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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 13  |  Issue : 3  |  Page : 130-134

Local infiltration anaesthesia for lateral internal anal sphincterotomy; a safe and effective alternative to regional or general anaesthesia


Department of Surgery, Osmania Medical College, Hyderabad, Telangana, India

Date of Web Publication17-Jan-2019

Correspondence Address:
Dr. Gayatri Priyanka Gadiraju
Department of Surgery, Osmania Medical College, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_46_18

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  Abstract 


Background: Chronic fissure in ano is one of the most common anal disorders in all age groups which causes significant distress to the patient even though the disease is benign in nature. Several treatment options are available ranging from medical to surgical of which surgical division of sphincter, lateral internal anal sphincterotomy, is one the most common surgical procedures done to relieve anal sphincter spasm and aid healing of fissure. Most commonly, surgery for fissure in ano is performed under regional or general anesthesia due to severe pain associated with disease. Patient acceptance is also low as the perianal area is very sensitive to pain which may be aggravated by patient positioning during surgery. Materials and Methods: This is a prospective study was done in Osmania General Hospital over a period of 3 years in patients who were treated in our unit with acute and chronic fissure in ano. All patients were counseled regarding disease and treatment options. Informed and written consent was obtained from all patients willing to undergo sphincterotomy under local anesthesia. These patients include females and males >15 years of age and also patients having medical comorbid conditions, such as chronic obstructive pulmonary disease, uncontrolled diabetes, and others in whom surgery under regional or general anesthesia was deferred or contraindicated due to high risk. Results: All lateral internal anal sphincterotomies were performed under local anesthesia. There was significant pain relief following surgery. Intraoperative complications related to administration and drug, and surgery were negligible, and the duration of surgery was very less compared to regional or general anesthesia cases. Patient acceptance was also very good as local anesthesia provided good pain relief during and after surgery and fissure healing rates were high with less complications and no recurrences. Conclusion: Local infiltrative anesthesia is a very effective and safe form of anesthesia for lateral anal sphincterotomy for acute and chronic fissure in ano in terms of minimal complications, ease of giving anesthesia, and cost-effective as no extensive pre-operative preparation and investigations are required. It can also be safely administered in all age group, and also in patients with medical comorbid conditions which precludes administration of spinal or general anesthesia.

Keywords: Anal hypertonia, fissure in ano, lateral anal sphincterotomy, local anesthesia


How to cite this article:
Kishan D, Gadiraju GP. Local infiltration anaesthesia for lateral internal anal sphincterotomy; a safe and effective alternative to regional or general anaesthesia. J Datta Meghe Inst Med Sci Univ 2018;13:130-4

How to cite this URL:
Kishan D, Gadiraju GP. Local infiltration anaesthesia for lateral internal anal sphincterotomy; a safe and effective alternative to regional or general anaesthesia. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2019 Feb 16];13:130-4. Available from: http://www.journaldmims.com/text.asp?2018/13/3/130/250104




  Introduction Top


Fissure in ano is a common anal disorder and causes significant agony and distress to the patient. An anal fissure is a linear ulcer in the mucosa of anal canal distal to dentate line and present with anal pain, spasm and/or with bleeding during defecation.[1] The cause of fissure is multifactorial. Most commonly, the fissure is single and located in the posterior midline, but it can also develop in the midline anteriorly, especially in parous females. There is no clear definition between acute and chronic fissure in ano, but many authorities believe that more than 6 weeks of persistence despite with conservative treatment is considered chronic fissure in ano. Most of fissure heal with conservative management within 4 to 6 weeks and some persist beyond 6 weeks and chronic.

Many believe that nonhealing of fissure is due to compromised blood circulation to the anoderm which is due to hypertonia of internal anal sphincter.[2] There is an increase in resting anal pressure in most of the patients as measured by anal manometry.[3],[4] Blood flow to internal anal sphincter is also decreased in those patients as evidenced by muscle probes.[5],[6] This explains how disruption of internal anal sphincter by surgery decreases anal tone and increases blood flow and promotes healing. Anal fissures with chronicity are unlikely to heal with conservative treatment as significant irreversible changes will happen in sphincter including fibrosis. Acute fissures usually heal with medical management but for reasons not well understood some fissures do not heal and become chronic and fail to respond to medical/conservative management.

