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 – 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 data Incontinence Pain Functional outcome/overall satisfaction Before Surgery After Surgery Gas 0 0 Liquid Stool 1 1 Solid 0 0 None 20 20 Severe 17 1 Mild 4 4 None 0 16 Good 15 Fair 5 Poor 1 Fissure/donor site YES 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