Skip to main content
SpringerLink
Log in

Subcutaneous Fissurotomy: A Novel Procedure for Chronic Fissure-in-ano. A Review of 109 Cases

  • Original Contribution
  • Published:
Diseases of the Colon & Rectum

Abstract

Purpose

The constant presence of a narrow subcutaneous tract extending caudad to chronic fissures-in-ano is reported. The efficacy of surgically unroofing this tract (subcutaneous fissurotomy) without sphincterotomy was evaluated.

Methods

By using a narrow-gauge, hooked probe, a constant, midline subcutaneous tract was identified extending from the caudad aspect of chronic anal fissures. These tracts are present within the sentinel tag, when present, and extend up to 1 cm caudad to the fissure in the subcutaneous plane. A proximal connection with the dentate line in the submucous plane also was identified. Surgically unroofing the tract (subcutaneous fissurotomy) resulted in significant widening of the distal anal canal, rendering internal sphincterotomy unnecessary. A 32-month prospective evaluation of this new technique was performed. Inclusion criteria included patients with chronic anal fissures that had failed conservative therapy, including topical agents. In each case, the tract was identified and surgically laid open along its entire length. No internal sphincterotomy was performed in any patient. Postoperatively, patients were instructed to apply topical 10 percent metronidazole t.i.d. The need for repeat surgery and/or subsequent internal sphincterotomy was recorded.

Results

A total of 109 patients were enrolled during the study period. Median follow-up was 12 months. During the study period, two patients (1.8 percent) required repeat surgery for persistent symptoms at 3 and 12 months postoperatively. No change in continence was reported in any patient.

Conclusions

Laying open the subcutaneous tract has a very high success rate and a low incidence of repeat surgery. This finding introduces a new debate relating to the etiology of fissure-in-ano and makes routine internal sphincterotomy unnecessary.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5

Similar content being viewed by others

References

  1. Orsay C, Rakinic J, Perry WB, et al.Standards Practice Task Force, The American Society of Colon and Rectal Surgeons. Practice parameters for the management of anal fissures (revised). Dis Colon Rectum 2004;47:2003–7.

    Article  PubMed  Google Scholar 

  2. Nelson RL. Meta-analysis of operative techniques for fissure-in-ano. Dis Colon Rectum 1999;42:1424–31.

    Article  PubMed  CAS  Google Scholar 

  3. Romono G, Rotondano G, Santangelo M, et al. A critical appraisal of the pathogenesis and morbidity of surgical treatment of chronic anal fissure. J Am Coll Surg 1994;178:600–4.

    Google Scholar 

  4. Abcarian H. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy—midline sphincterotomy. Dis Colon Rectum 1980;23:31–6.

    Article  PubMed  CAS  Google Scholar 

  5. Garcia-Aguilar J, Belmonte C, Wong WD, et al. Open vs closed sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum 1996;39:440–3.

    Article  PubMed  CAS  Google Scholar 

  6. Khubchandani IT, Reed JF. Sequelae of internal sphincterotomy for chronic fissure-in-ano. Br J Surg 1989;76:431–4.

    Article  PubMed  CAS  Google Scholar 

  7. Casillas S, Hull TL, Zutshi M, et al. Incontinence after a lateral internal sphincterotomy: are we underestimating it? Dis Colon Rectum 2005;48:1193–9.

    Article  PubMed  Google Scholar 

  8. Rotholtz NA, Bun M, Mauri MV, et al. Long-term assessment of fecal incontinence after lateral internal sphincterotomy. Tech Coloproctol 2005;9:115–8.

    Article  PubMed  CAS  Google Scholar 

  9. Wiley M, Day P, Rieger N, et al. Open vs. closed lateral sphincterotomy for idiopathic fissure-in-ano: a prospective, randomized, controlled trial. Dis Colon Rectum 2004;47:847–52.

    Article  PubMed  CAS  Google Scholar 

  10. Hyman N. Incontinence after lateral internal sphincterotomy: a prospective study and quality of life assessment. Dis Colon Rectum 2004;47:35–8.

    Article  PubMed  Google Scholar 

  11. Pernikoff BJ, Eisenstat TE, Rubin RJ, et al. Reappraisal of partial lateral internal sphincterotomy. Dis Colon Rectum 1994;37:1291–5.

