Question
Asked 14th Nov, 2012
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What is the ideal extent of lateral internal sphicterotomy ?

Should we end up at the apex of the anal fissure or reach up to dentate line irrespective of the extent of fissue?

Most recent answer

19th Dec, 2012
Alexander Julianov
Trakia University
I agree with Dr. Memon. The goal of internal sphincterotomy is to relieve the hypertonus of the internal sphincter in order to stop the vicious circle: pain-spasm-impaired blood flow & healing-pain.
I do LIS in an outpatient ambulatory practice under local anesthesia for more than 15 years. The lengths of the fissure or the dentate line are not important landmarks in LIS for me, as the effect of the procedure is related only to the relaxation achieved with it. To achieve good relaxation in my practice is usually sufficient to cut 50-60% of the length of the IS. I never experienced a post-LIS incontinence of any grade following this rule. However in about 5% of pts the fissure not healed with or without symptoms and another procedure may be necessary at the opposite side. The digital examination of the sphincter is the key when considering LIS, as you can face with fissures without spasm of the IS and surely LIS should be avoided in these patients.
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All Answers (6)

14th Nov, 2012
Doron Kopelman
Technion - Israel Institute of Technology
Shouldnt be at the site of the fissure at all, these are usually at the mid sagital plane. That is why this procedure is called "lateral sphinct....." the extent is 90-100% of the sphincter fibers. personaly I believe that we should try to avoid these procedures as much as possible due to future compromise of continence.
16th Nov, 2012
Jonathan N Lund
The lateral sphincterotomy should be "tailored" to the length of the fissure. Cutting to the dentate line is too far and results in greater incidence of impairment of continence, especially in women who have shorter internal sphincters and who also have a much greater chance of having a co-existinf or future obstetric sphincter injury.
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10th Dec, 2012
Ajaz Ahmad Malik
Sher-i-Kashmir Institute of Medical Sciences
SILS is an excellent procedure in anal fissure provided one takes into consideration its actual indication and does it the way that it does not harm the sphincter complex.. I also agree with Jonathan Lund.Refer to one of our studies:Subcutaneous internal lateral sphincterotomy (SILS) versus nitroglycerine ointment in anal fissure: A prospective study
Shiraz Ahmad Rathera, , , Tanveer Iqbal Dara, Aijaz Ahmad Malika, Aijaz Ahmad Rathera, Asima Khanb, Fazal Q. Parraya, Rauf Ahmad Wania
a Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, J&K 190011, India
b Department of gynecology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, J&K 190011, India
http://dx.doi.org/10.1016/j.ijsu.2010.01.013, How to Cite or Link Using DOI
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10th Dec, 2012
Aijaz Ahmed Memon
Muhammad Medical college Mirpurkhas Pakistan
The extent of sphincterotomy should be partial sphincterotomy so that after the procedure the sphincter is sufficiently relaxed to allow the fissure to heal.
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