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 dataBefore Surgery

After Surgery

Incontinence Gas 0 0

Liquid Stool 1 1

Solid 0 0

None 20 20

Pain Severe 17 1

Mild 4 4

None 0 16

Functional outcome/overall satisfaction

Good 15

Fair 5

Poor 1

Fissure/donor site

YES NO

HEALED FISSURE

18 3

HEALTHY DONOR SITE

19 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