Lateral Internal Sphincterotomy - Procedure and Recovery

Lateral internal sphincterotomy is a surgery for treating an anal fissure, i.e., a tear in the anus opening causing pain, itching, and bleeding. It aids in relieving pain arising due to spasms by reducing pressure inside the anus and increasing blood supply to the surrounding area enabling the tissue to heal.

An anal fissure is a common disease that affects both children and adults and is caused by forcefully passing a large, firm, or hard bowel.However, repeating cycles of such forced bowel movements can cause severe pain and bleeding, , that don't easily heal, leading to chronic anal fissures.

A lateral internal sphincterotomy is a surgery that repairs an anal fissure.

1. It helps reduce pressure inside the anus that can cause spasms and increases blood flow to the area to help the tissue heal.
2. It helps heal an anal fissure that has not improved with medicine or other treatments

Reasons for Considering Surgery

Complications of anal fissure can include:

A tear stretching to surrounding muscles – An anal fissure may tear into a muscle ring that holds the anus closed (internal anal sphincter), thus preventing the anal fissure from healing easily

 Failure to heal – Chronic anal fissure fails to heal within eight weeks and require further medical intervention.

 Pain or discomfort – Unhealed fissures cause despair, demanding medications or surgery to relieve the pain and cure the fissure.

1. Recurrence – After experiencing an anal fissure once, individuals may experience another one.
2. Trouble passing stool – Constant pain makes   bowel movement more difficult.
3. Constant bleeding – After wiping stool, people likely find bright red streaks of blood on toilet paper.
4. Clotting – Due to the frequent bleeding patient may find blood clots in the surrounding areas of the anal fissure.
5. Inability to control gas or bowel movements – People suffering from this may experience sudden or frequent gas or bowel movements.
6. Reduced quality of life – People often feel embarrassed due to constipation, constant pain & bleeding or frequent gas or bowel movements. This embarrassment further increases stress and affects   socio-psychological behaviour.

Sphincterotomy Procedure

1. At first, the surgeon carefully inspects the anal canal using an anoscope to identify the anal fissure.
2. At this point, the surgeon can go with any one of the two surgical methods: open or closed lateral internal sphincterotomy.
3. In the open technique, the internal sphincter muscle fibres are exposed by making a small incision on either side of the anal skin. The surgeon then lifts the internal anal sphincter muscle through a hemostat or similar tool, separating it sharply with a knife or thermal cautery. This process relaxes the pressure in the anus and enables the fissure to heal.
4. Unlike the open technique, the closed method begins by locating a groove between the internal and external sphincter muscles through touching them. After identifying, a scalpel is inserted down to this grove towards the internal sphincter to cut and separate the muscle.
5. In both approaches, the incision aims to release the tension of the sphincter as the high pressure inside the anus prevents anal fissures from healing.

What to expect before the procedure?

1. The patient's positioning is based on the preference of the surgeon.
2. The patient must change their garments and prepare in sterile clothing.
3. Lateral internal sphincterotomy can be performed in the office using a local anaesthetic or performed under regional or general anaesthetic in the operating room.
4. While performing Lateral internal sphincterotomy in the office, a local anaesthetic is used however performing in an operating room requires regional or general anaesthetic.
5. The type of anaesthesia used is decided according to patient and surgeon preference.
6. A lateral internal sphincterotomy usually takes 30 minutes to complete, and generally, the patients are discharged on the same day.
7. Patients can either be asleep or awake during surgery and if the patient is awake, the surgeon gives medicine to relax the patient. 
8. The surgeon inserts a scope, or lighted tube, into the anus during the procedure to better understand the injury. 
9. Small incision tools are used to cut the internal anal sphincter, the small muscle ring responsible for controlling the anus.

After Surgery

The pain mainly lasts for a few days and goes away within a week, thus allowing patients to resume their regular activities; however, it takes six weeks to recover completely.

Following are some suggestions for post-procedure care:

1. Get a lot of rest.
2. Take daily short walks to avoid constipation and enhance blood flow.
3. To avoid pain when using the bathroom, always keep hydrated and consume a fiber   enriched diet.
4. Use a little stool beneath your feet to put your body in a squatting position in the toilet.
5. To promote healing, take numerous short sitz baths throughout the day.
6. Use baby wipes or medicated wipes instead of toilet paper to clean the area.

The most common complication after surgery is anal incontinence. Around half of patients experience this after surgery, but for most, it resolves over time. This can show up as the loss of stool or the inability to control your gas. Other minor complications include: 

1. Infection
2. Excessive bleeding
3. Fistula