An anal fissure is an elliptical or oval shaped tear in the anal canal starting at the anal verge and extending proximally for a varying length towards the dentate line. According to the time of presentation it can be divided into acute and chronic anal fissure. Acute fissures appear as a shallow tear in the anoderm. The most common symptom is sharp anal pain with defecation, often described by patients as the feeling of “passing pieces of glass or razor blades.” The sharp pain can be followed by throbbing anal spasm. Anal bleeding can present as blood streaking on the stool or on the toilet paper (in western world). Anal fissures that are present for more than 6 to 8 weeks are considered to be chronic. Features of a chronic fissure include the presence of exposed internal sphincter fibers at the base, a hypertrophied anal papilla proximally, and a skin tag or sentinel pile distally.¹

Fissure-in-ano is the most common cause of severe anal pain. The pain may be so severe that patients may avoid defecation for days together, until they are severely constipated. This delay leads to hardening of the stools, which further tears the anoderm during defecation, setting a vicious cycle. Increased tone of the internal anal sphincter, mucosal ischemia along the posterior midline, chronic constipation and injury from hard stools are the factors causing development of chronic fissure in ano^{.2, 3}

Studies on the methods of treatment of chronic anal fissures range from medical applications to surgery; there is no general agreement on ideal therapy for chronic anal fissures. Management ranges from medical (conservative management) to surgical, but medical management do not achieve satisfactory results in many patents, while surgical techniques have their own advantages and disadvantages. Two widely performed surgeries include Lord’s anal dilatation (LAD) and lateral internal sphincterotomy (LIS). LAD is one of the ancient and simple surgical techniques, but with little higher incidence of incontinence theoretically. LIS is the preferred surgical technique these days but bleeding can occur and rarely hematoma can occur which can get infected and abscess formation may happen. Aim of this study is to compare LAD with LIS in the treatment of anal fissure with regard to symptoms, post-operative complications and recurrence.⁴

The present study was a retrospective study done in the department of general surgery of Narendra modi medical college and LG hospital from September 2024 to January 2025. All the patients with anal pain for more than 8 weeks with presence of induraton of the edges of the fissure were included in the study. Inclusion criteria followed in the study was the age of patient was to be between 18 – 50 years, having chronic anal fissure (CAF) and all the patients having CAF not responded to the medical management for more than 6 weeks. The patients who are fit for anesthesia and are included. The patients with the following criteria were excluded from the study: Patients with inflammatory bowel disease, AIDS, tuberculosis, sexually transmitted diseases; pregnancy/ puerperium; patients on anticoagulation/ immunosuppressant medications. All the included patients were explained about the study and the inform consent was taken from all the patients. Pre and post-operative pain was accessed using Visual Analogue scale (VAS)⁵. Third generation cephalosporin were administered before surgery as prophylactic antibiotics in stat doses. Both procedures were carried out in general or spinal anesthesia with patient in lithotomy position. After cleaning of the surgical field with Povidone-iodine, draping of the field was done.

Lord’s anal dilatation

Anal dilatation was performed as described by Watts et al.⁶ First digital rectal examination, and proctoscopy was performed to confirm clinical findings, and to rule out other causes of bleeding. Thereafter fully lubricated index finger of right hand was introduced, and anal spasm was palpated which corresponds to anorectal line. After palpating the anal spasm, fully lubricated index finger of each hand was introduced in the anal canal and continuous gentle outward pressure was applied, till the spasm overcome at 3 and 9 o'clock position for 15 to 20 seconds followed by repeation of same manuevour on 12 and 6 o'clock position. The procedure was stopped till the anal canal was relaxed enough to accept four fingers (two of each hand) at a time without much force.

