Dilip’s Transmucosal Internal Sphincterotomy: A Simplified Approach to Lateral Internal Sphincterotomy for Fissure-in-Ano

BACKGROUND: Fissure in ano is a prevalent and painful condition, typically treated by lateral internal sphincterotomy after conservative measures fail. Dilip’s transmucosal internal sphincterotomy introduces a simplified approach that reduces the risk of damaging the external sphincter, making it particularly suitable for less experienced surgeons. This innovation offers a less invasive method with minimal risk of incontinence, providing a safer, more accessible option. IMPACT OF INNOVATION: Transmucosal internal sphincterotomy simplifies the internal sphincterotomy process, offering a tailored approach that eliminates the need for extensive dissection. This method allows surgeons complete control over the internal sphincter bundle, facilitating a precise, customizable cut without the risks associated with traditional internal sphincterotomy, especially in obese patients where the intersphincteric groove is not visible, leading to potentially harmful blind incisions. TECHNOLOGY, MATERIALS, AND METHODS: The procedure is performed under saddle block anesthesia with the patient in the lithotomy position. A distinctive approach involving the use of retractors and stay sutures allows the internal sphincter to be made prominent and secured without extensive dissection. The division of the internal sphincter is achieved through a minimal mucosal incision, requiring no closure and significantly reducing postoperative pain and complications. PRELIMINARY RESULTS: Between December 2020 and February 2022, 124 patients received transmucosal internal sphincterotomy, showing significant benefits with a median operative time of 7 minutes and low postoperative pain. With a 2.5% infection rate effectively managed and a 3% transient incontinence rate, the majority healed within 9 weeks. Recurrence was rare at 1.6%. CONCLUSIONS AND FUTURE DIRECTIONS: Transmucosal internal sphincterotomy presents significant advantages over traditional internal sphincterotomy, including reduced pain, lower risk of complications, such as hematoma, abscess, or fistula formation, and the absence of painful postoperative nodules. The success of transmucosal internal sphincterotomy suggests that it should be incorporated into surgical education, offering a less daunting and more reproducible method for treating fissure in ano that is especially beneficial for junior surgeons and improving patient outcomes.