Topography and classification of defects
The anatomical location of the pathology has a clearly defined pattern that must be considered during diagnosis. The vast majority of defects — 90% of cases — are localized precisely on the posterior wall of the anal canal. Much less commonly, in only 10% of cases, the pathology forms on the anterior wall.
Patient management tactics are entirely determined by the duration of the problem. In clinical practice, two main forms are distinguished:
- Acute fissures — fresh mucosal defects.
- Chronic fissures — long-term non-healing wounds that have existed in the patient from four months to several years.
Choice of surgical tactics
A strictly regulated approach is provided for each stage of the disease. In the acute form, radical surgery is not indicated. The main treatment method is sphincter stretching (in Latin terminology — divulsio). Related terms are also found in medical nomenclature, such as sphincterotomia (dissection), fissurectomia (excision), and dilatatio (dilation), but it is specifically divulsio that is the method of choice in the acute stage.
If the disease has transitioned into a chronic stage and has existed for 4 months or more, conservative methods become ineffective. In this case, full surgical excision of the pathological focus is indicated.
Preparation for surgical intervention
To perform the excision, the patient must be properly positioned on the operating table. The optimal position is the lithotomy position — the classical posture for perineal surgeries. It is important to note that alternative surgical positions, such as Fowler's position, Trendelenburg's position, or the prone position, are strictly not used for this intervention.
Anesthesia is chosen individually: depending on the clinical situation, the surgical team uses either local anesthesia or full general anesthesia.
Step-by-step technique for excision of a chronic fissure
The course of the operation is strictly regulated and consists of several consecutive stages:
- A rectal speculum is carefully inserted into the anal canal. To create optimal working space, the blades of the instrument are spread to exactly 3 centimeters.
- An oval incision of the mucosa is made around the pathological defect.
- The mucosa itself and the base of the fissure are completely excised using specialized Cooper's scissors.
- The resulting wound is thoroughly dried using a tampon.
- The most critical stage of the intervention is the dissection of the posterior intestinal wall strictly along the midline. At this stage, it is critically important to consider anatomical sex differences: the depth of dissection in men should be exactly 1 cm, whereas in women it should not exceed 0.7 cm.
Completion of the operation and postoperative management
The specific nature of this proctological operation is that the resulting surgical wound is not sutured. The edges of the defect are left open.
A special pack, pre-soaked abundantly with a greasy anesthetic ointment, is placed into the intestinal lumen. Additionally, a flatus tube is inserted to remove intestinal gases.
The postoperative period requires special attention. The first dressings are accompanied by pronounced pain syndrome, which is why they are mandatorily performed exclusively under local anesthesia.
Briefly: answers to topical questions
Which arteries supply blood to the area of typical anal fissure localization?
The typical localization of an anal fissure is the posterior wall of the anal canal (90% of cases). The sources do not specify the blood supply to this exact area. In the rectal basin, the superior rectal artery — the terminal branch of the inferior mesenteric artery heading toward the ampullary part of the rectum — and the middle rectal artery, with which the superior rectal artery forms anastomoses, are indicated.
What surgical instruments are necessary to perform the anal fissure excision operation?
The following surgical instruments and materials are used to perform the chronic anal fissure excision operation:
- Rectal speculum — inserted into the intestine with the blades spread to 3 cm.
- Cooper's scissors — used to excise the mucosa and the base of the fissure.
- Tampon — used to dry the surgical wound.
- Pack and flatus tube — inserted into the intestine at the final stage (the wound itself is not sutured).
- Straight dressing forceps — an auxiliary instrument for inserting packs and preparing the operational field.
To avoid confusing the tactics, remember: "Stretch the acute, cut the old." Acute fissures are treated with stretching (divulsio), while chronic ones (from 4 months) are excised.
Class and exam questions
What is the most frequent localization of an anal fissure?
In 90% of cases, the pathological defect forms on the posterior wall of the anal canal. Only 10% of fissures are located on the anterior wall.
What is the difference in the treatment of acute and chronic fissures?
For an acute fissure, sphincter stretching (divulsio) is used. Chronic fissures, existing from 4 months to several years, require radical surgical excision.
In what position is the patient during the operation?
The patient is placed in the lithotomy position. This is the standard posture for performing any perineal surgical interventions, whereas Fowler's, Trendelenburg's, or prone positions are not used.
Is the wound sutured after fissure excision?
No, the specific feature of this operation is that the surgical wound is strictly never sutured. A flatus tube and a pack with a greasy anesthetic ointment are simply inserted into the intestinal lumen.
What else to study on this topic
- Comparative characteristics of surgical interventions: divulsio, sphincterotomia, fissurectomia, and dilatatio.
- Rationale for the difference in the depth of posterior intestinal wall dissection in men (1 cm) and women (up to 0.7 cm).
- Technique of using Cooper's scissors during the excision of the mucosa and the base of the fissure.
- Selection of medications for local anesthesia during the first painful postoperative dressings.
- Features of using the rectal speculum and controlling safe blade expansion up to 3 cm.
Master the complete topic in the "Topographic Anatomy" course
This is a summary. The course covers everything tested in classes and exams.
- Full textbook on "Operations for Anal Fissure" and 2,777 more subject pages
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 91 video lessons on the subject
Other topics in the section «Pelvic and Perineal Surgery»
Free video lessons: topographic anatomyShort lessons with study notes — no registration required.
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.