Symposium

Anorectal Problems:

L a t e r a l S u b c u t a n e o u s A n a l S p h i n c t e r o t o m y

ANTHONY HUNTER, F.R.A.C.S.*

Auckland, New Zealand

DR. FERGUSON

I would like now to call on Mr. Anthony Hunter , who will talk on lateral subcutane- ous anal sphincterotomy, a simple tech- nique.

MR. HUNTER

As is well known, the classic and true description of an anal fissure includes the fact that it lies in the lower half of the anal canal extending down from the level of the anal valves to the anal verge with a sentinel skin tag at its lower end and a pseudo- polyp at its upper extremity (Fig. 1). In this situation the fissure overlies the lowest third or quarter of the internal sphincter muscle.

Eisenhammer 2, Goligher et al. 4, and Morgan and Thompson I0 all emphasized that the muscle tissue underlying an anal fissure was the internal sphincter (Fig 2). Miles,9 in 1919, had an alternative view in- so much that he considered that the pale tissue exposed by a chronic fissure was not sphincter muscle at all, but instead a con- densation of fibrous tissue in the submucous plane of the anal canal forming a ring of fibrosis, which he called the "pecten band" (Fig. 3). I believe that this is the state of

affairs, and it is important to realize that due to chronic inflammation these fibrous

* 102 Remuera Road, Auckland, 5, New Zealand.

Dis. Col. & Reet. Nov.-Dec. 1975

665

PSEUDO-POLYP ....

ANAL FISSURE

SENTINEL SKIN T A 6 ~ J FIG. 1. Classic anal fissure.

i bands do extend out as a ring of fibrous tissue or a pecten in the submucous plane. I am convinced, too, that division of these bands is just as essential as division of the lower third of the internal sphincter as is carried out in internal sphincterotomy. I do not regard these bands as any part of the sphincter muscle. They can be readily palpated in the submucosal plane as a com- plete separate entity.

T rea tmen t

Over the years three types of operative procedures have been mainly used in the treatment of a chronic anal fissure: stretch- ing of the anal sphincter, excision of the fissure, and internal sphincterotomy. T o

Volume 18 Number 8

666 H U N T E R Dis. CoL & Rect. Nov.-Dec. 1975

Fro. 2. Submucosal pecten band, showing posi- tion of internal sphincter in relation to band.

Fro. 3. Submucosal pecten band, showing band of fibrosis extending out from base of fissure.

be effective, the stretching procedure must be very forcible and must be performed with the pat ient under deep general anes- thesia with the use of a relaxant drug; otherwise, the fibrous submucosal bands, and also some of the muscle fibers, will not be ruptured. Watts et al. I3 analyzed the re- sults of this procedure, and from this survey concluded that there was good evidence for making this procedure the first line of sur- gical attack on this condition.

Gabriela was the great advocate for ex- cision of the anal fissure, but in his method he divided the underlying muscle fibers of the internal sphincter, in addition to dila- tation of the sphincter. Admittedly, excision dealt with removal of the submucosal bands in the lateral edge of the fissure, but the patient was left with a rather uncomfortable anal wound for several weeks. Hughes r recommended grafting the anal wound to

shorten the period of convalescence, but the pat ient had a longer stay in hospital, and it could be a difficult area in which to ob- tain a good "take."

Eisenhammer 2 emphasized the impor- tance of the internal sphincter in anal fis- sure and introduced the modern operat ion of internal sphincterotomy. Morgan and Thompson10 revived this operat ion at St. Mark's Hospital, but contrary to the rec- ommendat ion of Eisenhammer 2 performed tile sphincterotomy in the midline poster- iorly. Bennett and Goligher, z in their analysis of the results of internal sphincter- otomy, found that the length of time for wound healing after this operation was seldom less than four weeks, and distressing problems such as incontinence of flatus and fecal soiling occurred in a high percentage of patients. Magee and ThompsonS con- firmed these results when performing this operation with local anesthesia as an out- patient procedure on 139 patients. From these results, Bennett and Goligher 1 and then Parks? 2 and later Hawley s strongly recommended lateral sphincterotomy where- by the lower part of tile internal sphincter was divided through a lateral curved in- cision. Notaras 11 recommended a simpler technique of lateral subcutaneous internal sphincterotomy, whereby the lower part of the internal sphincter was divided as in a subcutaneous tenotomy. Following this tech- nique the fissure healed rapidly, usually within three weeks, and there was a lower incidence of fecal soiling. These results were confirmed by Hoffmann and Goligher.~

