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Lateral Internal Sphincterotomy
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SamanthaL.Savitch, RichardE.Burney, andPasithornA.Suwanabol
1 Indications
Anal ssure, or ssure-in-ano, is dened as a shallow, linear tear in the transitional
squamous epithelium of the anal canal (i.e., anal mucosa), distal to the dentate line.
The most common symptom is pain, which is usually characterized as severe and
sharp during defecation due to repeat injury and may last for hours after. In addition, the patient may report throbbing pain or spasm for prolonged periods as a
result of internal anal sphincter spasm leading to difculty fully evacuating. Bright
red bleeding can occur, which is usually seen on toilet tissue, although some
patients will describe dripping into the toilet bowl [1]. Such symptoms can be distressing or even disabling among some. Patients with a history of constipation, anal
pain, and bright red blood per rectum should raise suspicion for an anal ssure.
Often, patients will report an episode of severe constipation or diarrhea as the precipitating event.
Anal ssures occur most frequently in the posterior midline in general (Fig.1),
with anterior ssures occurring most commonly among females [2]. Accounting for
only 3% of all ssures, concomitant posterior and anterior ssures are termed “kissing” ssures (Fig.2). Chronic ssures (those lasting >6weeks) may be accompanied by a small tuft of hypertrophied tissue, or sentinel tag, on the adjacent skin, and
internal sphincter muscle bers may be visible at the base of the ssure [1]. It should
be noted that a tuft of granulation tissue mimicking a sentinel tag is indicative of a
subcutaneous anal stula originating in the ssure. While rare, ssures can develop
in a lateral location, which along with multiple ssures should arouse suspicion of
inammatory bowel disease or, less commonly, other diagnoses such as HIV/AIDS,
S. L. Savitch · R. E. Burney · P. A. Suwanabol (*)
Department of Surgery, University of Michigan, Ann Arbor, MI, USA
e-mail: sasavitc@med.umich.edu; rburney@med.umich.edu; pasuwan@med.umich.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_33
389© The Author(s), under exclusive license to Springer Nature
390
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Fig. 1 Posterior anal
ssure with exposed
internal sphincter muscle
bers
Fig. 2 “Kissing” ssures
(i.e., anterior and posterior
midline ssures)
S. L. Savitch et al.
tuberculosis, syphilis, or anal carcinoma [1]. The diagnosis of most anal ssures can
be made by history alone. On physical exam, simple effacement of the anus everts
the anal canal epithelium and exposes the ssure. Anoscopy is not recommended in
those with known ssures and/or who are unable to tolerate a digital rectal exam. It
should be noted that patients who have persistent symptoms and are unable to tolerate a full anorectal examination (encompassing external visualization and palpation,
digital rectal exam, and anoscopy) should undergo an exam under anesthesia to rule
out other concerning pathologies.
While there is no consensus about the etiology of acute anal ssures, the most
widely accepted hypothesis is trauma during defecation leading to anal irritation
and tearing [1, 3, 4]. The resultant ssure causes internal anal sphincter spasm perpetuating a cycle of pain, fear of defecation, constipation, and further sphincter
spasm [5, 6]. Chronic ssures may persist due to local ischemia secondary to hypertonicity of the internal anal sphincter [4].
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2 Preoperative Assessment andCare
Prior to considering operative intervention, patients should undergo a trial of conservative management consisting of sitz baths and use of a stool bulking agent such
as psyllium ber, which resolves most acute ssures [6–10]. Some patients may
obtain additional symptomatic relief from a topical muscle relaxing agent, such as
nitroglycerine or calcium channel blocker (e.g., diltiazem, nifedipine) ointment, or
botulinum toxin injection. The goal of these therapies is to decrease internal sphincter spasm. These therapies may improve healing, but success rates vary [11], and
they are not a substitute for conservative measures. Fissures that persist for longer
than 6weeks despite these approaches or that are associated with intolerable pain
are candidates for surgical intervention [1, 3, 12].
Lateral internal sphincterotomy (LIS) is the preferred surgical procedure for the
treatment of chronic anal ssures [13–15]. Other, older procedures, such as anal
dilation, have lower success rates and worse outcomes compared to LIS [13–15].
LIS, either open or closed technique, is normally associated with rapid healing and
improved symptoms, and long-term success rates exceed 90% [13, 14, 16–18]. LIS
has the advantage of being performed in the ambulatory surgery setting with minimal morbidity. However, minor incontinence of stool or gas can occur in 2.5–25%
of patients if insufcient internal sphincter remains after sphincterotomy and is a
major concern in utilizing this technique as rst-line treatment [13, 17–19]. Limiting
LIS to the length of the ssure, or tailored sphincterotomy, as opposed to extending
to the dentate line (i.e., classic sphincterotomy), signicantly decreases the risk of
incontinence, though symptom relief may be inferior to classic LIS [19–22].