Aims and objectives of the study

The primary aim of this study is find whether lateral internal anal sphincterotomy can be safely and effectively performed under local anesthesia, to find intra- and post-operative complications due to local infiltration of drug and other surgical complications and also to find feasibility of local anesthesia in patients with significant medical comorbidities which precludes administration of regional or general anesthesia.

Inclusion criteria and exclusion criteria

In our study, both male and female patients between the age group of 15 and 70 years with complaints of severe pain in the anal region, bleeding during defecation, constipation, and failed treatment in the past for fissure in ano were included. In all cases, diagnosis of acute and chronic fissure was made by clinical examination only.

Patients with other, coexisting anal problems such as malignancy, anal incontinence, hemorrhoids, and fistula in ano were excluded from this study.

Anal canal anatomy

The anal canal is a continuation of the rectum and about 4-cm long. It extends from anorectal junction to anal verge. Interior of the anal canal shows many important features. The upper half of anal canal above dentate line is lined by columnar mucosa of the rectum and insensitive to pain. The mucosa below the dentate line is lined by squamous epithelium and is highly sensitive to pain and touch. Hence, any pathology below dentate line such as fissure in ano is very painful, and any pathology above dentate line such as hemorrhoids are painless in nature.

The anal canal is a muscular tube is has internal and external anal sphincters. The internal anal sphincter is a thickened involuntary muscle which is surrounded by voluntary external anal sphincter which is derived from the pelvic diaphragm. The external anal sphincter is divided into deep, superficial, and subcutaneous parts by longitudinal muscle of rectum which becomes fibrous in between anal sphincters.

Anal canal has a good blood supply and is supplied by the superior rectal artery above the dentate line and by the inferior rectal artery below the dentate line.

Above dentate line anal canal mucosa is supplied by autonomic nerves from both sympathetic (L1–L2) and parasympathetic (S2, 3, 4) through pelvic splanchnic nerves. Below pectinate line, it is supplied by inferior rectal nerve (S2, 3, 4) and carry pain, touch, and temperature sensations. Sympathetic nerves cause contraction of the internal anal sphincter and parasympathetic causes relaxation of internal sphincter. Contraction of external sphincter is effected by inferior rectal nerves and perineal branch of fourth sacral nerve.


  Materials and Methods Top


A total of 200 patients were included in our study over a period of 3 years from 2013 to 2016. Patients age ranged from 15 years to 70 years with or without medical comorbid conditions such as with the history of coronary artery disease, chronic obstructive respiratory diseases.

Before administration of local anesthesia, all patients were given a single dose of ceftriaxone and metronidazole. During surgery, one unit of fluid-containing normal saline with dextrose was administered. No special preoperative investigations were done except routine blood and urine investigations.

All patients were either placed in lithotomy or left or right lateral position. A volume of 10–20 ml of 1% lignocaine was taken in 10 ml syringe and half of which was infiltrated at 3 or 9'o clock position in the skin at anal verge [Figure 1] and up to dentate line in the submucosa of the anal canal [Figure 2]. Further, the needle was also directed toward the lesser ischial spine, and another 5–10 ml of lignocaine was administered to block pudendal nerve [Figure 3]. No drug was infiltrated in the base of the fissure. All patients were monitored during surgery by pulse oximetry and manually. Skin incision was given at either 3 or 9 o'clock position and internal anal sphincter was identified by its pearly white appearance and held with allis tissue forceps and divided [Figure 4].
Figure 1: Infiltration of perianal skin at nanal verge at 3'o clock position with xylocaine

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Figure 2: Infiltration of anoderm upto dentate line in the submucosa of anal canal

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Figure 3: Infiltration of lignocaine to block pudendal nerve and inferior rectal nerves. Needle is directed posterolaterally towards lesser ischial spine

