Indications/Contraindications

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PARTVI

SPHINCTEROTOMY–LATERAL

Chapter21

OpenLateralInternal Sphincterotomy

SurajAlvaandBertramT.Chinn

INDICATIONS/CONTRAINDICATIONS

Indications

Chronicfissuresthatfailtorespondtononoperativetherapy Acutefissureswithseverepain

Analfissureisacommondisorderthatresultsinbleedingandpainful defecation.Itisfrequentlyrelatedtohardoraconstipatedbowel movement.Alineartearisnotedintheanodermandisfrequentlyseen withgentleretractionofthebuttocks(Fig.21-1).Approximately80–90% offissuresareposteriorinlocationwiththeremainderintheanterior midline.Occasionally,fissuresmaybeseeninboththeanteriorand posteriormidlines.

FIGURE21-1Posteriorfissure.

Manyfissureshealbyincreasingdietaryfibertosoftenandbulkthe stoolandbyusinganemollientsuppositoryandwarmsitzbaths.Over thelastdecade,topicalnifedipineornitroglycerinointmentsandthe injectionofBotulinumtoxinAintotheinternalsphincterhaveimproved fissurehealingbyreducingsphincterspasms.

Inchronicconditions,irritation,itching,mucous,anddiscomfortmay bemoreevidentthanpainorbleeding.Scarringatthebaseofthefissure, rolledandinduratededges,asentinelskintag,and/orahypertrophic papillasuggestthatthefissurewillnothealwithoutsurgery.Aposterior sphincterotomywasoncerecommendedbutduetoaresultant“keyhole” deformity,Eisenhammeradvocatedalateralinternalsphincterotomy (LIS)forsurgicaltreatmentoffissures.

LISmayalsobenecessarywhenpainfromanacutefissureis overwhelming.AlthoughLIScontinuestobethemosteffectiveand definitivetreatmentmodalityinthemanagementofanalfissures,thefear offecalincontinencehasresultedinreluctanceinperformingLIS.

Contraindications

Diminishedsphincterintegrity

Inflammatoryboweldisease Infections(tuberculosisandsyphilis) LeukemiaandHIV

WhenconsideringanLIS,individualswithdiminishedsphinctertone orincontinenceshouldbeevaluatedfortheircandidacyforalternative therapies.Anatypicalfissuremaysuggestthepresenceofotherdiseases. Fissuresinthelateralquadrantsshouldraisetheconcernof inflammatoryboweldisease,specificallyCrohn’sdisease,tuberculosis, syphilis,leukemia,orHIV.Inthesesituations,treatingtheunderlying diseaseisrecommendedinsteadofperformingasphincterotomy.

PREOPERATIVEPLANNING

Routinepreoperativeevaluationandplanningthatincludeahistoryand physicalexaminationwithmeticulousattentiontotheanorectalregion shouldbeperformed.Althoughaphosphateenemaisrecommended priortothesurgery,discomfortfrequentlyprecludesitsuse.If diminishedsphinctertoneissuspectedorifthepatienthashadprior anorectalsurgery,preoperativeanorectalphysiologytestingmaybe helpful.

SURGERY

Positioning

Pronejackknifeposition

Thepronejackknifepositionallowstheentiresurgicalteamfullaccess totheoperativefield.Retracting3-inchsilktapethathasbeenplacedon thebuttocksandsecuringittothesidesoftheoperatingtableprovides exposure.LithotomyandaleftlateralormodifiedSims’positionscan alsobeused.

Anesthesia

Monitoredanesthesiacare(MAC) A0.25%bupivacaineand1:200,000epinephrine

AlthoughLIScanbeperformedundergeneralorregionalanesthesia, ourpreferenceisMACandalocalblock.Afterinitiallyattainingadequate sedationandcomfortunderMAC,alocalblockwithbupivacaineand epinephrineisused.Thisblockprovidesanalgesiaandallowsrelaxation ofthesphinctertofacilitatesurgery.Thevasoconstrictiveeffectsof epinephrinedecreasesvascularityduringthesurgeryandincreasethe periodofpostoperativeanalgesia.