The critical element in the pre-operative assessment of a patient with anal ssure
is measurement of sphincter length. This can be done in the ofce by digital rectal
examination. In order to maintain continence, it is recommended that no more than
25% or 1cm of internal anal sphincter be cut [21, 23]. As such, LIS should not be
pursued in patients with a short sphincter length or pre-existing fecal incontinence
[1]. Additionally, as vaginal delivery often leads to sphincter loss, LIS should be
avoided in women who have not nished childbearing due to the higher risk of
future incontinence.
3 Positioning andAnesthesia
Bowel preparation is not required for the procedure. The choice of positioning and
anesthesia is at the discretion of the surgeon and anesthesiologist as well as patient
preference. General anesthesia is frequently employed, although these operations
can be performed under local anesthesia with or without intravenous sedation, or
regional anesthesia [24]. In the opinion of many surgeons, prone-jackknife position
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gives the best exposure for anorectal surgery, especially if one is teaching. However,
this may not be optimal among those with cardiopulmonary comorbidities or morbid obesity, or those who are in late pregnancy [24]. In such instances, lithotomy
position is a reasonable alternative. The buttocks may be held apart with tape for
better exposure. Local anesthesia using 1% lidocaine with epinephrine can be inltrated at the intersphincteric groove for both analgesia and reduction of bleeding.
Alternatively, a pudendal block using 1% lidocaine with epinephrine mixed 1:1 with
0.25% bupivacaine may be used.
4 Description oftheProcedure
Lateral sphincterotomy can be done by either an open or closed technique, with
similar results [13, 16–18], though the open technique may allow for better visualization in a teaching setting. Following visual inspection, external palpation, and
injection of local anesthetic, a digital rectal exam is performed rst to initiate
sphincter relaxation and ensure accommodation of the anoscope or speculum [25].
A well-lubricated anoscope or speculum is then gently inserted, and all four quadrants of the anal canal and distal rectum are inspected. The authors prefer a Pratt
bivalve speculum, which facilitates identication and palpation of the intersphincteric groove by its greater exposure (versus a Hill Ferguson retractor).
In the open technique, the internal sphincter is exposed through a small, radial
incision in the anoderm over the intersphincteric groove. Fibers of the supercial
subcutaneous sphincter of the external anal sphincter may be visualized and are
divided with a Metzenbaum scissors, exposing the intersphincteric groove. The
internal sphincter muscle bers should be readily identied. They are picked up
with DeBakey forceps and divided with scissors (Fig.3). The traditional approach
is to divide the internal sphincter to the level of the dentate line. However, we prefer
a tailored approach, which is to divide the internal anal sphincter only to the level of
the apex of the ssure to reduce the risk of incontinence. Needlepoint electrocautery
Fig. 3 Open LIS. Image
courtesy of Mitchell
J.Mead, BSA
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393
is used to achieve hemostasis. The skin is closed with 3-0 or 4-0 absorbable suture.
No special dressing is needed other than a gauze pad.
In a closed sphincterotomy, the internal sphincter muscle is divided without
exposing it. Instead, division of the muscle is guided by the surgeon’s index nger.
After the intersphincteric groove has been identied, the index nger of the nondominant hand is inserted into the anal canal. A #11 scalpel is inserted into the
groove with the blade tangential to the bers of the internal sphincter (Fig.4a). The
blade is advanced to the level of the apex of the ssure, and the scalpel is rotated 90°
toward the mucosa (Fig.4b). The knife is then advanced toward the inserted index
nger with a sawing motion until the internal sphincter is transected without penetrating the mucosal surface. Any remaining bers are released when the area is
palpated after the scalpel has been removed. This may be repeated on the opposite
side of the anal canal if a deciency cannot be palpated. Pressure may be applied to
control any bleeding. No special dressing is needed.
Fig. 4 Closed LIS. (a) A
#11 scalpel is inserted into
the groove with the blade
tangential to the bers of
the internal sphincter. (b)
The blade is advanced to
the level of the apex of the
ssure, and the scalpel is
rotated 90° toward the
mucosa. (Images courtesy
of Mitchell J.Mead, BSA)
a
b
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S. L. Savitch et al.
Whichever technique is chosen, the patient may be discharged home on the day
of the procedure and should be instructed to continue conservative measures. Pain
can be managed with non-steroidal anti-inammatory medications alone and opioids are avoided. Dressing over the wound can be removed on postoperative day 1.
5 Special Postoperative Considerations
Postoperatively, all patients should be instructed to continue a ber supplement.
This will keep the stools soft, reduce pain, and aid healing. Warm sitz baths can be
used for comfort and to aid perianal hygiene.