 Lateral internal sphincterotomy

Lateral internal sphincterotomy was always performed on the left side with the patient in the lithotomy position. A small incision was made lateral to the lower edge of the internal sphincter, which was located by the finger in intersphincteric groove by knife no 11. The knife is then rotated 90 degree with blades at right angle to internal sphincter, facing inwards to anal mucosa. The knife is advanced towards the index finger and fibres are cut. During these maneuver feeling of give away is felt with  V shaped defect palpable at the incised site.⁷

Post-operative management

Post-operatively patient was given oral second-generation cephalosporin and metronidazole and discharged with same medication for one week. Injectable NSAIDs were administered the following evening and oral NSAIDs were started from the next day. Patients resumed eating after six hours of surgery. Sitz bath and laxatives were advised from the first postoperative day and continued for one week. Patients were discharged on first post-operative day, and any delay along with reason for the same, was noted. Patients were followed up to assess any complications of the procedure (pain, incontinence, abscess formation.) No patient was lost to follow up. At follow up symptoms were assessed and the anus examined for signs of recurrence.

Statistical analysis 

Data entered into MS excel 2010 spreadsheet and result were calculated using statistical software SPSS 20.

The male to female ratio was 1.85:1. The majority of the population was male.

Preoperative findings

There were complains of bleeding per rectum, itching on presentation and pain. The most common complaint was of pain and was present in 95% of cases. When the visual analogue pain score was done there were 75% of patients with moderate pain (45-74mm) and 25% had severe pain(75-100 mm). The second most presenting complaint was of bleeding per rectum, it was found in 70% of the patients. On examination sentinel tag was present in all the cases out of which 85% was posterior,10% anterior and multiple in 5% cases.

Post-operative findings

The post operative complains were, pain and bleeding per rectum. The evaluation of pain score at different points is shown in table below. The maximum pain score at 24 hours of operation were seen less in patient with LIS group as compared to LAD group. However, there was no significant difference in the pain score between the two groups when evaluated subsequently i.e. 2 weeks, 6 weeks.

There was no specific bleeding per rectum at 24 hours after operation. And it was insignificant in both group. Other non significant complain known on follow up includes itching in the perianal region in 2 out of 10 in LIS and 1 out of 10 in LAD; which was insignificant and relieved on medication.

The functional results were better after sphincterotomy than after anal dilatation. 1 out of 10 patients, treated by anal dilatation, fecal soiling was a major problem. Furthermore, 1 of the patient treated by dilatation had impaired control of flatus at the time of follow up, whereas none of the patients treated by lateral internal sphincterotomy suffered from any of these complications (p < 0.002). Impaired control of feces was not present in any of the patients in either the groups (Table-2).

The ratio of male and female (1.85:1) in this study is comparable to other studies as of Nahas et al (2.3: 1)⁹ and Gupta V et al (1.4: 1)⁸.

In this study pain was main presenting complaint, followed by associated bleeding per rectum this was in accordance to results by Mapel et al.¹⁰ On examination posterior anal fissure (6 O’ Clock) was most common finding, followed by anterior (12 O’ Clock) and mixed. These observations were in accordance with observations of previous studies.^8-10

In this study, pain score in first 24 hours was significantly higher in LAD group as compared to LIS group reason might be due to inter-individual difference in the application of force in anal dilatation, intra-operatively. This difference was negated in subsequent days and difference at the time of discharge was non-significant.

Incontinence is one of the complications of surgeries around anal canal. In this study also, author had such incidences but were temporary and subsided in due course of time. At the end of six weeks complete healing occurred in 90-95% cases in both the group which were in accordance to other studies conducted Gupta V et al.⁸

These findings show that lateral internal sphincterotomy is better than simple anal dilatation for chronic  anal fissure in patients. The recurrence rate of the fissures was significantly less after sphincterotomy, and the functional results with respect to control of flatus and soiling of underwear were significantly better in patients treated by sphincterotomy.

Anal fissure is a very common problem worldwide. It causes considerable morbidity and adversely affects the quality of life. Therefore, appropriate treatment is mandatory. Hence we conclude compared with anal dilatation, lateral internal sphincterotomy is the treatment of choice for patients with chronic anal fissure.

Funding: No funding sources

Conflict of interest: None declared

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