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Figure 4: Internal anal sphincter exposed and held with tissue forceps and divided (inter anal sphincter is identified by its pearly white appearance)

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Figure 5: Sex distribution of patients who underwent sphincterotomy

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Figure 6: Age distribution of patients

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  Results and Observations Top


All lateral internal anal sphincterotomies were done under local anesthesia and the anesthesia was administered by the operating surgeon himself (n = 200). There were no significant intra- and post-operative complications either due to the drug (lignocaine) or related to surgery. Intraoperative Pain was the most common complaint which was reduced by giving further lignocaine locally. The pain ranged from mild-to-moderate and severe in few patients. Most patients complained of dragging and pricking type of pain while holding the sphincter with tissue forceps. none of our patients needed supplemental sedation or conversion from local anaesthesia to regional or general anaesthesia. Intraoperative blood loss was less very minimal. Surgery time measured in all patient starting with infiltration of local anesthetic till division of internal anal sphincter, which ranged from 5 to 15 min average is 7–8 min. This is very significant as average surgery time during spinal or general anesthesia varies from 45 min to 90 min. Postoperatively, all patients were monitored either in general ward or in intensive care unit depending on patient comorbidities. Many patients complained minimal post-operative pain which was controlled by injection tramadol or diclofenac intramuscularly. All patients were able to walk freely and without pain within 2–3 h after surgery. No patient required bladder catheterization and able to void urine freely either at bedside or toilet. None of our patients who had severe medical comorbid conditions such as cardiac and respiratory problems had any significant intra- or post-operative complications.


  Discussion Top


It is accepted that the majority of anorectal surgeries such as lateral internal anal sphincterotomy and hemorrhoidectomy can be performed under local anesthesia and on an ambulatory basis. However Lateral anal sphincterotomy is most frequently performed under general or regional anesthesia. Lateral sphincterotomy under local anesthesia is not routinely done, as local infiltration of the perianal region is very painful and consequently, patient acceptance is also low. Lateral anal sphincterotomy can be performed under either local, general, or regional anesthesia with equally good results and healing rates. Patients who are not suitable for regional or general anesthesia due to medical comorbid conditions, local anesthesia may be a safe and effective alternative. Local anesthesia if optimally given has very good outcome in terms of hospital stay, decreased pain, reduction of cost, post-operative complications and speed of recovery and served a day-care surgery.[7] Lateral sphincterotomy performed under local anesthesia would reduce hospital stay for patients and result in early mobilization associated with the minimal postoperative complications.

Sánchez Romero et al.[7] carried out a prospective study in 120 patients with acute and chronic fissure in ano under local anesthesia and concluded that complications rates are similar in local anesthesia patients compared with regional anesthesia. He reported complications such as wound ecchymosis, in (2.5%), recurrence of fissures in (7.5%) of cases, and incontinence in few cases. Clearly, these are not anesthetic complications and may occur in any patients undergoing surgery under regional or general anesthesia complications. In our study, two patients (1%) had developed ecchymoses in the perianal region which subsided after 5–7 days of conservative management. Postoperative bleeding occurred in 5 (2.5%) patients in the immediate postoperative period due to inadequate compression dressings and hemostasis [Table 1]. These cases were managed by adequate bandages and pressure for a few minutes. Wound infection was the most common complication and occurred in 10 (5%) cases. All these patients had moderate pus discharge, induration, and swelling. All these cases were taken to operation theater, pus was evacuated under local anesthesia and the wound thoroughly irrigated with antiseptic solution.
Table 1: Patients who developed early postoperative complications

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The benefits of local anesthesia, as our study showed, is the minimal incidence of postoperative nausea and vomiting, headache, early mobilization, avoidance of catheterization as none of our patients had retention of urine in the postoperative period. All patients were ambulatory 2–4 h after surgery and diet were resumed as soon as possible.

