Hofer - Liebl - Specialists in Visceral Surgery and Proctology
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Hofer - Liebl - Specialists in Visceral Surgery and Proctology
When ointment no longer helps
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
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.
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