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17 Role ofLasers inPilonidal Sinus
Fig. 17.8
Postoperative wound after 1 week. (d) Complete healing of the wound after 2 weeks
17.17.1 Opinion
VALAPS is a minimally invasive procedure with
good results in pilonidal sinus disease. Formation
of a large wound secondary to removal of the primary opening is common. The best results are
achieved with hemoglobin spray and PHMB
Amnion Chorion granules. The same can be
injected into the sinus tract.
(a) Presence of primary pit in anococcygeal region. (b) Pit excision done using skin biopsy forceps. (c)
Recurrence may be due:
(a) Omission of the tracts.
(b) Infection.
(c) Dead and necrotic tissue—Recurrence
might be triggered by the collection of
dead or necrotic tissue in the intergluteal
cleft, poor hygiene, or excessive
sweating.
(d) Midline suture—A suture placed in the
midline is under signicant tension.
17.18 Your Queries, My Answers
(e) Depth of natal cleft—One of the promi-
nent reasons for recurrence is the deep
1. Why recurrence after Pilonidal sinus
surgery?
“The term ‘recurrence’ is used when symptoms of
the disease reappear after complete wound healing” [55]
(f) Inappropriate wound care.
natal cleft.
Recurrence in individuals with excisional wounds is also caused by poor
wound management and a lack of depilation [56].
References
295
2. Is there a role of Vacuum-Assisted Closure
(VAC) in pilonidal sinus?
VAC after pilonidal sinus excision reduces
the healing time and promotes wound closure.
In a study, Tomasz Banasiewiz etal. found that
VAC treatment reduces wound healing time,
postoperative pain, and job absenteeism [57].
3. What is the role of pit excision in pilonidal
sinus?
The term “pit” refers to a small opening in
the natal cleft through which hair can enter.
The pits are seen in the midline and are treated
by excision. These pits may form the primary
root of infection or entry point of the hair.
4. Is there any role of laser removal of hair in
pilonidal sinus treatment?
Entrapped hair in the pilonidal sinus cavity
remains the primary etiologic factor in the
formation of the disease. Keeping the area
free from hair can prevent a recurrence.
Therefore, shaving the natal cleft is advised as
a routine, postoperatively. Some authors do
recommend laser epilation.
5. Is there the role of FiXcision in pilonidal
sinus surgery?
Sometimes I wonder, can xcision be used
in treating pilonidal sinus tracts, especially
with secondary openings? FiXcision is an
instrument that is routinely used in coring out
the stula tracts. A xcision instrument measuring 3–4 mm in diameter can be used to
core out the pilonidal sinus tracts. The advantage of the coring of the pilonidal sinus tract is
that all the hair and necrotic material can be
removed. The procedure is minimally invasive and looks promising.
Take-Home Message
The video-assisted laser ablation of the pilonidal
sinus (VALAPS) technique is viable for managing the pilonidal sinus. It allows the surgeon to
examine the sinus tract directly, and the hair,
which is the primary cause of pilonidal sinus disease, can be removed under vision. Laser ablation helps to ablate the necrotic material and
shrink the tract. Low postoperative discomfort
and a quick return to work are advantages of this
technique. Results so far look promising.
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Role ofLasers inAnal Fissures
“Such extreme pain in the patient like no other with such tiny spatial dimensions”
Peters, 1920
18
Key Concepts
• An anal ssure is a linear tear extending from
the mucocutaneous junction to the dentate
line.
• An anal ssure may be acute or chronic,
depending upon the duration.
• The majority of anal ssures are either posterior or anterior midline.
• An acute anal ssure can be treated with topical application and dietary modications.
• The gold standard for treating ssures is the
“lateral internal sphincterotomy.”
• Using lasers to treat anal ssures involves cutting the internal anal sphincter.
18.1 Introduction
A linear tear in the anal canal that may stretch
from the mucocutaneous junction to the dentate
line is known as an anal ssure [1]. It is a painful
anorectal condition predisposed to nonhealing
and persistence [2]. Anal ssures are usually the
result of constipation and diarrhea. Despite being
a painful condition, its etiopathogenesis remains
obscure [3].
18.2 Historical Aspect
Anal ssure was rst mentioned in 1689 by Louis
Lemonnier in “Traité de la stule de l’anus ou du
fondement” [4] In 1818, Boyer rst described the
treatment of anal ssure by sphincterotomy [3].
Later in 1824 Raphael B.Sabatier described anal
ssures in his “De la Médecine opératoire” [4].
