Anal Fissure Surgery (Sphincterotomy / Laser)

Medically reviewed by Dr Murlidhar Boob, MS, FAIS, DLS, FMAS - Laparoscopic Surgeon & Surgical Gastroenterologist

What it is

An anal fissure is a small tear in the skin lining the lower end of the back passage. It is tiny, often just a few millimetres, yet it causes a sharp, cutting pain during and after passing motion that can last for hours. The pain makes the ring of muscle around the anus - the internal anal sphincter - clench in spasm. That spasm squeezes off the blood supply to the tear, so it cannot heal, and the next hard motion tears it again.

Fissure surgery breaks that cycle. The commonest operation is a lateral internal sphincterotomy (LIS): a small, measured cut in the internal sphincter muscle that releases the spasm so the tear can heal. Laser sphincterotomy achieves the same release using a laser fibre instead of a blade. Neither operation stitches the fissure shut; they take away the reason it will not heal.

Who needs it

Most fissures never need an operation. I recommend surgery when:

• The fissure has lasted more than six to eight weeks despite proper treatment - a chronic fissure.
• You have tried the medicines (stool softeners, fibre, ointments, sitz baths) correctly and the pain persists or returns.
• There is a hard ridge, a skin tag or a swollen papilla around the tear - signs of long-standing disease.
• The pain is affecting your life - dreading the toilet, avoiding food, losing sleep.
• Repeated fissures keep coming back in the same spot.

“Can I just keep using the ointment?” If a fissure is recent, yes - give it a proper course. But ointments help most people only while they are being used, and chronic fissures often return when the course ends. If you have had three or four rounds of treatment and the pain keeps coming back, surgery is not a defeat; it is the treatment that works. A fissure that does not heal also needs a proper look to make sure it is not something else.

How it is done

The surgeon first examines the area gently under anaesthesia to confirm the diagnosis and make sure there is no hidden fistula, abscess or other cause.

Lateral internal sphincterotomy. A tiny incision is made at the side of the anal canal. A small segment of the internal sphincter - generally only up to the level of the top of the fissure - is divided, which relieves the spasm. The wound is small and often left open, or closed with a single stitch.

Laser sphincterotomy. A fine laser fibre is used to divide the same small portion of the muscle, with the energy controlled so surrounding tissue is spared. Some surgeons also use the laser to tidy the edge of the fissure.

Fissurectomy and tag removal. If there is a hard sentinel pile, a hypertrophied papilla or scarred edges, these may be trimmed at the same sitting so that the fissure has clean edges to heal from.

Anaesthesia, duration and hospital stay

The operation is done under spinal anaesthesia or a short general anaesthetic; you are comfortable and pain-free throughout. It takes about 15 to 30 minutes.

This is usually day-care surgery. You walk within a couple of hours, eat the same day and go home that evening or the next morning.

Recovery

Day 1. A dull ache and a little spotting on the dressing are normal. The terrible, tearing pain of the fissure itself is usually gone or much reduced. Warm sitz baths start now - ten minutes, two or three times a day - along with a stool softener.

The first week. Pain on passing motion is mild and settles day by day. Drink plenty, eat fibre, and do not strain. Most desk workers are back within three to five days.

Weeks 2 to 4. The wound closes and the spotting stops. Keep up the fibre and water. Avoid heavy lifting and very long bike rides until it is comfortable.

By 6 weeks. The fissure has usually healed completely and normal life, including exercise, has resumed. If it has not, tell us - it is easier to deal with early.

“I still feel a little burning with the first motion. Is something wrong?” Not usually. A mild burning or soreness in the first week or two is part of healing. What I want to hear about is pain that is increasing, a lump that is getting bigger, fever, or bleeding that is more than spotting.

Risks and complications

• Difficulty holding wind for a few weeks, which is usually temporary.
• Minor soiling or leakage of liquid stool - uncommon, and rarely permanent; it is the reason the amount of muscle divided is chosen carefully.
• Bleeding or a small haematoma at the wound.
• Infection or a small abscess, rarely.
• Recurrence of the fissure, particularly if constipation returns.
• Delayed healing of the wound, needing longer dressings.
• The usual risks of anaesthesia, which the anaesthetist will discuss with you.

Women who have had a difficult vaginal delivery, and anyone with a weak sphincter to begin with, need a particularly careful assessment before any muscle is divided.

Alternatives

Medical treatment. Fibre, plenty of water, stool softeners, warm sitz baths and a muscle-relaxing ointment (such as diltiazem or glyceryl trinitrate) heal many fissures, especially recent ones.

Botulinum toxin injection. A temporary way to relax the sphincter. It helps some people but the effect wears off, and recurrence is more likely than after surgery.

Advancement flap. A flap of healthy skin is brought over the fissure. It is reserved for people in whom cutting the sphincter carries extra risk.

Many people with anal pain assume they have piles when the problem is a fissure, or the reverse - an examination settles it. You can read more in our blog on why an anal fissure hurts so much and how it heals without surgery, and about related conditions on our pages for laser and stapler piles surgery and fistula surgery. Our general surgery and gastroenterology team will examine you and tell you which it is, and you can see all the procedures we perform.

What it costs

Lateral internal sphincterotomy: ₹25,000 – ₹45,000

Laser sphincterotomy: ₹25,000 – ₹50,000

These ranges are all-inclusive - surgeon’s fee, operation theatre, anaesthesia, room rent for a typical stay, medicines and routine investigations.

Please note: The figures above are indicative estimates for a typical case. The final cost depends on your individual condition, the complexity of the surgery, the room category you choose, how long you stay, and any complications that arise. Deluxe and super-deluxe rooms are charged higher. Emergency admissions and night or holiday surgery attract additional charges. These charges are subject to change without prior intimation. Please call us on +91-8668954915 for a written estimate for your own case before you decide anything.

Preparing for your surgery

• Bring your records - previous prescriptions, any earlier procedure notes and your list of medicines.
• Tell us about bowel habits - long-standing constipation, diarrhoea, blood in the stool or weight loss need to be looked into first.
• Blood thinners must be discussed well before the date; never stop a heart medicine on your own.
• Fasting. Nothing to eat for six hours and nothing to drink for two hours before surgery, or as the anaesthetist instructs.
• Start fibre and water now so your first motion after surgery is soft.
• Arrange a basin or tub for sitz baths, loose cotton underclothes and a few pads.
• Tell us if you have had childbirth injuries or any trouble with bowel control before.

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If you have been living with this pain, you do not have to. The surgical team at Shubham Hi-Tech Hospital and Test Tube Baby Centre, Amravati, will examine you, tell you honestly whether medicines will do or whether an operation is the better choice, and explain which one suits you. Call +91-8668954915 or get in touch here.

Disclaimer: This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor for guidance specific to your situation.