In a study, done by Keighley et al.,[8] the author recommends that lateral anal sphincterotomy should be done under general anesthetic. In his study, 71 consecutive patients with acute anal fissure were randomly allocated to treatment by lateral subcutaneous sphincterotomy under either local anesthesia (n = 34) or general anesthesia (n = 37). Four months after treatment, there were 18 patients with a recurrent or persistent anal fissure, who had local anesthesia (50%) and only one had a recurrent fissure after general anesthesia (3%). These results indicate that if lateral subcutaneous sphincterotomy is used for the treatment of anal fissure, the operation should be performed under a general anesthetic. He ascribed poor results of lateral subcutaneous sphincterotomy under local anesthetic due to the inadequate division of the internal sphincter intense patients having a procedure on the anal canal which was inherently painful or frightening to them.

Contrary to above study, all the patients in our study underwent surgery under local anesthesia and in all cases, fissure healing was excellent and no recurrence reported in any of the patients during the follow-up period for 6 months. Local infiltration of lignocaine provided adequate anesthesia and in all cases internal sphincter was divided under direct vision upto dentate line. Another advantage is internal sphincter is easily felt under local anesthesia, whereas it may be difficult to feel under spinal as it is completely relaxed and the extent of division is difficult to estimate intraoperatively.

Arora et al.[9] performed closed lateral internal anal sphincterotomies in 45 patients with fissure in ano and concluded that local anesthesia is effective as a day care surgery for fissures as good healing rates were obtained. He also concluded that there are no significant differences between closed or open sphincterotomy in terms of healing, recurrences, and complications rates.

Samuel Argov et al. Reported minor complications in 54 anal operations, of which 30 were Milligan-Morgan hemorrhoidectomy and 24 were lateral internal anal sphincterotomies for fissure in ano. All patients were placed in jack knife position, perianal skin and anal mucosa was painted with 5% lignocaine jelly for topical anaesthesia. A cocktail of local anaesthesia containing bupivacaine, adrenaline and lidocaine was infiltratrated around perianal region to overcome sphincter spasm and for local infiltration anaesthesia. Supplemental midazolam was given during surgery to alleviate apprehension and fore amnesia. However, in our study, no topical local anesthesia was applied and operating times were significantly less (5–10 min) and intraoperative and pooperative pain was not higher and complications and patients acceptance was also very good. However, it appears that topical application of jelly locally may reduce needle prick pain, and patient acceptance may be high, especially in patients who are not cooperative under L. A.

In a comparative study done by Goudar et al.[11] in which a total of 90 patients with fissure in ano were randomly divided into two groups A and B, comprising 45 patients in each group. Group A cases underwent surgery under Local anesthesia and Group B cases underwent surgery under spinal anesthesia and found no statistically difference in the pain at surgery, but postoperative pain was significantly less in LA group at 5th h and 24 h after surgery. Hospital stay in LA group is significantly less when compared to SA group (1.92, vs. 3.75 days, respectively).

In our study of 200 patients, all cases underwent surgery under local anesthesia and pain ranged from mild-to-moderate in few patients. Most of the pain was felt at the time of first needle prick in the perianal area and also felt during the holding and division of the sphincter. If pain persisted during surgery few milliliters of lignocaine was infiltrated locally. No patient either needed supplemental sedation or conversion to general anesthesia.

Notaras[12] recommended that most of the ano rectal surgeries can be done under local anesthesia and on an ambulatory basis. He used lignocaine of 0.5%–1% with adrenaline to decrease bleeding as the perianal area and anal canal is highly vascular and supplemented with diazepam to alleviate apprehension and achieved good results. In our study, 20 ml of 2% lignocaine diluted to 1% was injected locally without adrenaline and supplemental sedation. Moreover, systemic absorption of adrenaline may produce systemic complications, especially in patients with Hypertension and cardiac diseases. In our patients, postoperative hemeostasis was achieved by firm gauze packing after surgery. Postoperatively, 5 (2.5%) patients had bleeding immediately after surgery due to inadequate compression. 2 patients were taken to operation theater, and firm pressure bandage applied. In remaining cases firm anal packing was done in the postoperative ward to arrest bleeding. All anal packs were removed in the next postoperative day, and no patient had recurrent bleed.

