Preferred technique. Most surgeons agree that the operation of choice for a fissure that will not heal is a lateral subcutaneous internal sphincterotomy, which can easily be performed in the outpatient setting using local anesthesia. Here's how we do it:
With the patient in the prone jackknife position, we infiltrate the perianal tissues on one side of the anus with 15 mL of 0.25% bupivacaine(Drug information on bupivacaine) with epinephrine(Drug information on epinephrine). We always include the area adjacent to the fissure in the anesthetic field so that the anus can be dilated comfortably. Next, the proctoscope is inserted. Careful proctoscopy is performed to ensure that the patient has no other pathological anorectal condition.
We then insert a Hill-Ferguson anoscope into the anal canal, which stretches the anal sphincters. With the sphincters stretched by the instrument, the intersphincteric groove is easily palpable, as is the abnormally fibrotic portion of the internal sphincter that causes the fissure to persist. With the left index finger in the anus, a No. 11 blade scalpel is inserted into the intersphincteric groove, with the blade parallel to the internal sphincter (Figure 2 [A, B]). The blade is then turned perpendicular to the internal sphincter, and the fibrotic band in the sphincter is divided as pressure is applied to the sphincter under the blade with the finger in the anus. As pressure is applied over the scalpel, you can feel the fibers of the internal sphincter separating. The blade is removed through the incisional site, leaving the anoderm intact. Brief manual pressure ensures hemostasis.
Postoperative care. Our patients have surprisingly little discomfort after this procedure. We prescribe acetaminophen and ask them to continue sitz baths for a few days. We re-examine the patient in 2 weeks to verify healing. The published success rate for this procedure is greater than 90%, and complications such as incontinence are quite rare.2THROMBOSED HEMORRHOID
Diagnosis. The second most common cause of anal pain is a thrombosed external hemorrhoid. The patient reports pain of sudden onset that is associated with an anal mass. The diagnosis is immediately apparent when you see a swollen, dark-colored mass located at the anal verge. This is a clot in the external hemorrhoidal vein. The key here is to understand the time course of this process: the pain is most intense during the first 24 to 48 hours after the clot forms, and then it resolves rapidly, even with no treatment.
Treatment. Because surgical treatment of a thrombosed hemorrhoid is usually painful, we try to determine whether the procedure will cause more pain than conservative management. If the patient's pain is beginning to diminish, we usually recommend medical therapy with topical corticosteroids, warm soaks, and stool softeners.
Only if the patient has severe pain do we recommend excision. Although we prefer to perform the procedure in the operating room, it can be accomplished in the office with the aid of a local anesthetic (0.25% bupivacaine). The bupivicaine is infiltrated under and around the hemorrhoid, and the entire hemorrhoid, consisting of skin and thrombosed vein, is excised in an elliptical fashion. Electrocautery can be used for hemostasis. It is acceptable to leave the wound open and allow healing to occur by secondary intention, but we often approximate the skin edges with a running 3-0 absorbable suture. The entire hemorrhoid must be completely excised, because simply evacuating the thrombus often results in reaccumulation of the thrombus.
Patients usually have significant discomfort after the excision of a thrombosed hemorrhoid, so we recommend a leave from work for several days. The postoperative care is similar to that described for sphincterotomy.
ANORECTAL ABSCESS
The third common cause of anal pain is an anorectal abscess. This condition is the most subtle, and yet the most dangerous, of the three. Even if a fissure or thrombosed hemorrhoid remains untreated, it will likely resolve; it almost never becomes worse. In contrast, an untreated abscess can extend to adjacent areas and, in some instances, can be life-threatening, particularly in immunocompromised patients.
Origins and types of abscesses. Most anorectal abscesses originate in the anal glands at the base of the anal crypts. These glands are located between the internal and external anal sphincters. Thus, the origins of anorectal abscesses are cryptoglandular, and since the process arises in the space between the internal and external sphincters, most abscesses originate as intersphincteric abscesses. The intersphincteric plane is a conceptual space rather than a real one, and abscesses arising in the location must find egress as they expand (Figure 3). Such abscesses can extend in any direction, but most often the infection descends caudally between the sphincters, out to the perianal skin, a process that results in a tender, indurated perianal abscess. Occasionally, the pus travels in a lateral direction, penetrating into the large, fatty ischiorectal space, forming an ischiorectal abscess. Rarely, an abscess will extend in a cranial direction into the pelvis above the levator complex, the so-called supralevator abscess, which can elude even the seasoned clinician.