Open versus closed lateral internal anal sphincterotomy for chronic anal fissure: A prospective randomized comparative study.

Dr G.  Surendhar; Dr. Velpula  Sathish; Dr. D  Surender

doi:10.51168/sjhrafrica.v6i12.2440

Authors

Dr .G. Surendhar Assistant Professor, Department of General Surgery, Government Medical College, Mahabubabad, Telangana, India
Dr .Velpula Sathish Senior Resident, Department of General Surgery, Government Medical College, Mahabubabad, Telangana, India
Dr. D .Surender Assistant Professor, Department of General Surgery, Government Medical College, Mahabubabad, Telangana, India

DOI:

https://doi.org/10.51168/sjhrafrica.v6i12.2440

Keywords:

Anal fissure, lateral internal anal sphincterotomy, open technique, closed technique, postoperative pain, hospital stay

Abstract

Background

Chronic anal fissure is frequently associated with internal anal sphincter hypertonia and persistent post-defecatory pain. Lateral internal anal sphincterotomy (LIAS) remains the definitive surgical treatment, but open and closed techniques differ in operative exposure and tissue handling.

Objectives: To compare open and closed LIAS with respect to operative and early postoperative outcomes, including pain, length of stay, complications, and recurrence.

Methods

A prospective randomized comparative study was conducted at St. Philomena Hospital, Bengaluru, between December 2020 and June 2022. Sixty adults with chronic anal fissure were randomized to open LIAS (Notaras technique) or closed LIAS (n=30 each). Outcomes included type of anesthesia, duration of surgery, hospital stay, postoperative pain scores (VAS) at 12 and 24 hours, complications (bleeding, hematoma, infection/abscess), continence status, and recurrence during follow-up.

Results

Baseline characteristics were comparable between groups. Closed LIAS was performed predominantly under spinal anesthesia and had a shorter operative duration (13.36±3.11 vs 16.60±2.49 minutes). Hospital stay was shorter after closed LIAS (1.30±0.74 vs 2.36±0.80 days). Pain scores were lower in the closed group at 12 hours (2.83±0.87 vs 3.50±1.27) and 24 hours (3.23±0.85 vs 5.30±1.08). Bleeding and hematoma occurred only after open LIAS (6.7% each). No fecal or flatus incontinence was recorded in either group. Recurrence occurred in 6.7% of open LIAS and none after closed LIAS.

Conclusion

Closed LIAS provided faster surgery, earlier discharge, and lower early postoperative pain, with a low complication profile and no continence impairment in this cohort.

Recommendations

Where surgical expertise is available, the closed technique can be preferred for an uncomplicated chronic anal fissure, alongside standardized analgesia, fiber supplementation, and scheduled follow-up.

Author Biographies

Dr .G. Surendhar, Assistant Professor, Department of General Surgery, Government Medical College, Mahabubabad, Telangana, India

is an Assistant Professor in the Department of General Surgery at Government Medical College, Mahabubabad, Telangana, India. He completed his MBBS from Kakatiya Medical College, Warangal, and subsequently obtained DNB (General Surgery) in Bangalore, India. His clinical and academic interests include comprehensive general surgical care, perioperative decision-making, and structured training of undergraduate and postgraduate learners, with a strong focus on patient safety and evidence-based practice. ORCID iD: https://orcid.org/0009-0006-9661-2539

Dr .Velpula Sathish, Senior Resident, Department of General Surgery, Government Medical College, Mahabubabad, Telangana, India

is a Senior Resident in the Department of General Surgery at Government Medical College, Mahabubabad, Telangana, India. He completed his MBBS at Mamata Medical College, Khammam, and pursued his MS (General Surgery) at Bhaskar Medical College. In his current role, he is actively involved in emergency and elective surgical services, inpatient management, and perioperative care, while contributing to departmental academic activities and clinical skill development. His interests include structured clinical audit, strengthening surgical workflows, and improving outcomes through protocol-based practice in a teaching-hospital environment.

