Editing Fissure-in-ano (section)

=== Third-line: ===

** Anal dilatation - old, now not used.
** Internal sphincterotomy. Risk of incontinence 5%. Pre-op enema. Incontinence and soiling is usually transient up to 3/12, but 20% will get flatus incontinence. Complete long-term healing rates exceed 90%. '''Used only as last resort in women''' - exclude low-pressure fissure with clinical examination and manometry prior.
*** Lateral internal sphincterotomy is preferred method, can be performed either open or closed technique, fairly equivalent results, however most modern surgeons would stay well clear of the closed technique now.
***

{| class="wikitable"
|Open
|Parkes retractor to put fibres on stretch (if struggling to identify groove, try without muscle relaxant). Small, radially-oriented incision over the intersphincteric groove at 3 or 9 o'clock (not directly under the fissure - can lead to keyhole deformity and chronic leakage), dissecting out a plane both superficial and deep to the internal sphincter muscle, grasping it with Allis forceps, and cutting in the muscle with scissors or diathermy, for 5mm (previously up to length of the fissure, but this gives a higher risk of incontinence in long fissure; classically to the level of the pectinate line). Close the incision with absorbable suture in anoderm.
|-
|Closed
|Index finger in the anal canal, insert an 11-blade scalpel in the intersphincteric groove, and cutting the muscle towards the finger
|}

** Fissurectomy, with or without advancement flap
*** Especially when patients have a low baseline sphincter resting pressure