Perioperative management - Fissurectomy

• chronic anal fissure after failed first-line medication therapy
• Surgical therapy can be performed as a first-line treatment if the patient desires it or if there are additional fistulas and/or pronounced secondary morphological changes present.

Note: Lateral internal sphincterotomy, with a success rate of >90%, is the most effective therapy. In German-speaking regions, fissurectomy, with a success rate of 80%, is preferred due to the significantly lower risk of incontinence.

In a fissurectomy, the secondary morphological changes of the fissure are resected, and the base of the fissure is sparingly excised or debrided. Additionally, a wide extra-anal drainage triangle is created to support healing from the inside out. The primary goal of the operation is the removal of inflammatory fibrotic changes that are important for the pathogenesis of the fissure.

Absolute Contraindications

• Acute infections in the surgical area (e.g., perianal abscesses, active proctitis) due to an increased risk of wound healing disorders and sepsis
• Malignant tumors in the anal region
• Unclear histologically unconfirmed anal lesions, because there is a risk that a significant underlying disease may be overlooked.

Relative Contraindications

• In chronic inflammatory bowel diseases (e.g., Crohn's disease, ulcerative colitis), a procedure should be avoided if possible, because there is a significant risk of fistula and wound healing problems.
• Severe coagulation disorders or ongoing anticoagulation, if no adequate adjustment is possible.
• Severe general diseases with increased surgical risk (e.g., decompensated heart or lung disease).
• Previous surgeries with sphincter-straining procedures, because the risk of incontinence increases.

Medical history with proctological examination: inspection, palpation, proctoscopy, and rectoscopy as far as pain allows.

The main symptom of anal fissure is severe pain, especially during bowel movements and often for some time afterward.

The anal fissure can be clinically diagnosed by visual inspection with a typical medical history and typical proctological appearance.

The ulcer-like lesion of the mucosa and possibly secondary changes are usually located at the 6 o'clock lithotomy position (LP) in primary fissures, less commonly at the 12 o'clock LP.

However, fissures can often be difficult to visualize due to pain during examination or a narrow anal canal. In case of doubt, the indication for examination under anesthesia should be generously considered to ensure diagnosis.

The anal fissure is an ulcer-like lesion in the anal canal, usually located at the 6 o'clock LP (lithotomy position) and characterized by severe pain during bowel movements.

Before a fissurectomy, it is usually checked whether conservative methods (e.g., ointments, dilation, Botox injection) have been unsuccessful. Only when these have been exhausted and no contraindications are present, surgery is performed.

The combination of a fissurectomy with botulinum toxin injection could have additional benefits, as both measures target the pathogenetic factors of the fissure, namely sphincter hypertonia and fibrotic-inflammatory ulceration. There are currently no randomized controlled trials on this combination therapy.

Possibly administer an enema before the procedure

General:

• Bleeding
• Thrombosis
• Embolism, etc.

Specific:

• Consecutive disturbance of fine continence (e.g., stool smearing)
• Sensory deficit with incontinence complaints or stenoses
• Stenoses due to scar formation
• Secondary wound healing
• Abscess
• Recurrence

Depending on the general condition of the patient:

• Intubation anesthesia (Intubation anesthesia, Laryngeal mask anesthesia)
• Regional anesthesia (Spinal anesthesia, Caudal anesthesia)
• In selected cases, local anesthesia is also possible

• Lithotomy position

The surgeon sits in front of the patient positioned in the lithotomy position, with the first assistant to the left. The scrub nurse stands or sits to the right side of the surgeon.

• Various probes (especially hook probe for fistula search)
• electrosurgical knife (HF needle)
• anal retractor
• bipolar forceps

postoperative analgesia: Non-steroidal anti-inflammatory drugs are usually sufficient; if necessary, an increase with opioid-containing analgesics can be made.
Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management).
Follow the link here to the current guideline Treatment of acute perioperative and post-traumatic pain.medical follow-up: Rectal digital examination should be performed before discharge.
thrombosis prophylaxis: Small proctological procedures (outpatient or short inpatient, surgery time < 60–90 min, rapid mobilization) → No routine medication prophylaxis if no additional risk is present.
Follow the link here to the current guideline Prophylaxis of venous thromboembolism (VTE).mobilization: Immediate full mobilization possible after the effects of anesthesia subside
physical therapy: Not required
dietary progression: Full diet on the first postoperative day
bowel regulation: For bowel regulation, a fiber-rich diet together with adequate fluid intake should be sufficient.
work incapacity: Work incapacity should not exceed 1 week.