Anal fissures that do not heal are usually caused by poor blood supply in the affected area and high levels of contraction of the anal sphincter muscles. The internal sphincter muscle is an involuntary muscle that supports the anus. Together with the external anal sphincter muscles, they are responsible for the smooth passage of the stool during bowel movement and for the prevention of involuntary leaking of rectal content. When the anal sphincter muscles contract more vigorously than normal, ulceration could occur. Anal fissure may resolve through conservative measures such as by taking over-the-counter pain medications, topical steroids, or anesthetics, as well as by following a high fiber diet. However, if conservative measures fail, more invasive procedures are needed.
Anal fissurectomy is a surgical procedure that involves removal of the fissures. Indication for anal fissurectomy includes chronic anal fissure, fissures complicated by fistulas, and fissures associated by increased sphincter tone. In the procedure, skin tags found near the anal fissure are also removed. The entire base of the incision is cauterized and absorbable stitches are used to suture the wound. Electrocauterization prevents the incision from bleeding. Nowadays, fissurectomy is usually performed together with lateral internal sphincterectomy.
Lateral internal sphincterectomy will not just remove the fissures, it will also prevent the anal muscles from having increased resting contractions. This can help to prevent future occurrences of anal tears. Local anesthesia is often used for this procedure. However, general anesthesia may be used for anxious or uncooperative patients. The patient is placed in a facedown jack knife position wherein the buttocks are strapped apart for the fissures to be clearly exposed. The whole procedure lasts for 35-40 minutes. Recovery may take 4-5 weeks.
Nowadays, most doctors recommend anal fissurectomy to be done together with Botulinum Toxin injection. Botox is a neurotoxin that prevents the release of acetylcholine from the nerves. Acetylcholine is responsible in the contraction of the muscles. Injecting Botox to the internal and external anal sphincters will help the muscles relax, which in turn allows the anal fissures to heal.
Anal fissurectomy can be done as an outpatient procedure. After staying in the recovery room, the patient is allowed to go home. The physician will prescribe medications that will help relieve the pain from the operation. Proper cleaning of the surgical site will also be explained to prevent infection. The doctor will also explain the signs and symptoms that should be watched out for during the recovery period. Mild bleeding is just a normal complication of the surgery. However, if the bleeding from the site have soaked more than two large gauze pads, then immediate medical attention is necessary. Pain that is not relieved by prescribed pain medications is also another thing to watch out for. Shortness of breath, chest pain, and severe pain in the abdominal area must also be immediately reported to the doctor.
Every surgical procedure comes with risks or possible complications. Some of the complications which may arise after the procedure are infection, damage in the anal sphincter muscles, anal fistula, and recurrence of anal fissure. Although such complications may arise, the success rate of treating anal fissure through fissurectomy is still undeniably high.
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