Initially,10mlofthelocalanestheticisinjectedcircumferentiallyinto theperianalskinandthesubcutaneoustissuewitha1.5inch×25gauge needle.Acircumferentialdeeperinjectionintothesphincteristhen performed.Typically,atotalof20–30mlofthelocalanestheticisneeded tocompletetheoperation.

Regardlessoftheanesthesiaselected,patientsmaybenefitfromthe useofalocalblockthatcontainsepinephrineinadditiontothe analgesic/anesthetic.Proceduresperformedundergeneralanesthesia stillbenefitfromtheadditionalsphincterrelaxationandhemostasis attainedwiththebupivacaineandepinephrine.Thevasoconstrictive effectsofepinephrinearealsohelpfulinoffsettingthevasodilatoryeffects ofaspinalanesthetic.

p.160

p.161

Technique

Confirmationofafissureandhypertonic/spasticsphincter Insertionofa35-mmHillFergusonretractorwithidentificationofthe

internalsphincterandintersphinctericgroove Incisionoftheperianalskinoverlyingtheintersphinctericgroove

Isolationoftheinternalsphincteranddivisionunderdirectvision Fissuredebridementandexcisionofasentineltagandhypertrophic

papilla Closureofthesphincterotomysitewithinterruptedabsorbablesutures

Afterappropriatepositioningandanesthesiaadministrationare performed,thepresenceofafissureisconfirmedwithcircumferential examinationoftheanalcanalusingaHirschmannanoscope.A35-mm HillFergusonretractorprovidesaconsistentmeasureofthediameterof theanalcanal.Resistanceduringinsertionofthisretractorconfirmsthe presenceofahypertonic/spasticsphincterandataut,band-likeinternal sphincterisseen(Fig.21-2).Failuretoidentifyahypertonicsphincter shouldpromptfurtherevaluationbeforeasphincterotomyisperformed.

FIGURE21-2Hypertonicinternalsphincter.

Selectionofeithertheleftortherightlateralquadrantforthe sphincterotomyiscontingentonwheretheinternalsphincterisbest notedandwhetherhemorrhoidaltissuewouldinterferewiththe operativefield.Anincisionismadeattheintersphinctericgrooveand extended1.5–2.0cmproximallytotheperianalskin.Afine,curved hemostatisusedtomobilizetheanodermfromtheinternalsphincterup tothelevelofthedentateline(Fig.21-3).Cautionisexercisedtoprevent violationoftheanodermbecausenonhealingofaniatrogenicdefectmay resultinafistula.Theintersphinctericplaneisaccessedandtheinternal sphincterisisolatedwiththehemostatuptothedentateline(Fig.21-4). Electrocauterymaybeusedtocontrolsmallpointsofbleeding.

FIGURE21-3Mobilizationofanoderm.

FIGURE21-4Isolationofinternalsphincter.

ApairofBuiescissorsisusedtodividetheinternalsphincterunder directvision(Fig.21-5).Historically,themuscleisdivideduptothe dentateline.A“tailored”LISmaybeperformedbydividingtheinternal sphincteruptotheleveloftheproximalextentofthefissure.Ifthere remainsresistancetoinsertionoftheHillFergusonretractor,extension ofthesphincterotomytothedentatemaybeneeded.Divisionofthe internalsphincterbeyondthedentatelineisunnecessaryand inadvisable.

FIGURE21-5Divisionofinternalsphincter.

Tofacilitatefissurehealing,thefibrosisatthebaseofthefissureis debridedwithacuretteorbyobliquelyscrapingthefissurewithascalpel. Underminedorrollededgesofthefissureshouldbeexcisedor saucerized.Excisionofasentineltagorhypertrophicpapillaeis performedifpresent.

Afterhemostasisisconfirmed,theLISsiteisclosedwithtwoorthree interruptedsuturesof3-0chromicorVicryl.Atopicalhemostaticagent maybeleftatthefissuresite.

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