What is a Sphincterotomy?

A fissure is the tearing of anal skin as a result of the overstretching of the anal opening by a big hard stool. Normally, sphincterotomy is related to constipation, chronic diarrhea (less often), inflammatory bowel disease or sexually transmitted infections that have anal and rectal effects. At times, the cause remains unknown.

There are two forms of anal fissures: acute and chronic. In an acute fissure, the tear occurs in the anal lining’s surface for a short time and heals.  The tear in chronic fissure deepens and may lead to the exposure of the inner muscle. If anal fissures do not heal after medical treatment and changes in the diet and lifestyle, they become chronic and a surgery known as sphincterotomy is required. 

Unlike the old methods like back internal sphincterotomy and anoplasty, lateral internal has fewer side effects than the former. It also offers more effective and long-term solutions for fissure than topical glyceryl trinitrate with similar fecal continence.

 

The Two Types of Sphincterotomy

1.    Lateral Internal Sphincterotomy (LIS) – the only sphincterotomy method for treating anal fissure.

2.    Endoscopy Sphincterotomy (EST) – this surgical operation involves the removal of gallstones from bile by the use of an endoscope. It is not a treatment for anal fissure.

Sphincterotomy is normally recommended to individuals:

• With unusually tight anal muscle.
• Who experience regular spasms while moving or defecating.
• With scar tissues as a result of past wounds whose healing process takes an extended period.

 

Surgical Operation Procedure for Sphincterotomy

The internal sphincter is cut or stretched during lateral internal sphincterotomy. When the muscle is cut, spasms are avoided and the muscles are temporarily weakened to assist in the healing process of the region. The surgeon extracts the fissure and all the tissues of the underlying scar.

The surgical procedure may involve local anesthesia where the immediate region is injected with the drug. The injected drug can be similar to the one used by dentists or during a spine surgery to numb the whole lower body.

Sometimes, the surgeon may use general anesthesia which makes the patient fall unconscious. You and your doctor must choose the best option of anesthesia depending on your preference, health and the basic practice of the facility where the surgery is performed.

You will be asked to lie on a table in a position which will make your anus and the rectum exposed. This position can be achieved by lying facing down with your butt slightly raised or lying face upwards with your legs clamped upwards. Antiseptic solution is used for cleaning the region after anesthesia is injected.

The operation is carried out for approximately 20 to 30 minutes.  Normally the wound is then stitched up using stitches that will dissolve with time.

 

Ways of Carrying out the Surgery

This operation is performed in a single day without requiring the patient to be admitted to a hospital. The two options for the surgery include 'open' and subcutaneous methods.

• In an open technique, a cut is made across intersphincteric groove and blunt dissection is used for separating internal sphincter from the mucosa in the anus.
• In a subcutaneous technique, the surgeon inserts a scalpel where the blade lies parallel to the sphincter found in the internal area of the anus. The surgeon then makes a tiny cut which proceeds to the intersphincteric groove and then divides the inner sphincter by turning the knife towards it.

The two techniques involve the division of lower third to a half of the internal sphincter. This reduces the pressure without affecting the sphincter’s functions.  Although the effectiveness of both methods is equal, the closed technique causes smaller wound when compared to the open method.

 

What Next after Sphincterotomy?

After the procedure is complete, patients are put into postanesthesia recovery unit where the nurses monitor them closely til they become stable. The rate of recovery as well as the type of anesthesia used will determine the period of a patient’s stay in the postanesthesia recovery unit. Usually, the patients who receive local anesthesia get better soon. The patients who get general anesthesia must be awake and sound before they are taken to the recovery unit.

Patients are given ice chips and then water if no intolerance is noted. The fluids may be administered immediately after the completion of the surgery in case if local anesthesia was applied. At times, general anesthesia may lead to nausea making the patient take a longer time before drinking fluids.  Patients may start taking solid foods once they tolerate clear liquids.

Then the patient is taken from the PACU to the outpatient or ambulatory unit for complete recovery and inpatients to their respective room. Once the patients wake up and can walk around, they are discharged from the hospital. A majority of patients will continue feeling dizzy throughout the day even after the anesthesia wears off. The patient should be accompanied by a relative or a friend if they intend to undergo the surgical operation and go home the same day.

Anesthetic administered on the spine wears off normally within several hours. After the surgical operation, patients lie flat facing upwards to reduce the chances of having a headache as a result of the anesthetic. The patient must have full sense on the numbed body part before being allowed to go home.   

The patients may need to take prescribed pain-relieving drugs for few days after the surgical procedure to reduce the pain that arise from the operation.

Apart from drugs, several other methods can be used to minimize discomfort and make the patient recover faster. The patients should not remove the bandage or dressing for some hours after getting out of the hospital. In order to clean the area and reduce the pain, the patients can take sitz bath in the evening of the operation day or the following morning. Sitz bathing should be done not less than two times a day for 10-15 minutes. Putting Epsom salts in the bath may or may not be recommended.

Many patients fear passing stool after having anal surgery since it is usually uncomfortable. Failure to defecate may make them constipated thus worsening the condition. Constipation can be prevented by eating foods with high fiber content as well as drinking approximately seven glasses of water daily.  Another option is the use of stool softeners.

The patients may bleed slightly particularly when defecating. Wiping the affected area with a wet toilet paper or baby wipes minimizes irritation and maintains cleanliness within the region. An ointment may be recommended to minimize the risk of infections as well as to help in the process of recovery. This must be applied after defecation or sitz bath, depending on the prescription.

 

Complications that Arise from Sphincterotomy

Although the chances of having surgery-related complications are low, it may occur sometimes. The most prominent problems include:

• Excessive loss of blood
• Inability to hold back faeces
• Inability to pass urine
• Infections
• Anesthesia-related issues
• increased vulnerability to abscess or fistula

 

Postoperative Expectations

The rectal region becomes painful especially while passing stool. Wash and dry the region after defecation to minimize the risks of developing an infection. 

Eat foods with high fiber content and drink approximately seven glasses of water daily to avoid constipation. Your physician may also ask you to use certain laxative drugs to soften the stool and avoid pain while defecating.

 

Further Treatment

A fissurectomy or anal advancement flap may be recommended if the fissure fails to heal even after having sphincterotomy.