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SURGERY FOR ANAL FISSURES

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

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SURGERY FOR ANAL FISSURES

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  1. SURGERY FOR ANAL FISSURES UNIVERSITY OF HULL ACADEMIC SURGICAL UNIT CASTLE HILL HOSPITAL

  2. SURGICAL OPTIONS • ANAL STRETCH • LATERAL SPHINCTEROTOMY • EXCISION • ISLAND FLAP • ROTATION FLAP

  3. AIM OF TREATMENT • HEALING OF THE FISSURE • RESTORE NORMAL PRESSURE • RESTORE BLOOD FLOW • MAINTAIN CONTINENCE • ONLY SURGEONS MAKE PATIENTS INCONTINENT

  4. ANAL STRETCH PLEASE DO NOT DO (? Balloon dilatation)

  5. ANAL STRETCH

  6. EXCISION +/- SUTURE • UNCOMMON PROCEDURE • FRESHEN EDGES • CLEAN FISSURE BASE • MAY SUTURE CLOSED • DOES NOT TREAT THE CAUSE • ? COMBINE WITH BOTOX

  7. LATERAL ANAL SPHINCTEROTOMY • OPEN TECHNIQUE MOST ACCURATE • IAS ONLY 2mm ACROSS • CUT NO FURTHER THAN DENTATE LINE • GREAT CARE IN WOMEN • SCAN IF POSSIBLE

  8. LATERAL ANAL SPHINCTEROTOMY

  9. LATERAL ANAL SPHINCTEROTOMY

  10. RESULTS • ANAL STRETCH 80 – 90 % • LATERAL SPHINCTEROTOMY 80 – 90 % • EXCISION ?

  11. PROBLEMS • FAECAL INCONTINENCE

  12. INCONTINENCE

  13. INCONTINENCE

  14. ISLAND / V-Y FLAPS • “ARE NON DESTRUCTIVE” • NEW, VASCULARISED TISSUE • PROMOTE HEALING

  15. ISLAND FLAPS

  16. ISLAND FLAPS

  17. ISLAND FLAPS

  18. ROTATIONAL FLAPS • USING LATERAL SIDE AS A FULCRUM • AIM TO AVOID DONOR SITE INFECTIONS

  19. Operative technique

  20. Operative technique

  21. Proposed flap

  22. Proposed flap

  23. Rotation and tension free closure

  24. Sutured flap

  25. Questionnaire data

  26. Fissure/donor site

  27. 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

  28. 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

  29. CONCLUSIONS • WARN ABOUT INCONTINENCE • USE LEAST DESTRUCTIVE METHOD • NO LAS IN WOMEN • ROTATIONAL FLAPS ARE LEAST RISKY

  30. ACTION PLAN FOR FISSURES • DIETARY CHANGE • CHEMICAL SPHINCTEROTOMY • STILL A PLACE FOR LIS! • ASSESS INCLUDING USS • ROTATION / ISLAND FLAP • ? HYPERBARIC OXYGEN

  31. Operative technique • No bowel prep • GA • Single dose of prophylactic antibiotics • Jack-knife position • Edges of fissure lifted • Proposed flap marked

  32. Results • Median hospital stay 2 days (range 1-4) • No post-operative morbidity • Post-operative questionnaire

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