Technique

After performing this simple type of operation in 90 patients I believe that it is the most reliable and satisfactory operat ion available for the t reatment of anal fissure. I do, however, consider that: 1) General anesthesia should be used; 2) the general anesthesia should be light so that the in- ternal sphincter can he easily palpated. 8)

Volume 18 S Y M P O S I U M - - A N A L S P H I N C T E R O T O M Y 667 Number 8

17IG. 4. Insertion of knife. FIc. 5. Division of muscle.

With the left forefinger inserted (Fig. 4) into the anorectum, a no. 15 Bard Parker knife blade should be inserted just lateral to the left lateral edge of the anus and then passed up into the subrnucosal plane; with a sweeping motion outwards the lower third or quarter of the internal sphincter muscle is divided (Fig. 5). The blade is then returned to the subrnucosal plane to divide with several strokes the small bands of the so-called "pecten," which can be easily palpated by the left forefinger in the anorectum. After these have been divided, and not until they have been completely severed, the left forefinger can easily be flexed into a small depression created by this division. 4) After pressure has been exerted on the perianal region to control hernostasis a simple 0 or 00 atraumatic plain catgut suture should be inserted to close the very small cutaneous stab wound (Fig. 6). FIG. 6. ~Vound closed.

668 H U N T E R Dis. Col. &Rect. Nov..Dec. 1975

Results

A questionnaire was mailed to the 90 patients who had undergone this surgical procedure. The following questions were asked: Were your symptoms relieved? Have you had perfect control of your bowel move- ments since operation? Do you have full control of flatus? Is soiling of underwear a problem?

Of the 74 patients who replied, 65 (88 per cent) had relief of their symptoms; 54 (73 per cent) had perfect control of bowel

movements; 54 (73 per cent) had full control of flatus; 50 (66 per cent) had no soiling of their underwear.

These results give one satisfaction that this is a reasonable and beneficial method of treating anal fissure. Thirty-four per cent of the patients did state that there was some soiling of the underwear, but there was no doubt that this question was a little ambiguous, and, on closer questioning, there was no doubt that this number of patients did not have fecal soiling. I con- sider this is a good operation.

References

1. Bennett RC, Goligher JC: Results of internal sphincterotomy for anal fissure. Br Med J 2: 1500, 1962

2. Eisenhammer S: The internal anal sphincter: Its surgical importance. S Afr Med J 27: 266, 1953

3. Gabriel WB: The Principles and Practice of Rectal Surgery. Ed 4. London, H. K. Lewis and Co., Ltd., 1948

4. Goligher JC, Leacock AG, Brossey JJ: The sur- gical anatomy of the anal canal. Br J Surg 43: 51, 1955

5. Hawley PR: The treatment of chronic fissure- in-ano: A trial of methods. Br J Surg 56: 915, 1969

6. Hoffman DC, Goligher JC: Lateral subcutane- ous internal sphincterotomy in treatment of anal fissure. Br Med J 3: 673, 1970

7. Hughes ES: Anal fissure. Br Med J 2: 803, 1953 8. Magee HR, Thompson HR: Internal anal

sphincterotomy as an out-patient operation. Gut 7: 190, 1966

9. Miles WE: Observations upon internal piles. Surg Gynecol Obstet 29: 497, 1919

10. Morgan CN, Thompson HR: Surgical anatomy of the anal canal with special reference to the surgical importance of the internal sphincter and conjoint longitudinal muscle. Ann R Coil Surg Engl 19: 88, 1956

11. Notaras MJ: Lateral subcutaneous sphincter- otomy for anal fissure--a new technique. Proc R Soc Med 62: 713, 1969

12. Parks AG: The management of fissure-in-ano. Hosp Med 1: 737, 1967

13. Watts JM, Bennett RC, Goligher JC: Stretch- ing of anal sphincters in treatment of fissure- in-ano. Br Med J 2: 342, 1964