Dr. D .Surender, Assistant Professor, Department of General Surgery, Government Medical College, Mahabubabad, Telangana, India

Surender is an Assistant Professor in the Department of General Surgery at Government Medical College, Mahabubabad, Telangana, India. He completed his MBBS from RIMS, Kadapa, and obtained his MS (General Surgery) from Kakatiya Medical College, Warangal. Before his current academic appointment, he served as Senior Resident at Government Medical College, Mahabubabad. His professional work focuses on comprehensive general surgical care, perioperative decision-making, and surgical training of undergraduate and postgraduate learners, with a consistent emphasis on patient safety and evidence-based practice.

References

Davids JS, Hawkins AT, Bhama AR, Feinberg AE, Grieco MJ, Lightner AL, et al Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures. Dis Colon Rectum. 2023 Feb 1;66(2):190-199. doi: 10.1097/DCR.0000000000002664. Epub 2022 Nov 1. PMID: 36321851.2.Stewart DB Sr, Gaertner W, Glasgow S, Migaly J, Feingold D, Steele SR. Clinical Practice Guideline for the Management of Anal Fissures. Dis Colon Rectum. 2017 Jan;60(1):7-14. https://doi.org/10.1097/DCR.0000000000000735 PMid:27926552

Notaras MJ. The treatment of anal fissure by lateral subcutaneous internal sphincterotomy--a technique and results. Br J Surg. 1971 Feb;58(2):96-100. https://doi.org/10.1002/bjs.1800580204 PMid:5548514

Millar DM. Subcutaneous lateral internal anal sphincterotomy for anal fissure. Br J Surg. 1971 Oct;58(10):737-739. https://doi.org/10.1002/bjs.1800581007 PMid:5124401

Abcarian H. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy--midline sphincterotomy. Dis Colon Rectum. 1980 Jan-Feb;23(1):31-36. https://doi.org/10.1007/BF02587197 PMid:7379649

Garcia-Aguilar J, Belmonte C, Wong WD, Lowry AC, Madoff RD. Open vs. closed sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum. 1996 Apr;39(4):440-3. https://doi.org/10.1007/BF02054061 PMid:8878506

Kortbeek JB, Langevin JM, Khoo RE, Heine JA. Chronic fissure-in-ano: a randomized study comparing open and subcutaneous lateral internal sphincterotomy. Dis Colon Rectum. 1992 Sep;35(9):835-837. https://doi.org/10.1007/BF02047868 PMid:1511641

Littlejohn DR, Newstead GL. Tailored lateral sphincterotomy for anal fissure. Dis Colon Rectum. 1997 Dec;40(12):1439-1442. https://doi.org/10.1007/BF02070709 PMid:9407982

Richard CS, Gregoire R, Plewes EA, Silverman R, Burul C, Buie D, et al. Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group. Dis Colon Rectum. 2000 Aug;43(8):1048-57; discussion 1057-8. https://doi.org/10.1007/BF02236548 PMid:10950002

Arroyo A, Pérez F, Serrano P, Candela F, Calpena R. Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: prospective randomized study of clinical and manometric long-term results. J Am Coll Surg. 2004 Sep;199(3):361-7. https://doi.org/10.1016/j.jamcollsurg.2004.04.016 PMid:15325604

Wiley M, Day P, Rieger N, Stephens J, Moore J. Open vs. closed lateral internal sphincterotomy for idiopathic fissure-in-ano: a prospective, randomized, controlled trial. Dis Colon Rectum. 2004 Jun;47(6):847-852 https://doi.org/10.1007/s10350-004-0530-2 PMid:15129311

Gupta V, Rodrigues G, Prabhu R, Ravi C. Open versus closed lateral internal anal sphincterotomy in the management of chronic anal fissures: a prospective randomized study. Asian J Surg. 2014 Oct;37(4):178-183. https://doi.org/10.1016/j.asjsur.2014.01.009 PMid:24637183

Garg P, Garg M, Menon GR. Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis. Colorectal Dis. 2013 Mar;15(3):e104-e117. https://doi.org/10.1111/codi.12108 PMid:23320551

Arroyo Sebastián A, Pérez Vicente F, Miranda Tauler E, Sánchez Romero A, Serrano Paz P, Calpena Rico R. Surgical (close lateral internal sphincterotomy) versus chemical (botulinum toxin) sphincterotomy as treatment of chronic anal fissure. Med Clin (Barc). 2005 Apr 23;124(15):573-5. doi: 10.1157/13074137. PMID: 15860170. https://doi.org/10.1157/13074137 PMid:15860170