References
1. Davids JS, Hawkins AT, Bhama AR, Feinberg AE, Grieco MJ, Lightner AL, etal. The American
Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anal
ssures. Dis Colon Rectum. 2023;66(2):190–9.
2. Hananel N, Gordon PH.Re-examination of clinical manifestations and response to therapy of
ssure-in-ano. Dis Colon Rectum. 1997;40:229–33.
3. Scott-Connor CEH.Lateral internal sphincterotomy for chronic anal ssure. In: Scott-Conner
C, editor. Chassin’s operative strategy in general surgery. NewYork: Springer; 2001. p.546–7.
4. Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal
blood ow. The vascular pathogenesis of anal ssures. Dis Colon Rectum. 1994;37:664–9.
5. Keighley M, Williams N, Church JM, Scholeeld J, Pahlman L, Scott N.Fissure-in-ano. In:
Keighley M, Williams N, Church JM, Scholeeld J, Pahlman L, Scott N, editors. Surgery of
the anus, rectum & colon. Philadelphia: Saunders Elsevier; 2008. p.383–411.
6. Jensen SL.Treatment of rst episodes of acute anal ssure: prospective randomised study of
lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. Br Med J
(Clin Res Ed). 1986;292:1167–9.
7. Gough MJ, Lewis A.The conservative treatment of ssure-in-ano. Br J Surg. 1983;70:175–6.
8. Shub HA, Salvati EP, Rubin RJ.Conservative treatment of anal ssure: an unselected, retrospective and continuous study. Dis Colon Rectum. 1978;21:582–3.
9. Jensen SL.Maintenance therapy with unprocessed bran in the prevention of acute anal ssure
recurrence. J R Soc Med. 1987;80:296–8.
10. Gupta P. Randomized, controlled study comparing sitz-bath and no-sitz-bath treatments in
patients with acute anal ssures. ANZ J Surg. 2006;76:718–21.
11. Bobkiewicz A, Francuzik W, Krokowicz L, etal. Botulinum toxin injection for treatment of
chronic anal ssure: is there any dose-dependent efciency? A meta-analysis. World J Surg.
2016;40:3064–72.
12. Floyd ND, Kondylis L, Kondylis PD, Reilly JC.Chronic anal ssure: 1994 and a decade laterare we doing better? Am J Surg. 2006;191:344–8.
13. Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S.Operative procedures for
ssure in ano. Cochrane Database Syst Rev. 2011;11:CD002199.
14. Saad AM, Omer A.Surgical treatment of chronic ssure-in-ano: a prospective randomised
study. East Afr Med J. 1992;69:613–5.
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15. Ram E, Vishne T, Lerner I, Dreznik Z.Anal dilatation versus left lateral sphincterotomy for
chronic anal ssure: a prospective randomized study. Tech Coloproctol. 2007; https://doi.
org/10.1007/s10151- 007- 0373- 7.
16. Kortbeek JB, Langevin JM, Khoo RE, Heine JA. Chronic ssure-in-ano: a randomized
study comparing open and subcutaneous lateral internal sphincterotomy. Dis Colon Rectum.
1992;35:835–7.
17. Arroyo A, Pérez F, Serrano P, Candela F, Calpena R.Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal ssure:
prospective randomized study of clinical and manometric longterm results. J Am Coll Surg.
2004;199:361–7.
18. Wiley M, Day P, Rieger N, Stephens J, Moore J.Open vs. closed lateral internal sphincterotomy for idiopathic ssure-in-ano: a prospective, randomized, controlled trial. Dis Colon
Rectum. 2004;47:847–52.
19. Elsebae MM.A study of fecal incontinence in patients with chronic anal ssure: prospective,
randomized, controlled trial of the extent of internal anal sphincter division during lateral
sphincterotomy. World J Surg. 2007;31:2052–7.
20. Menteş BB, Ege B, Leventoglu S, Oguz M, Karadag A.Extent of lateral internal sphincterotomy: up to the dentate line or up to the ssure apex? Dis Colon Rectum. 2005;48:365–70.
21. Murad-Regadas SM, Fernandes GO, Regadas FS, etal. How much of the internal sphincter
may be divided during lateral sphincterotomy for chronic anal ssure in women? Morphologic
and functional evaluation after sphincterotomy. Dis Colon Rectum. 2013;56:645–51.
22. Littlejohn DR, Newstead GL.Tailored lateral sphincterotomy for anal ssure. Dis Colon
Rectum. 1997;40:1439–42.
23. Billantino A, Izzo D, Iacobellis F, Maglio M, Grillo M, Vicenzo L, etal. Safety and effectiveness of minimal sphincterotomy in the treatment of female patients with chronic anal ssure.
Updat Surg. 2021;73(5):1829–36.