    Article  PubMed  CAS  Google Scholar 

  12. 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.

    Article  PubMed  CAS  Google Scholar 

  13. Goligher J. Surgery of the anus, rectum and colon. Anal fissure. 5th ed. London: Balliere Tindall, 150–166:1984.

    Google Scholar 

  14. Ram E, Alper D, Gideon Y, et al. Internal anal sphincter function following lateral internal sphincterotomy for anal fissure. A long-term manometric study. Ann Surg 2005;242:208–11.

    Article  PubMed  Google Scholar 

  15. Thornton MJ, Kennedy ML, King DW. Manometric effect of topical glyceryl trinitrate and its impact on chronic anal fissure healing. Dis Colon Rectum 2005;48:1207–12.

    Article  PubMed  CAS  Google Scholar 

  16. Antropoli C, Perrotti P, Rubino M, et al. Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study. Dis Colon Rectum 1999;42:1011–5.

    Article  PubMed  CAS  Google Scholar 

  17. Kocher HM, Steward M, Leather AJ, Cullen PT. Randomized clinical trial assessing the side-effects of glycerol trinitrate and diltiazem hydrocholoride in the treatment of chronic anal fissure. Br J Surg 2002;89:413–7.

    Article  PubMed  CAS  Google Scholar 

  18. Perrotti P, Bove A, Antropoli C, et al. Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: results of a prospective, randomized, double-blind study. Dis Colon Rectum 2002;45:1468–75.

    Article  PubMed  Google Scholar 

  19. Jonas M, Neal KR, Abercrombie JF, Scholefied JH. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum 2001;44:1074–8.

    Article  PubMed  CAS  Google Scholar 

  20. Minguez M, Herreros B, Espi A, et al. Long-term followup (42 months) of chronic anal fissure after healing with botulinum toxin. Gastroenterology 2002;123:112–117.

    Article  PubMed  Google Scholar 

  21. Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 1994;37:664–9.

    Article  PubMed  CAS  Google Scholar 

  22. Schouten WR, Briel JW, Auwerda JJ, et al. Ischaemic nature of anal fissure. Br J Surg 1996;81:63–65.

    Article  Google Scholar 

  23. Gupta PJ, Kalaskar S. Removal of hypertrophied anal papillae and fibrous anal polyps increases patient satisfaction after anal fissure surgery. Tech Coloproctol 2003;7:155–8.

    Article  PubMed  CAS  Google Scholar 

  24. Ravikumar TS, Sridahr S, Rao RN. Subcutaneous lateral internal sphincterotomy for chronic fissure-in-ano. Dis Colon Rectum 1982;25:798–801.

    Article  PubMed  CAS  Google Scholar 

  25. Carapeti EA, Kamm MA, McDonald PJ, Phillips RK. Double-blind randomized controlled trail the effect of metronidazole on pain after day case hemorrhoidectomy. Lancet 1998;351:169–72.

    Article  PubMed  CAS  Google Scholar 

  26. Nicholson TJ, Armstrong DN. Topical metronidazole (10 percent) decreases posthemorrhoidectomy pain and improves healing. Dis Colon Rectum 2004;47:711–6.

    Article  PubMed  Google Scholar 

  27. Stringer E, Nicholson TJ, Armstrong DN. Efficacy of topical metronidazole (10 percent) in the treatment of anorectal Crohn’s disease. Dis Colon Rectum 2005;48:970–.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Georgia Colon & Rectal Surgical Clinic, 5555 Peachtree Dunwoody Road, Suite 206, Atlanta, Georgia, USA

    Arie E. Pelta M.D., Kurt G. Davis M.D. & David N. Armstrong M.D., F.R.C.S

Authors
  1. Arie E. Pelta M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kurt G. Davis M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David N. Armstrong M.D., F.R.C.S
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David N. Armstrong M.D., F.R.C.S.

Additional information

Dr. Armstrong has a patent licensing agreement with SLA Pharma AG for topical 10 percent metronidazole.

About this article

Cite this article

Pelta, A.E., Davis, K.G. & Armstrong, D.N. Subcutaneous Fissurotomy: A Novel Procedure for Chronic Fissure-in-ano. A Review of 109 Cases. Dis Colon Rectum 50, 1662–1667 (2007). https://doi.org/10.1007/s10350-007-9022-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10350-007-9022-5

Key words

Search

Navigation