Proctological surgery

What is an anal fissure?

Anal fissure is a tear in the skin of the anal canal (much like a crack on the hand or foot) usually responsible for anal pain punctuated by defecation. When it is chronic, it can be accompanied by a fold of flesh partially covering it (marisque) or by a hypertrophic papilla (formation of intracanal flesh). It can be complicated by an anal abscess. The uncomplicated fissure is however a benign disease that does not systematically require surgical treatment. It is linked to anal hypertonia which weakens the mucous membrane and occurs preferentially in the event of constipation.

In the event of failure of medical treatment, when the fissure is responsible for significant and repeated pain or when the fissure is associated with complications, surgical management may become the solution. There are several surgical techniques which may or may not involve, to varying degrees, a section of the anal sphincter (muscle of the anus), the removal of the fissure and/or a reconstruction procedure (called anoplasty). The goal of fissurectomy with mucosal anoplasty is to remove the fissure. In addition, it allows the associated formations (mariscus, hypertrophic papilla) to be removed at the same time. Another intervention consists in partially cutting the internal sphincter in order to release the anal sphincter and allow the healing of the fissure. This technique has been known and practiced for many years on a large number of patients. The risk of recurrence is estimated at less than 10%.

Role of surgery in the treatment of an anal fissure

This is a surgical procedure performed in the operating room under general or locoregional anesthesia (this choice is discussed with the anesthesiologist during your pre-anaesthesia consultation but does not in any way modify the surgical procedure itself).

This intervention consists in removing, at the level of the posterior pole of the anus, a tab of skin in the middle of which is the fissure (= “fissectomy”), to carry out a partial section (= “sphincterotomy”) of the anal sphincter ( to combat hypertonia) with partial covering of the wound by a small part of the mucosa (internal lining) of the rectum (= “mucosal anoplasty”). The goal is to replace the diseased cracked skin with another covering in better condition.

What is your background during the surgical treatment of an anal fissure?

After having met your surgeon, who has confirmed that this crack should be surgically treated, you will meet your anesthetist who will ensure that anesthesia is possible.

The day before the operation, you must be fasting from midnight. If you take medication on a daily basis, you should discuss this with your surgeon and your anesthesiologist, who may want you to take some of your medication on the morning of the procedure with a background of water. If you take aspirin or medication to thin your blood, tell your surgeon and your anesthesiologist.

The Charcot clinic team (Lyon) welcomes you on admission, the morning of the operation, checks the administrative formalities, ensures that there is no new information and that the instructions given before intervention (shower, fasting, etc.) have been respected.
Then you are taken to the operating room in the operating room, where your surgeon and your anesthesiologist surrounded by their team welcome you and carry out the usual checks (identity, compliance with instructions, etc.).

When you are asleep, your surgeon, assisted by a nurse, will treat this fissure. The duration of the intervention varies from 20 to 45 minutes and depends on the importance and impact of your crack. Local anesthesia (puddendal blocks) is systematically performed in order to limit the pain associated with the procedure.

Once awake, after a few hours in the recovery room, you return to your room. A nurse on the ward makes sure that you are not in too much pain, that you are not nauseous or vomiting, that you gradually come to your senses. A snack is served. Your surgeon comes by at the end of the day to make sure that you are well, authorizes your discharge if necessary and gives you post-operative instructions.

What Complications Can Occur After Anal Fissure Surgery?

This operation is frequent, the technique of this intervention is precise, but, as in any intervention, certain complications can occur: a reaction to anesthesia, early urinary disorders (10 to 20% of cases), marked by retention of urine most often linked to a reflex phenomenon, may appear. It can be treated medically, but may sometimes require the temporary placement of a catheter in the bladder. Early hemorrhage, which sometimes involves an additional action by the doctor to coagulate the bleeding vessel, is also a complication. Rare secondary bleeding is possible (< 1% of cases, up to the 15th day) due to the loss of scar tissue. It most often requires a short hospital stay to coagulate the vessel, possibly under general anesthesia. It is therefore advisable not to go far and to refrain from any train or plane travel for a period of 2 weeks. Constipation may require an increase in laxative treatment. Sometimes the formation of a real “plug” of materials may require the use of an enema. Local infection is exceptional and may require re-intervention. No guarantee can be given regarding the appearance of the scar. Marisques (painless growths around the anus) and unsightly scarring are sometimes observed without it being possible to speak of a complication.

Healing delay may occur. The wounds usually heal in 4 to 8 weeks but longer delays are possible (sometimes several months) in 10 to 20% of cases very rarely requiring a re-intervention. Exceptional continence disorders have been reported. Continence disorders can be favored by prior anomalies, secondary in particular to difficult deliveries, transit disorders or a history of proctologic surgery. They may exist before the surgery. Don’t hesitate to talk to your surgeon about it because they can modify the treatment. Very rare fistulas by superinfection of the operative wound can occur at a distance then most often requiring a re-intervention.

New findings during the operation may lead your surgeon to modify the course of the operation in your interest.

The list of complications described is not exhaustive, but it is important to understand that one of the objectives of the preoperative consultation is to allow your surgeon to weigh up the risks that you would take by not having surgery with the risks inherent in an intervention. If an indication for surgery has been selected, unlike cosmetic surgery, it is very likely that there would be more risks in not carrying out this intervention. If in doubt on your part, do not hesitate to ask your surgeon for clarification.

How are the days after anal fissure surgery?

The creation of a cutaneous wound wider than the crack itself imposes a healing of the order of 4 to 8 weeks. However, there is no real contraindication to resuming an activity in the absence of pain. Classically, pain may be present post-operatively for a few days, although in most cases this pain is less than that which existed before the intervention. Weeping or discharge is usual after the procedure, as well as minimal bleeding, which usually persists until the wound has healed. Post-operative care is simple (cleaning with soap or antiseptic in the shower or in sitz baths, possible application of cream or ointment, etc.) and usually does not require the intervention of a nurse. These treatments will be detailed to you by your surgeon.

What to do in case of problems at home after anal fissure surgery?

You must absolutely contact your surgeon in case of persistent fever, heavy bleeding, pain that resists the medication prescribed after the operation, persistent nausea, vomiting or difficulty in urinating. If in doubt, do not hesitate to speak up.

When you leave, the documents provided by your surgeon and/or the nurses in the service include the telephone number of the surgery secretariat and the telephone number of the general practitioner on duty (7 days a week, 24 hours a day) practicing at the Charcot clinic. (Lyons). He can, if he deems it necessary, hospitalize you. Do not hesitate to contact us.

Post-operative advice after anal fissure surgery

Post-operative care is simple (cleaning with soap or antiseptic in the shower or in sitz baths, possible application of cream or ointment, etc.) and usually does not require the intervention of a nurse. These treatments will be detailed to you by your surgeon.

Smoking increases the risk of surgical complications. Quitting smoking 6-8 weeks before the procedure eliminates this additional risk. If you smoke, talk to your doctor, your surgeon and your anesthetist or call the Tobacco-Info-Service line at 39 89 to help you reduce the risks and put the odds in your favor.