Published: 2019-05-29

Is open lateral anal sphincterotomy really a safe and satisfactory treatment option for refractory chronic anal fissures? - a prospective study

Shabir Ahmad Mir, Zubair Gull Lone, Waseem Ahmad Dar, Mumtazdin Wani


Background: Chronic anal fissure is a familiar entity in surgical outdoor departments of hospitals in our valley. The muslim women are usually reluctant to expose their anal canal related pathologies to male surgeons, letting anal fissures to reach the chronic stage. Under this background, the present study was conducted to look for the feasibility of lateral anal sphincterotomy in the management of chronic anal fissure in our patients.

Methods: This prospective study was carried out over a period of 3 years in the unit 2nd of department of surgery at SMHS (Shri Maharaja Harisingh) hospital, an associated hospital of Government Medical College Srinagar. During this period, 59 patients presented to the outpatient department with typical chronic anal fissures and were included in this study.

Results: Fifty-nine patients, diagnosed on clinical evaluation as chronic anal fissure were included in this study. The age varied from 19 to 58 years with mean age of 36.38±7.14 (SD= 7.14) years. There was a female predominance, with a female to male ratio of 2.1:1. Fifty-two (88.1%) patients had posterior midline fissure and 7 (11.8%) patients had an anterior anal fissure. Thirty-one patients were not satisfied with the conservative treatment and insisted for surgical management. All 31 patients were managed by open lateral anal sphincterotomy.

Conclusions: Lateral anal sphincterotomy (LAS) is a safe and effective method of management for chronic refractory anal fissures. The complications are minimal and negligible.


Anal fissure, Lateral anal sphincterotomy, Midline posterior, Pain

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Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum. 1989;32:43-52.

Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. 1996;83:63-5.

McNamara MJ, Percy JP, Fielding IR. A manometric study of anal fissure treated by subcutaneous lateral internal sphincterotomy. Ann Surg. 1990;211:235-8.

Xynos E, Tzortzinis A, Chrysos E, Tzovaras G, Vassilakis JS. Anal manometry in patients with fissure-in- ano before and after internal sphincterotomy. Int J Colorectal Dis. 1993;8:125-8.

Zaghiyan KN, Fleshner P. Anal fissure. Clin Colon Rectal Surg 2011;24:22-30.

Vila S, García C, Piscoya A, De Los Ríos R, L Pinto J, Huerta Mercado J, et al. Use of glycerol trinitrate in an ointment for the management of chronic anal fissure at the National Hospital “Cayetano Heredia”. Rev Gastroenterol Peru. 2009;29:33-9.

Whatley JZ, Tang SJ, Glover PH, Davis ED, Jex KT, Wu R, et al. Management of complicated chronic anal fissures with high-dose circumferential chemodenervation (HDCC) of the internal anal sphincter. Int J Surg. 2015;24:24-6.

Utzig MJ, Kroesen AJ, Buhr HJ. Concepts in pathogenesis and treatment of chronic anal fissure-a review of the literature. Am J Gastroenterol. 2003;98(5):968-74.

Arslan K, Erenoglu B, Dogru O, Turan E, Eryilmaz MA, Atay A, et al. Lateral internal sphincterotomy versus 0.25% isosorbide dinitrate ointment for chronic anal fissures: a prospective randomized controlled trial. Surg Today. 2013;43(5):500-5.

Giridhar CM, Babu P, Rao KS. A comparative study of lateral sphincterotomy and 2% diltiazem gel local application in the treatment of chronic fissure in ano. J Clin Diag Res. 2014;8(10):NC01.

Mentes BB, Tezcaner T, Yılmaz U, Levento_glu S, Oguz M. Results of lateral internal sphincterotomy for chronic anal fissure with particular reference to quality of life. Dis Colon Rectum. 2006;49:1045-51.

Giordano P, Gravante G, Grondona P, Ruggiero B, Porrett T, Lunniss PJ. Simple cutaneous advancement flap anoplasty for resistant chronic anal fissure: a prospective study. World J Surg. 2009;33:1058-63.

Leong AF, Seow-Choen F. Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure. Dis Colon Rectum. 1995;38:69-71.

Hanaanel N, Gordon PG. Lateral internal sphincterotomy for fissure in ano e revisited. Dis Colon Rectum. 1997;40:597-602.

Oh C, Divino CM, Steinhagen RN. Anal fissure. 20 years experience. Dis Colon Rectum. 1995;38:378-382.

Nahas SC, Sobrado Jr CW, Araujo SE, Aisaaka AA, Habar GA, Pinotti HW. Chronic anal fissure: results of the treatment of 220 patients. Rev Hosp Clin Fac Med. 1997;52:246-9.

Melange M, Colin JF, Van Wynersch T, Van Heuverzwyn R. Anal fissure: correlation between symptoms and manometry before and after surgery. Int J Colorectal Dis. 1992;7:108-11.

McNamara MJ, Percy JP, Fielding IR. A manometric study of anal fissure treated by subcutaneous lateral internal sphincterotomy. Ann Surg. 1990;211:235-8.

Eisenhammer S. The evaluation of the internal anal sphincterotomy operation with special reference to anal fissure. Surg Gynecol Obstet. 1959;109:583-90.

Notaras MJ. The treatment of anal fissure by lateral subcutaneous internal sphincterotomy: a technique and results. Br J Surg. 1971;58:96-100.

Poh A, Tan KY, Seow-Choen F. Innovations in chronic anal fissure treatment: a systematic review. World J Gastrointest Surg. 2010;2:231-41.

Araujo SE, Sousa MM, Caravatto PP, Habr-Gamai A, Cecconello I. Early and late results of topical diltiazem and bethanechol for chronic anal fissure: a comparative study. Hepato-Gastroenterol. 2010;57:81-5.

Vaithianathan R, Panneerselvam S. Randomised prospective controlled trial of topical 2% diltiazem versus lateral internal sphincterotomy for the treatment of chronic fissure in ano. Indian J Surg. 2015;77:1484-7.

Brady JT, Althans AR, Neupane R, Dosokey EM, Jabir MA, Reynolds HL, et al. Treatment for anal fissure: Is there a safe option?. Am J Surg. 2017;214(4):623-8.

Salih AM. Chronic anal fissures: open lateral internal sphincterotomy result: a case series study. Ann Med Surg (Lond). 2017;15:56-8.

Emile SH, Youssef M, Elfeki H, Thabet W, El-Hamed TM, Farid M. Literature review of the role oflateral internal sphincterotomy (LIS) when combined with excisional hemorrhoidectomy. Int J Colorectal Dis. 2016;31:1261-72.

Nyam DC, Pemberton JH. Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum. 1999;42:1306-10.

Mathai V, Ong BC, Ho YH. Randomized controlled trial of lateral internal sphincterotomy with haemorrhoidectomy. Br J Surg. 1996;83:380-2.

Garg P, Garg M, Menon GR. Long term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis. Colorectal Dis. 2013;15:104-17.