Anal Fissure Surgery , Procedure, Risks and Benefits

Overview

Fissure dilatation is a procedure done as an adjunct to other treatment methods for anal fissures. Also known as the Lord’s dilatation, this procedure involves dilating the anal sphincter manually or with rectal dilators under general anesthesia. A proctologist (a doctor specializing in treating diseases of the anus and rectum) or a general surgeon performs the procedure. Fissure dilatation helps to lower intra-anal pressure (pressure in the anal canal), thus making the passage of stools easy and painless. The procedure is done on an outpatient basis, and you can go home the same day. Recovery from fissure dilatation takes 3 to 4 weeks.

What is Meant by Fissure Dilatation ( Anal Fissure Surgery )?

Anal fissures are painful, bleeding tears or cuts in the lining of the anus that are caused by trauma or injury to the lining of the anus. The most common cause is chronic constipation. Frequent diarrhea, unhealthy anal intercourse, obesity, and faulty eating habits can also cause anal fissures. When you have fissures in the anus, passing stools can be extremely traumatic, with immense pain, burning, and bleeding. 
Dilating the anal sphincter to release some tension helps the stools pass freely, reducing the intense pain. The procedure of dilating the anal sphincter is called Lord’s Dilatation. This procedure involves placing the fingers inside the anal opening and stretching gently to widen the anal sphincter opening. Alternatively, the procedure can be done using anal dilators (cylindrical tools of increasing diameter).
Fissure dilatation provides immense relief from the symptoms of fissures. It works even better when used as an adjunct to other non-surgical treatment options like stool softeners, nitroglycerine ointments, topical anesthetic creams, and blood pressure medications.
Fissure dilatation works best for people under 50 years with mild to moderate fissures and when done by an experienced surgeon. There may be complications like fecal incontinence (involuntary passage of stools) when this procedure is done in the elderly and in people with severe fissures. Forceful dilation can harm the anal tissue necessitating further surgical interventions to repair the damage.

When is a Fissure Dilatation recommended?

Fissure dilatation or Lord’s dilatation is the manual dilatation of the anal sphincter. This is done to reduce the tension in the anal sphincter to allow free passage of stools. Fissure dilatation is always used as an adjunct to other non-surgical treatment methods for fissures. Fissure dilatation is effective with stool softeners, nitroglycerine ointments, topical anesthetic creams, and blood pressure medications.
Indications for the use of fissure dilatation include-

• Chronic anal fissures causing severe symptoms
• Fissures with increased tone in the sphincter muscles

Fissure dilatation is not usually recommended in old people with weak muscles as dilatation in such cases, carries a high risk of fecal incontinence (involuntary passage of stools).

How to Prepare For a Fissure Dilatation ( Anal Fissure Surgery )

Anal fissures are tears in the lining of the anal canal. Fissures are generally associated with constipation and cause severe pain during and after a bowel movement. Small fissures usually resolve on their own or with medical treatment. Long-standing chronic fissures lead to the development of a skin fold over the tear, either inside or outside the anal opening. Fissure dilatation provides immense relief from the symptoms of fissures. Here is how you can prepare for the procedure. 

• Your surgeon will discuss your medical and personal history in detail.
• A rectal examination to understand the location of the fissure will be performed.
• Your surgeon will suggest some tests for diagnosing the anal fissure:-
• Anoscopy- This test involves inserting a tubular device fitted with a camera that helps to view your anus and rectum
• Flexible sigmoidoscopy- In this procedure, a tube known as a sigmoidoscope is inserted into your anus to help the surgeon visualize the anus and rectum. This procedure is recommended if you are under 45 years of age and have no risk factors for developing colon cancer and intestinal diseases.
• Routine tests like a complete blood count, X-ray, ECG (electrocardiogram), and routine urine tests.
• High-definition imaging tests like CT scans or an MRI may be suggested.
• You can ask your surgeon to explain the procedure's details, outcome, and prognosis. You will be asked to sign an informed consent form agreeing to proceed with the surgery.
• On the day of the surgery, you will be asked to fast for at least 12 hours before the surgery.
• You can go home on the same day of the surgery. You will be asked to arrange for a friend or relative to drive you home after the surgery is completed.