24. Ternent CA, Fleming F, Welton ML, Buie WD, Steele S, Rafferty J.American Society of
Colon and Rectal Surgeons Clinical Practice Guideline for Ambulatory Anorectal Surgery. Dis
Colon Rectum. 2015;58(10):915–22.
25. Suwanabol PA, Maykel JA. Patient evaluation. In: Beck D, Steele S, Wexner
S, editors. Fundamentals of anorectal surgery. Cham: Springer. https://doi.
org/10.1007/978- 3- 319- 65966- 4_2.
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Part VII
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Hernia Surgery
Lichtenstein Tension-Free Open Inguinal
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Hernia Repair
ZacharyN.Weitzner, DavidC.Chen, andIanT.MacQueen
1 History
Inguinal hernias have been described in the literature as early as 1552 in ancient
Egypt [1]. Franz Hesselbach dened inguinal anatomy in the late 1700s, and
repair had been described as early as 1716. However, it wasn’t until 1887 when
Eduardo Bassini described suturing of the conjoint tendon to the transversalis
fascia that the importance of restoring strength of the inguinal oor was recognized. Suture repair of the inguinal oor in various methods was the standard of
care for treatment of inguinal hernias until the 1980s, when it was recognized that
approximating weakened tissue under tension is a frequent cause of hernia
recurrence.
Various prosthetic materials were experimented with for reinforcement of the
inguinal oor, but none demonstrated safe and effective proles until the introduction of polypropylene mesh, which does not generate a signicant inammatory
reaction from surrounding tissue and thus allows tissue ingrowth and incorporation
of mesh into the soft tissue of the inguinal oor.
Drs. Irving Lichtenstein, Alex Schulman, and Parviz Amid rst described the
Lichtenstein tension-free hernioplasty in 1986 at the Lichtenstein Hernia Institute in
Los Angeles, CA [2]. With careful evaluation of outcomes, the Lichtenstein Hernia
Z. N. Weitzner
Department of Surgery, David Geffen School of Medicine at the University of California,
Los Angeles, CA, USA
e-mail: zweitzner@mednet.ucla.edu
D. C. Chen · I. T. MacQueen (*)
Department of Surgery, Lichtenstein-Amid Hernia Clinic, David Geffen School of Medicine
at the University of California, Los Angeles, CA, USA
e-mail: dcchen@mednet.ucla.edu; imacqueen@mednet.ucla.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_34
399© The Author(s), under exclusive license to Springer Nature
400
https://t.me/med1917
Institute was able to demonstrate the benets of tension-free hernia repair with synthetic mesh in terms of recurrence and complications. By placing mesh between the
transversalis fascia and the external oblique aponeurosis, the mesh is secured in
place without tension by normal intraabdominal pressure. This pressure helps to
prevent recurrence and strengthens the repair [3]. In contrast, intraabdominal pressure in tissue-based repairs results in increased tension along the suture line of
the repair.
In the 1990s, Dr. Parviz Amid published several modications to the Lichtenstein
tension-free hernia repair [3]. These changes to the technique were aimed at decreasing recurrence, chronic pain, and other complications. These modications are
included in the technical steps of the operation described in this chapter.
Z. N. Weitzner et al.
2 Anatomy
The inguinal canal is a passageway that allows the spermatic cord in males or round
ligament in females to pass from the peritoneum into the groin through the abdominal wall. It spans from the deep ring to the supercial ring, and is bounded anteriorly
by the external oblique aponeurosis, inferiorly by the inguinal ligament, posteriorly
by the transversalis fascia and transversus abdominis aponeurosis, and superiorly by
the internal oblique muscle and transversus abdominis. The oor of the canal is
formed by the shelving edge of the inguinal ligament laterally and the lacunar ligament medially. Knowledge of the anatomy of the innervation of the groin is crucial
to safe inguinal hernia repair. Identication of the ilioinguinal nerve, iliohypogastric
nerve, and genital branch of the genitofemoral nerves allows surgeons to protect
these nerves from damage intraoperatively. The ilioinguinal nerve joins the spermatic cord near the opening of the deep ring, after which it can be found adjacent to
the cord within the canal. The iliohypogastric nerve typically pierces the internal
oblique muscle cephalad to the cord and courses between the external and internal
oblique aponeuroses. The genital branch of the genitofemoral nerve is found in the
spermatic cord. Hesselbach’s triangle is the site of direct hernias, lateral to the rectus abdominis but medial to the epigastric vessels and bounded inferiorly by the
inguinal ligament. Hernias lateral to this triangle arise from the deep ring and are
known as indirect hernias.
3 Pre-operative Management
Patients seen in the Lichtenstein-Amid Hernia Clinic are screened for hernia type
and comorbidities. Patients are risk stratied and optimized prior to surgery, as hernia repair is an elective procedure that should be conducted in the best conditions
possible. Patients are encouraged to quit smoking preoperatively and diabetic
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