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 treatment | yes, guideline |
| Availability | nationwide (Germany) |
| Treatment is offered by us | yes |
| Statutory health insurance | |
| Private/self-payer | |
| Integrated care | |
| Outpatient/Inpatient | both, depending on pre-existing conditions |
| Anesthesia | General anesthesia, spinal anesthesia |
| Time | 20 - 30 min |
| Repeatable feasible | yes, rarely necessary |
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 study from 2021 (full text with surgical images) up to 96.7% with complete healing after one month in almost 50% of cases. Whether these excellent results can be reproduced in further studies remains to be seen.
Further developments of proven technology
Laser surgery and microsurgery
The operation with the diode - laser (980 nm Intros Lina or 1479 nm Biolitec Ceralas) has a number of advantages compared to the standard operation. The use of magnifying glasses, which make the smallest details visible during the operation, can further increase the accuracy of the operation.
- Tissue protection: There is no current flow through the tissue and we observe significantly less thermal collateral damage, i.e. the impairment of neighboring tissue by heat, than with the electric scalpel. Wound healing begins earlier and the scars become smooth and elastic.
- Precision: Laser energy has a very focused effect and thus allows unrivalled accuracy in the incision. Because minor bleeding is automatically stopped, the surgeon has an optimal view of the treatment area.
- Promotion of wound healing: The healing-promoting stimulation of the surrounding tissue comparable to the effect in Low Level Laser Therapy (LLLT) by the laser light is a "desired side effect" of laser surgery
| Quick check fissurectomy laser | |
|---|---|
| Recommended treatment | yes |
| Availability | Specialized institutions |
| Treatment is offered by us | yes |
| Statutory health insurance | |
| Private/self-payer | |
| Integrated care | |
| Outpatient/Inpatient | With us only outpatient |
| Anesthesia | General anesthesia, spinal anesthesia |
| Time | 20 - 30 min |
| Repeatable feasible | yes, rarely necessary |
For this reason, we have been using laser fissurectomy with the diode laser for almost a decade. It includes the
- Peeling of the anal fissure
- Converting a deep, tight wound into a smooth, shallow wound
- Removal of all pathological growths
- Dissolving scarring and restoring the elasticity of the anus
- Sealing the wound edges to reduce bleeding
- Open wound treatment to prevent infections
- Fine tissue examination to exclude malignant degeneration
Laser surgery anal fissure: surgical procedure
A surgical video of a laser fissurectomy will follow here shortly:
Laser surgery anal fissure: after surgery
The wound is not sutured to avoid additional pain, infection and scar tissue. The external wound may appear quite large to the patient, but the secretion drainage it provides is critical for healing. After defecation, the wound is cleaned only with running water in the shower, by a sitz bath, or simply with a damp toilet paper or baby wipe on the way.
After the procedure, the patient is unable to work for about two weeks. Normally, healing begins from the 10th postoperative day. Now the secretion of wound fluid and wound pain also decrease. Towards the end of the third week, the restrictions are usually hardly present. Only in a few isolated cases was the scar not completely healed until after a year.
Literature on anal fissure - surgery
- Gabriel WB (1930) The treatment of pruritus ani and anal fissure. Br Med J 2:311-312
- Hancke, E., Suchan, K., & Voelke, K. (2021). Anocutaneous advancement flap provides a quicker cure than fissurectomy in surgical treatment for chronic anal fissure-a retrospective, observational study. Langenbeck's Archives of Surgery, 406(8), 2861-2867..
- Pappas, A., & Christodoulou, D. (2017). A novel minimally invasive treatment for anal fissure. Annals of Gastroenterology, 30(5), 583-583.
- Patel, S., Oxenham, T., & Praveen, B. (2011). Medium-term results of anal advancement flap compared with lateral sphincterotomy for the treatment of anal fissure. International Journal of Colorectal Disease, 26(9), 1211-1214.
- Stewart, D., Gaertner, W., Glasgow, S., Migaly, J., Feingold, D., & Steele, S. (2017). Clinical Practice Guideline for the Management of Anal Fissures. Diseases of the Colon & Rectum, 60(1), 7-14.
- Theodoropoulos, G., Spiropoulos, V., Bramis, K., Plastiras, A., & Zografos, G. (2015). Dermal Flap Advancement Combined with Conservative Sphincterotomy in the Treatment of Chronic Anal Fissure. The American Surgeon, 81(2), 1