Anal Fissure: Surgical Therapy

If there is still no healing after 6-8 weeks of conservative therapy (= chronic anal fissure) and the symptoms last, surgical therapy should be performed.

1st order

  • Fissurectomy (according to Gabriel): excision (cutting out) of the fissure/scar in chronic anal fissure; the resulting wound area is left to free granulation (formation of young connective tissue as part of wound healing).The procedure has a higher healing rate than all conservative therapies and has a low incontinence rate (i.e., ability to retain stool and deliberately empty the bowel (first-line therapy).
    • Performance of the above procedure with anal advancement flap: in this procedure, anal mucosa (mucosa) is mobilized over the fissurectomy wound and, in part, perianal skin (“around the anus“) is displaced externally over the fissure.The procedure can be performed in addition to conventional fissurectomy as first-line surgical therapy or as second-line therapy after unsuccessful fissurectomy [S3 guideline].

2nd order

  • Lateral internal sphincterotomy (LIS) – surgical transection of the internal anal sphincter; here, open and closed lateral sphincterotomy achieve similar results in terms of healing and side effects.The procedure has a higher healing rate than fissurectomy, but has a higher incontinence rate than fissurectomy.In the United States, the procedure goes as the gold standard (level 1a evidence – with strong recommendation) because of the high healing rates. Relative contraindication: postpartum (“after birth”) patients, with decreased sphincter tone or previous anal surgery, including failure of other surgical therapies.

Other notes

  • The S3 guideline indicates that combined therapy of fissurectomy with botulinum toxin injection may have additional benefit, as both procedures target the pathogenetic factor of the fissure, namely sphincteric hypertension (increased pressure of the anal sphincter).
  • Anal dilation: anal dilation (uncontrolled and manual) has a lower cure rate than LIS and the highest postoperative incontinence rate of all procedures and should therefore not be used” [S3 guideline].