In a study done by Sarkar and Kapur et al.[13] concluded that the advantages of open sphincterotomy under local anesthesia, better healing of fissures, and less postoperative complications. This technique has the added advantage of not requiring hospital admission, an operating theater, or preoperative studies. Moreover, the lower morbidity associated with local anesthesia as compared to general or spinal anesthesia gives the patient a higher degree of satisfaction. They also found an increased incidence of incontinence in their patients due to a lower anal tone, induced by spinal anesthesia which resulted in the extensive division the internal anal sphincter because the internal anal sphincter could not be properly felt under spinal anesthesia. The portion of the internal anal sphincter divided under local anesthesia tends to be smaller as the sphincter can be made out easily, as the sphincter is not paralyzed.


  Conclusion Top


Lateral internal anal sphincterotomy is the most effective treatment for many patients with acute and chronic anal fissures and can be safely performed under local anesthesia. It can also be safely administered in patients with significant medical comorbid conditions which precludes administration of regional or general anesthesia [Table 2]. Sphincterotomy under local anesthesia is cost-effective as no special preoperative investigations and preparations are needed except simple and routine hematological investigations. Prolonged admission to hospital is also minimized as this procedure can be done as day care surgery. Fissure healing rates, complications, and recurrence rates are similar to other forms of anesthesia.
Table 2: Patients with comorbid conditions underwent sphincterotomy

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zaghiyan KN, Fleshner P. Anal fissure. Clin Colon Rectal Surg 2011;24:22-30.  Back to cited text no. 1
    
2.
Gibbons CP, Read NW. Anal hypertonia in fissures: Cause or effect? Br J Surg 1986;73:443-5.  Back to cited text no. 2
    
3.
Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 1994;37:664-9.  Back to cited text no. 3
    
4.
Arabi Y, Alexander-Williams J, Keighley MR. Anal pressures in hemorrhoids and anal fissure. Am J Surg 1977;134:608-10.  Back to cited text no. 4
    
5.
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: A possible cause of chronic, primary anal fissure. Dis Colon Rectum 1989;32:43-52.  Back to cited text no. 5
    
6.
Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg 1996;83:63-5.  Back to cited text no. 6
    
7.
Sánchez Romero A, Arroyo Sebastián A, Pérez Vicente F, Serrano Paz P, Candela Polo F, Tomás Gómez A, et al. Open lateral internal anal sphincterotomy under local anesthesia as the gold standard in the treatment of chronic anal fissures. A prospective clinical and manometric study. Rev Esp Enferm Dig 2004;96:856-63.  Back to cited text no. 7
    
8.
Keighley MR, Greca F, Nevah E, Hares M, Alexander-Williams J. Treatment of anal fissure by lateral subcutaneous sphincterotomy should be under general anaesthesia. Br J Surg 1981;68:400-1.  Back to cited text no. 8
    
9.
Arora B. Closed lateral internal sphincterotomy under local anaesthesia: A day surgery procedure. Global J Res Analysis X 2016;5:150.  Back to cited text no. 9
    
10.
Argov S, Levandovsky O. Local anesthesia in anal surgery: A simple, safe procedure. The American J Surg 2006;191:111-3.  Back to cited text no. 10
    
11.
Goudar BY, Kalburgi EB, Lamani YP, Gowd YC. Feasibility of local anaesthesia in lateral internal anal sphincterotomy for chronic anal fissure. Int Surg J 2018;5:2578-81.  Back to cited text no. 11
    
12.
Notaras MJ. Treating fissure in ano in outpatients under local anaesthesia. Br Med J (Clin Res Ed) 1984;289:1539.  Back to cited text no. 12
    
13.
Sarkar S, Kapur N. Lateral internal sphincterotomy under local and spinal anaesthesia for chronic anal fissure: A randomised control trial. Hellenic J Surg 2016;88:398-401.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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