surgery for anal fissures
DESCRIPTION
SURGERY FOR ANAL FISSURES. UNIVERSITY OF HULL ACADEMIC SURGICAL UNIT CASTLE HILL HOSPITAL. SURGICAL OPTIONS. ANAL STRETCH LATERAL SPHINCTEROTOMY EXCISION ISLAND FLAP ROTATION FLAP. AIM OF TREATMENT. HEALING OF THE FISSURE RESTORE NORMAL PRESSURE RESTORE BLOOD FLOW MAINTAIN CONTINENCE - PowerPoint PPT PresentationTRANSCRIPT
SURGERY FOR ANAL FISSURES
UNIVERSITY OF HULLACADEMIC SURGICAL UNITCASTLE HILL HOSPITAL
SURGICAL OPTIONS
ANAL STRETCH LATERAL SPHINCTEROTOMY EXCISION ISLAND FLAP ROTATION FLAP
AIM OF TREATMENT
HEALING OF THE FISSURE– RESTORE NORMAL PRESSURE– RESTORE BLOOD FLOW
MAINTAIN CONTINENCE– ONLY SURGEONS MAKE PATIENTS
INCONTINENT
ANAL STRETCH
PLEASE DO NOT DO
(? Balloon dilatation)
ANAL STRETCH
EXCISION +/- SUTURE
UNCOMMON PROCEDURE FRESHEN EDGES CLEAN FISSURE BASE
MAY SUTURE CLOSED
DOES NOT TREAT THE CAUSE
? COMBINE WITH BOTOX
LATERAL ANAL SPHINCTEROTOMY
OPEN TECHNIQUE MOST ACCURATE IAS ONLY 2mm ACROSS CUT NO FURTHER THAN DENTATE
LINE
GREAT CARE IN WOMEN SCAN IF POSSIBLE
LATERAL ANAL SPHINCTEROTOMY
LATERAL ANAL SPHINCTEROTOMY
RESULTS
ANAL STRETCH 80 – 90 % LATERAL SPHINCTEROTOMY
80 – 90 % EXCISION ?
PROBLEMS
FAECAL INCONTINENCE
INCONTINENCE
INCONTINENCE
ISLAND / V-Y FLAPS
“ARE NON DESTRUCTIVE” NEW, VASCULARISED TISSUE PROMOTE HEALING
ISLAND FLAPS
ISLAND FLAPS
ISLAND FLAPS
ROTATIONAL FLAPS
USING LATERAL SIDE AS A FULCRUM
AIM TO AVOID DONOR SITE INFECTIONS
Operative technique
Operative technique
Proposed flap
Proposed flap
Rotation and tension free closure
Sutured flap
Questionnaire dataBefore Surgery
After Surgery
Incontinence Gas 0 0
Liquid Stool 1 1
Solid 0 0
None 20 20
Pain Severe 17 1
Mild 4 4
None 0 16
Functional outcome/overall satisfaction
Good 15
Fair 5
Poor 1
Fissure/donor siteYES NO
HEALED FISSURE
18 3
HEALTHY DONOR SITE
19 2
Fissure/donor site Complete resolution 16 patients No new continence defects Three recurrent fissures Two donor site dehiscence
– Fissure fistula complex– Haemorrhoidectomy and advancement flap
Conclusions Use of rotation flap is simple, safe and
successful Fewer problems than island flaps Potential procedure of choice for chronic
anal fissures particularly in patients with risk of incontinence
CONCLUSIONS
WARN ABOUT INCONTINENCE USE LEAST DESTRUCTIVE METHOD NO LAS IN WOMEN ROTATIONAL FLAPS ARE LEAST
RISKY
ACTION PLAN FOR FISSURES DIETARY CHANGE CHEMICAL SPHINCTEROTOMY STILL A PLACE FOR LIS!
ASSESS INCLUDING USS
ROTATION / ISLAND FLAP
? HYPERBARIC OXYGEN
Operative technique No bowel prep GA Single dose of prophylactic antibiotics Jack-knife position Edges of fissure lifted Proposed flap marked
Results Median hospital stay 2 days (range 1-4) No post-operative morbidity Post-operative questionnaire