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For large bundles, an operating anoscope (i.e., Fansler) can be used to
see the prolapsing tissue. A Hill-Ferguson anoscope can also facilitate
pre-resection reconnaissance and to check for bleeding after excision.
Leave at least one cm between the hemorrhoidal columns that are
excised to help avoid anal stenosis.
A medium Hill-Ferguson anoscope can be placed at the completion to
help ensure anal stenosis is avoided.
Suggested Readings
Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and
Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon
Rectum. 2018;61(3):284-292.
Sohn VY, Martin MJ, Mullenix PS, Cuadrado DG, Place RJ, Steele SR. A comparison of open versus
closed techniques using the Harmonic Scalpel in outpatient hemorrhoid surgery. Mil Med.
2008;173(7):689-692.
Chapter 9
Anal Fissures: Lateral
Internal Sphincterotomy
JAMES S. WU
Perioperative Considerations
An anal fissure is a longitudinal tear in the anoderm of the anal canal that
exposes the internal sphincter and allows sphincter spasm when the area is
stimulated.
The majority of fissures are located in the midline (posterior > anterior) of
the anal slit (Fig. 9-1). Fissures located at lateral locations are atypical and
are associated with HIV infection, Crohn disease, syphilis, tuberculosis,
and hematologic malignancy.
FIGURE 9-1 Fissures most commonly occur at the posterior and anterior ends of the
anal slit (arrows).
Acute fissures (present for <8 weeks) appear as a longitudinal tear.
Fissures present for >8 weeks are classified as chronic; these may show a
“sentinel” skin tag at the distal end of the fissure and exposed internal anal
sphincter muscle.
First-line treatment generally is nonoperative and includes warm sitz
baths, psyllium fiber, topical anesthetics, topical nitrates, and topical
calcium channel blockers. Botulinum toxin injection and balloon dilation
are alternate therapies.
Operative treatments include lateral internal sphincterotomy, debridement,
and anoplasty.
History
A common presentation of anal fissure includes anal pain and bright red
anal bleeding associated with defecation.
Other benign causes of anal pain include abscess, external hemorrhoid
thrombosis; levator spasm; and coccygodynia.
Bleeding also can arise from internal hemorrhoids, neoplasm, and
inflammatory bowel disease.
Examination
Gentle lateral traction on the perianal skin may demonstrate a “sentinel”
pile and fissure.
If a fissure is not seen, gentle palpation of the distal anal canal with a welllubricated finger confirms the presence of a fissure and its location.
Because the internal anal sphincter is hypertonic and the area of the fissure
is tender, anoscopy may not be tolerated and can be omitted if the
diagnosis is established without it. Examples of fissure, shown in Figure
9-2, demonstrate a variety of appearances.
FIGURE 9-2 A. Chronic posterior anal fissure with exposed internal anal sphincter
(IAS). B. Chronic anterior anal fissure (arrows) with exposed IAS. C. Three simultaneous
posterior and posterolateral anal fissures, arrowheads depict the fissures. D. Acute anal
fissure caused by diarrhea during bowel preparation and seen during colonoscopy with
narrow-band imaging. E. Simultaneous anterior and posterior anal fissures.
LATERAL INTERNAL SPHINCTEROTOMY
Perioperative Considerations
Patient characteristics that might contraindicate division of the internal
sphincter are considered (Table 9-1).
TABLE 9-1 Preexisting conditions that might contraindicate division of the internal anal
sphincter
Preexisting fecal incontinence
Prior obstetric injury to the anal sphincter
Prior anal sphincterotomy
Prior anal fistulotomy
Sterile Instruments/Equipment
Betadine solution for skin preparation
Needle driver
Operating anoscope (lighted preferred; eg, Hill-Ferguson)
Lidocaine with epinephrine 0.5% and injection equipment for anal block
#15-blade (optional)
Electrocautery
Tonsil clamp
Forceps
3-0 Vicryl or chromic suture
Technique
The operation may be done under local or general anesthesia in the prone
jackknife or lithotomy positions using open or closed techniques.
The following examples were done under general anesthesia in the prone
jackknife position over an orthopedic frame with the buttocks separated
with 2-in adhesive tape using an open technique.
The prone position was chosen because it provides a clear view of the
operative field and allows an assistant to stand on the opposite site of the
table.
A preoperative bowel preparation was not administered. The perianal skin
and anus were prepared with topical antiseptics.
The anal orifice is enlarged with an operating anoscope. The presence of a
fissure or fissures is/are confirmed (Fig. 9-3). The internal sphincter
muscle is palpated.
FIGURE 9-3 Anoscopy with a lighted operating anal retractor identifies the fissure and
places the internal sphincter on stretch so that it can be palpated beneath the skin
(arrowheads).
Sphincterotomy in the anterior or posterior positions may result in a
“keyhole” deformity that may lead to incontinence. Therefore, the
anoscope is positioned to expose the lateral internal sphincter muscle.
Access to the internal anal sphincter is obtained through an incision in the
intersphincteric groove (Fig. 9-4).
FIGURE 9-4 A chronic posterior anal fissure with sentinel pile and exposed internal
sphincter. Hypertonicity of the internal sphincter accentuates the groove between the
internal and external sphincters.
The internal sphincter is isolated from the anoderm medially and the
intersphincteric groove laterally using a hemostat. The distal internal
sphincter is grasped with an Allis clamp, punctured with a curved tonsil
clamp, and elevated into the operative field (Fig. 9-5).
FIGURE 9-5 A. The white internal anal sphincter muscle has been grasped with an
Allis clamp. B. The distal internal sphincter muscle is punctured with a tonsil clamp and
elevated into the operative field.
The white fibers of the internal sphincter are divided under direct vision
with electrocautery (Fig. 9-6). The internal sphincter is divided for the
length of the fissure.
FIGURE 9-6 A. The internal anal sphincter (IAS) muscle is divided with electrocautery
under direct vision. B. The cut edges of the distal IAS are displayed.
Hemostasis is obtained, and the wound is left open or closed loosely. Tight
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