How is Fissure Dilatation( Anal Fissure Surgery ) Performed ?

Fissure dilatation is performed under general anesthesia as an outpatient procedure. A proctologist (a doctor specializing in treating diseases of the anus and rectum) or a general surgeon performs this procedure. The procedure is done manually or by using anal dilators. The time taken for the procedure to complete varies depending on the surgeon and the severity of the fissure. Here is how the procedure is done:

• An enema will be given 2 hours before the start of the procedure to empty your bowels.
• You will be advised to lie lithotomy position (lying on your back with your legs wide apart). This helps the surgeon to get a good view of the anal region.
• The surgeon will insert 2 fingers into the anal opening up to the anorectal line (where the anus and rectum meet). 
• After this, with a gentle stretch, 2 more fingers are inserted into the anus.
• Once four fingers are inside, the hand is gently pronated (palm facing downwards). The fingers are spread, and the stretching is carried out in the 3 and 9 o’clock positions as the muscles in the 6 and 12 o’clock positions are naturally weaker. The stretch is held for 3 to 4 minutes at a time.
• The surgeon decides the number of stretches required based on the fissure's severity and the clinical assessment.
• Alternatively, the surgeon may use anal dilators to dilate the sphincter. The dilators are cylindrical instruments with increasing diameters.

Once the procedure is completed, you will be shifted to an observation room. You can go home once the effects of anesthesia wear off. After this procedure, recovery time from the fissure is about 3 to 4 weeks. The relief from the symptoms of the fissure can be seen immediately.

What to Expect After a Fissure Dilatation ( Anal Fissure Surgery )?

Fissure dilatation helps to loosen the tense sphincter muscles and allows for the painless passage of stools. Once the procedure is done, there is an almost instant relief from the fissure symptoms. Complete recovery from this procedure takes about 3 to 4 weeks. After the dilatation, you can speed up the procedure using other non-surgical treatment options like nitroglycerine cream, topical anesthetic creams, blood pressure medications, and stool softeners.
Upon discharge, you will be given instructions to follow at home that will aid in speedy recovery.

After The Procedure

• You may have pain while passing stools for the first one or two times However, this pain will be significantly lesser than before the surgery and will reduce gradually. 
• Take frequent Sitz baths. This is a technique that helps to reduce the pain and swelling in the anal area. You must sit in a shallow tub or basin filled with warm water for fifteen to twenty minutes. You may add a betadine solution for extra protection. A Sitz bath is beneficial for the following reasons:
  • Pain relief
  • Improvement in blood flow to the anal region, ensuring better healing
  • Relaxation of the muscles of the sphincter that have undergone dilatation
• You will be given stool softeners and laxatives to help you pass soft stools.
• Avoid using tissues after bowel movements. Instead, use mild soap and water to wash and pat dry the area well. 
• Avoid spicy, oily, and salty food. Include a lot of fibrous food in your diet as they help prevent constipation and ensure free motion.
• Ensure you stay hydrated by drinking water at regular intervals.

What are the Benefits and Risks of Anal Fissure Surgery

Fissure dilatation is a quick procedure that helps relieve you of fissures' symptoms. The procedure is beneficial when used as an adjunct to other non-surgical treatment methods. Fissure dilatation also carries some risks. 

 Benefits of fissure dilatation

• Quick relief from symptoms of fissure
• Done as an outpatient procedure, a hospital stay is not required
• Faster recovery process
• When done in a systematic, standardized way, the results are visible for long-term

 Risks of fissure dilatation

• Not very useful as a standalone procedure. Has to be used with other non-surgical methods
• Not advisable for old people 
• High risk of fecal incontinence (involuntary passage of stools) when performed uncontrolled manner
• Risk of flatus incontinence (involuntary passage of gas).
• Not a curative procedure; surgical treatment for fissure would be needed at some point.

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