the sensitive anal skin tearing or it feels like you have broken glass in your stool? When these symptoms first appeared, you used an ointment or changed your diet to a high-fibre diet and things quickly got better. Maybe the problem even disappeared on its own. 

But the discomfort keeps coming back or doesn't go away completely. At first the pain was forgotten after a few minutes, now it torments you for half the day. Even if you have very soft stools, you no longer feel well. Skin flaps or growths have appeared on the anus. In women, it is not uncommon for swelling to occur synchronously with menstruation.

All these symptoms indicate that the anal fissure has become chronic. It can't go on like this? By now you know every ointment that has helped someone, all the "stool softeners" and have treated yourself with anal dilators or fissure pens. Many things have helped somehow, but not in the long run?

Then it is time to face the facts. The likelihood that your anal fissure will still heal on its own or with some conservative treatment. A wound has become a chronic and scarring inflammation, similar to an ulcer. Niches or pockets have formed at the edges of the wound where intestinal bacteria can take hold even with the best hygiene.

Surgery is the only thing that can help. But at the word operation all alarm bells are ringing. Won't the pain get worse with a surgical wound? How long will you be absent after an operation?) Is there a risk of stool retention weakness (incontinence)? Which surgical technique do the experts recommend(AWMF 2020 expert guideline on anal fissure, patient guideline understandable for medical laypersons)?

What is standard: Europe vs. USA

Fissurectomy or sphincterotomy?

Opinions differ widely as to the best surgical technique. The theory of "sphincter spasm" and the theory of local infection clash irreconcilably, and the dividing line is between Europe and the Anglo-American world.

Excision of the anal fissure (fissurectomy according to Gabriel)

The so-called fissurectomy (Gr. ἐκτομή, "cutting out") removes the fissure and the surrounding inflammatory and scarred tissue in a triangular shape with a shallow incision. It dates back to the British surgeon W. B. Gabriel, one of the pioneers of rectal surgery at the famous St. Marks Hospital in London. What is the point of converting a small wound into a large wound?

The purpose of fissurectomy is to convert a deep, tight tear into a shallow wound and eliminate any pocket or niche formation. The removal of scarring can improve the elasticity of the anus. Therefore, the wound after a properly performed fissurectomy will often appear unexpectedly large to the layperson. Misconceived restraint with "freshening" of the wound edges will not solve the problem of colonization of bacteria of the intestinal flora in the depth of the wound.

The wound will heal from the depth and long-term freedom from symptoms can be expected. This procedure should always be performed under anesthesia (general or spinal anesthesia) for patient comfort alone, but also to provide the best possible overview. It would be too easy to overlook an inflamed anal gland (cryptitis), a hemorrhoid interfering with healing, or an underlying anal fistula under local anesthesia.

Short check fissurectomy conventional
Recommended treatmentyes, guideline
Availabilitynationwide (Germany)
Treatment is offered by usyes
Statutory health insurance
Integrated care
Outpatient/Inpatientboth, depending on pre-existing conditions
AnesthesiaGeneral anesthesia, spinal anesthesia
Time20 - 30 min
Repeatable feasibleyes, rarely necessary
Scalpel and electric scalpel (diathermy)

Most surgeons use the electric scalpel (diathermy) for this operation in order to avoid or immediately stop bleeding. However, electrical cutting causes unwanted heat to build up in adjacent tissues, which can have an unfavorable effect on wound healing. Excessive use of electric current can lead to charring (carbonization) of the tissue, as a result of which fine structures can no longer be optimally delineated.

Success rates of between 70 and 90% are found in studies. Fissurectomy is a standard benefit of public health insurance. An additional benefit of the combination with an injection of botulinum toxin to improve the results is not proven. The rate of continence restriction is reported to be 4.9-11% after fissurectomy.

You want to know more? On the Thieme Verlag site you will find a sample of the informed consent form for anal fissure surgery.

(Partial) transection of the internal sphincter (lateral sphincterotomy, LIS).

In this operation, the internal sphincter ring is cut laterally ("laterally"). A distinction is made between open sphincterotomy, in which the corresponding sphincter function is first exposed, and closed sphincterotomy, in which the transection is performed without direct vision, controlled only by the palpating finger. The sphincter is typically transected from the inferior border of the sphincter to the level of the linea dentata. This corresponds to approximately ½ - ¾ of the extent of the internal sphincter! As an alternative, limited splitting down to the level of the fissure base is reported.

The 2017 American Society of Colon and Rectal Surgeons guideline and a 2018 American review call lateral sphincterotomy the gold standard in the treatment of chronic anal fissure. The high cure rate of 95% is listed as justification for this view. At the same time, limitation of control for intestinal gas (incontinence for flatus) in 5-30% and fluid (soiling) in 20% and for formed stool in 1% of operated patients is mentioned with a number of cases in the study of 4500 patients. Other investigators found incontinence of varying degrees in up to 60%. 

In accordance with the current German guideline Anal Fissure, I cannot share this opinion. I consider the rate of incontinence, which will probably even increase with longer observation time, i.e. aging patients, to be unacceptable and therefore do not perform this operation.

Surgery by means of displacement flap: Anal Advancement Flap

In reconstructive surgery, flapplasty is the transfer of autologous tissue to cover a defect. A connection of the flap to the circulatory system must be maintained (pedicled flap) or newly created (free flap).

Since the open wound treatment after fissurectomy entails impairment for the patient due to moisture and wound pain, and not infrequently requires 3-6 months for complete healing, the desire to close the wound in some form is understandable. However, wound healing of sutured wounds in the bacteria-rich region of the anus is not without problems, and a simple surgical suture would be under tension. Therefore, attempts are made to achieve healing by relocating well-vascularized tissue into the wound. Various shapes of flap have been described, including triangular, rhombus, V-Y ("house"), and oval. A broad-based, triangular-shaped flap has proven most effective.

Healing rates are reported in a