In 1920 Peter described this as a severely painful
condition in which the pain is not only restricted
to the anal region but also radiates to the back [4].
18.3 Epidemiology
It is common in both sexes and affects people of
all age groups [5]. Women are most affected in the
childbearing age or at parturition. Chaudhary etal.
in a study, found that 18 percent of patients with
anorectal symptoms had anal ssures [6]. The
prevalence of 1.1/1000 persons a year equates to a
lifetime risk of 7.8%, indicating that anal ssures
are common [7]. Anterior anal ssures affect
women more than men, approximately 25%:8%
[8]. Approximately 235000 new cases of anal ssures are reported in U.S every year and 40% of
them persist for months and even years [9].
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
K. Gupta, Lasers in Proctology, https://doi.org/10.1007/978-981-19-5825-0_18
299
300
18.4 Etiology ofAnal Fissure
The etiology of the ssure depends upon whether
the ssure is primary or secondary.
The causes of a primary ssure include:
• Diarrhea
• Passage of hard stools
• Injury due to trauma or anal sex
• Vaginal delivery [10]
A secondary ssure may be due to:
18 Role ofLasers inAnal Fissures
• Lund etal. in 1996 considered constipation as one of the major causes of anal
ssures [10].
• Elía Guedea M et al. in 2008, considered bariatric surgery in obese patients
to cause anal ssures [14].
• Garg P. in 2010 identied a water stream
in a bidet-toilet as a source of anterior
ssure-in-ano [15].
• Inammatory bowel diseases like Crohn’s
[10]
• Granulomatous diseases like tuberculosis,
sarcoidosis
• Surgical procedures in the anorectal region
• Malignancy
• Infections like HIV and syphilis [10]
18.5 Risk Factors
• Women in adolescence and childbearing age
• Constipation
• Low-ber diet
• Obesity
Literature Digging into Various Causes of
Anal Fissure
• Delley, in 1855 described that during
childbirth, as the head of the fetus
advances, the perineum is pushed back,
which causes lengthening of the anal
opening resulting in anal ssure. Injury to
the anus can be caused by enemas, cannulas, and an unnatural sexual urge [11].
• Rick, in 1924 listed hemorrhoidal dis-
ease, burns, rashes, sweat, and fecal
remains as the causes of anal ssure [12].
• Willemsen, in 1958, described iron de-
ciency as one of the reasons for the formation of anal ssures, similar to the
formation of angular stomatitis [13].
18.6 Pathophysiology ofAnal
Fissure
Straining during defecation, trauma, and passage
of hard stool can lead to tearing. Once there is
tearing of anal canal mucosa (anoderm), there is
pain and internal anal sphincter spasm. A high
resting pressure of the anal canal develops, causing increased anal tone. As a result, the blood
ow to the local area is reduced, leading to ischemia and poor healing. This results in a vicious
cycle, and the ssure does not heal till the cycle is
broken, as shown in Table18.1 [16].
Other theories which are related to the forma-
tion of anal ssures are:
• Tearing of the anal valves due to passage of
hard stool.
• Anal infection theory related to the crypto-
glandular origin.
• Loss of elasticity due to infection and
brosis.
• Straining during parturition and chronic
constipation.
• Iatrogenic—As a complication of any inap-
propriate anal surgery [17]. Anal stenosis after
hemorrhoidectomy can lead to a chronic anal
ssure.
Lockhart—Mummery postulated that anal
mucosa is best supported laterally and weakest
posteriorly due to the external sphincter structure. The bers of the external anal sphincter are
not circular but elliptical that split around the
anus. Further, the external anal sphincter’s length
18.8 Classication ofAnal Fissures Based onMorphology
301
Table 18.1 Pathophysiology of anal ssure
Trauma
Pain
Internal anal spasm
High resting
pressure
Decreasein
anodermal perfusion
rectal arteries [19]. Because of this, the posterior commissure of the anal canal is less profused in approximately 85% of cases. Once
the anal ssure is formed, the internal sphincter spasm further restricts the blood ow to the
ssure site since the internal pudendal vessels
run vertically upwards through the internal anal
sphincter [20]. It leads to delayed healing resulting in a chronic ischemic ulcer. Using Doppler
owmetry, Schouten and colleagues evaluated
microvascular perfusion of the anoderm. They
concluded that anodermal blood circulation
was much lower at the posterior commissure.
Reduction of anal pressure by internal sphincterotomy improved anodermal blood ow, resulting
in ssure healing [20, 21].
Goligher proposed that the internal anal
sphincter below the dentate line was spastic.
