Lateral internal sphincterotomy for fissure-in-ano

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding or haematoma at the sphincterotomy site
• incontinence to flatus, usually temporary
• faecal soiling or incontinence, rarely permanent
• perianal abscess or fistula at the stab site
• tear of the anal lining (anoderm)
• fissure not healing or coming back
• need for further surgery

Pre-operative details for this operation

1. Fissure details on examinationsite (posterior / anterior midline / other), duration of symptoms, sentinel tag, hypertrophied papilla
2. Conservative treatment trieddrug (e.g. diltiazem 2% or GTN ointment), duration, fibre, sitz bath, and result
3. Continence status before surgeryFully continentSome impairment (describe)record it now, so any later change can be compared
4. Risk factors against sphincterotomyprevious vaginal delivery with tear or forceps, previous anorectal surgery, known sphincter injury, IBD, HIV, TB
5. Atypical fissure featuresNoneLateral / multiple / painless / indurated: biopsy planned
6. Anticoagulants or antiplateletsdrug and date stopped, or not on any

Anaesthesia and position

1. AnaesthesiaSaddle block (low spinal)Short GAGA with pudendal blockLocal infiltration with adrenaline 1:200,000
2. PositionLithotomyProne jackknifeLeft lateralclock positions in the note refer to this position

Operative findings

1. Fissure position and lengthclock position, length in cm from the anal verge towards the dentate line
2. Signs of chronicitysentinel tag, hypertrophied papilla, rolled or fibrosed edges, internal sphincter fibres visible in the base
3. Anal tone under anaesthesiaIncreased (hypertonic)NormalReduced
4. Associated diseaseNoneHaemorrhoidsFissure abscessSuperficial fistulaOther
5. Intersphincteric grooveEasily palpableDifficult to feel

Procedure (steps)

1. Examination under anaesthesiaanal canal lubricated with lignocaine jelly, gentle digital examination and anoscopy
2. Retractor placedParks speculumBivalve anal retractoropened gently to put the internal sphincter on stretch
3. Side of sphincterotomyRight lateralLeft lateralwrite the clock position; always away from the fissure
4. TechniqueClosed (stab)Open
5. Closed method: blade and planeNo. 15 bladeNo. 11 bladeBeaver / cataract bladeblade passed in the intersphincteric groove parallel to the anoderm, then turned towards the internal sphincter with a finger in the canal as guard
6. Open method: incision and division1 to 2 cm circumferential or radial incision at the anal verge, white internal sphincter lifted on a clamp, divided with scissors or cautery
7. Extent of divisionUp to the proximal end of the fissure (tailored)Up to the dentate linenever above the dentate line; write the length in cm
8. Release confirmedgroove felt on palpation, residual fibres broken with the finger, blade not re-inserted
9. HaemostasisPressure for 3 minBipolar cauterySuture
10. Sentinel tag / hypertrophied papillaExcisedNot present
11. Fissure edgesFreshenedLeft alone
12. Associated abscess or superficial fistulaNoneLaid open

Closure, drains and dressing

1. Sphincterotomy woundLeft openClosed with absorbable sutureif closed, material and size, e.g. polyglactin 910 (Vicryl) 4-0
2. Anoderm integrity checkedIntactBreached and repaired (suture)
3. Local anaesthetic infiltration for post-op paindrug, strength, volume
4. Dressinggauze pad, anal pack (yes / no)

Specimens and implants

1. Sentinel tag / papilla sent for HPEYesNot excised
2. Fissure biopsy or swabNot neededBiopsy sent (atypical fissure)Swab sent for culture

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Check dressing for bleedingbefore discharge; look for a swelling at the stab site (haematoma)
2. Voidingnote time of first void before discharge
3. Analgesiadrug, dose, frequency
4. Dietoral fluids when awake, then normal diet with plenty of fibre and 6 to 8 glasses of fluid a day
5. Stool softener or bulk laxativedrug and timing, to avoid hard stools
6. Warm sitz bathplain warm water, after each motion and 2 to 3 times a day
7. Dischargesame day or next morning once pain is controlled and patient has voided
8. Follow-upOPD date to check healing and ask about control of flatus and stool; HPE report

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery