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

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

11. PROBLEMS  FAECAL INCONTINENCE

12. INCONTINENCE

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

15. ISLAND FLAPS

26. ROTATIONAL FLAPS  USING LATERAL SIDE AS A FULCRUM  AIM TO AVOID DONOR SITE INFECTIONS

27. Operative technique

29. Proposed flap

31. Rotation and tension free closure

32. Sutured flap

33. Questionnaire data Before Surgery After Surgery IncontinenceGas00 Liquid Stool11 Solid00 None20 PainSevere171 Mild44 None016 Functional outcome/overall satisfaction Good15 Fair5 Poor1

34. Fissure/donor site YESNO HEALED FISSURE 183 HEALTHY DONOR SITE 192

35. 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

36. 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

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

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

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

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