Hence, ssures are always limited to the dentate
line, except those linked with inammatory
bowel illness [17].
18.7 Types ofAnal Fissures
Local Ischemia
Poor Healing
Anal Fissure
is half in females compared to males, leading to
decreased anterior support [18]. This is believed
to cause approximately 10% of anterior ssures
in females [18].
Klosterhalfen et al. observed an absence of
collaterals between the left and right inferior
An anal ssure may be acute or chronic.
• An acute ssure is formed as a linear tear that
heals within 6 weeks and has fresh mucosal
edges [22].
• A chronic anal ssure heals after 6weeks and
may be associated with sentinel piles, hyper-
trophic anal papillae, and internal sphincter
brosis at the ssure site [22].
Studies have revealed that 40% of the patients
suffering from acute anal ssures advance to
chronic anal ssures [23].
18.8 Classication ofAnal
Fissures Based
onMorphology
Anal ssures may be supercial or deep.
302
ab
18 Role ofLasers inAnal Fissures
18.8.1 Characteristics ofSupercial
Anal Fissure
• Severe pain and bleeding.
• Anoderm separation on the surface with sharp
edges.
• The internal anal sphincter is not breached at
the base of the ssure.
• Heals spontaneously within days or weeks
after conservative treatment [22, 24].
18.8.2 Characteristics ofDeep Anal
Fissure
• The internal anal sphincter bers are often
visible.
• Wide pear-shaped ulcer.
• A triad of indurated ulcer edges, sentinel pile,
and proximal hypertrophic anal papillae is
present [22, 24].
Most chronic anal ssures have three components; some have two, whereas others may present with only a persistent ssure (Fig.18.1) [25].
18.9 Grading ofAnal Fissures
Grading of anal ssures is shown in Fig.18.1a–e.
Grade 1: Supercial linear tear
Grade 2: A deep linear tear with a small sentinel
pile
Grade 3: Deep linear tear with brosed margin
and sentinel pile
Grade 4: A wide tear with visible bers of the
internal anal sphincter and sentinel pile
Grade 5: A wide pear-shaped tear with visible
bers of the internal anal sphincter with hypertrophic anal papillae with sentinel piles
Fig. 18.1 (a) Supercial linear tear. (b) Deep linear tear
with small sentinel pile. (c) Deep linear tear with brosed
margin. (d) A wide tear with visible bers of the internal
anal sphincter. (e) A wide pear-shaped tear with visible
bers of the internal anal sphincter with hypertrophic anal
papillae with sentinel piles
18.10 Location ofAnal Fissure
303
c
d
e
Fig. 18.1 (continued)
18.10 Location ofAnal Fissure
The anal ssure may be located at
• Midline posterior—approximately in 70%
(Fig.18.2a)
• Midline anterior—25% in women and 8% in
men (Fig.18.2b)
• Both anterior and posterior—3% [26, 27]
(Fig.18.2c)
Fissures that are located laterally [22] may
indicate an underlying etiology of:
• Ulcerative colitis
• Crohn’s illness
• HIV and syphilis
• Tuberculosis
• Malignancy
• Leukemia
The anal ssure is located distal to the dentate
line. Most anal ssures occur at the posterior or
anterior midline, the posterior midline being
most common [8]. The reason may be attributed
to the fact that:
• The posterior commissure has a lesser blood
ow than the rest of the anal canal [28].
• The external sphincter is elliptical in arrange-
ment posteriorly, which causes less support to
the anal canal [2].
304
ab
c
18 Role ofLasers inAnal Fissures
Fig. 18.2 (a) Anterior ssure. (b) Posterior ssure. (c) Presence of both anterior and posterior ssure
• The anal canal perfusion is inversely proportional to sphincter spasm or increased anal
tone [2]. More the sphincter spasm, less is the
perfusion.
The anal papillae may become hypertrophic due
to constant irritation [29].
18.12 Why Does aSentinel Pile
Form inanAnal Fissure?
18.11 Anatomical Considerations: Why Anal Fissures Are Painful?
The intermediate zone between the dentate line
and mucocutaneous junction is innervated by the
pudendal nerve, rendering ssures painful. Due
to internal anal sphincter spasm, there is present
increased anal tone leading to painful defecation.
Sentinel means “to guard.” When a ssure is
formed, it causes inammation and pain. As a
response to the inammation, reactive stromal
hyperplasia may form at the proximal end of the
lesion [30]. This is histologically identical to a
broepithelial polyp. If healing does not occur
across the defect produced by the ssure, the
body attempts to heal it through the overgrowth