Mucosal advancement flap anoplasty faculty smsmc…richa jain

Step One - fissurectomy Dashed lines indicate the site of incisions for fissurectomy

Step Two – Creation of Mucosal Flap Creation of the mucosal advancement flap; the underlying fibers of the internal sphincter (IAS) are meticulously preserved.

Step Three – Advancement of flap Tension-free advancement flap is sutured in the anal canal by interrupted 3` /2`o vicryl

And in between….this too For anal stenosis due to stricture rather than spasm Excision of eschar Trasverse suturing of rectal mucosa to anal sphincter and sphincterotomy

Sphincterotomy ….one Lysis of the anal sphincter permits insertion of a ferguson retractor

Suturing…. The rectum is sutured to the underlying internal anal sphincter

For further widening…. When further widening is required, this can be done to opposite side

What appealed to me Converting caf into acute The concept…… Fissurectomy Without sphincterotomy And coverage with mucosal flap Converting caf into acute Avoiding permanent damage to int sphincter Improving blood supply to ulcer by the flap

fissurectomy Upto fissure apex Rather than upto dentate line

Role of fissurectomy Converts a chronic into acute ulcer Wound heals by primary intention Without scarring Avoiding anal stenosis

The anal mucosal flap… Improves blood supply to chr ulcer base Coverage of ulcer base promotes quick healing Healing by primary intention Results in less scarring and stenosis Postop pain is reduced Recovery is quick

ERAS…enhanced recovery after srgery Day case LA…pudendal or perianal block Easy and quick Minimal pain Early recovery Less bleeding

Durability of flap New fissures may form elsewhere Coz it doesn’t address cause of fissure

Why not LIS We do permanent damage to the int sphin….omg!!! previous damge to sphincter eg.fistulectomy Multiparous with obstretic trauma Old age with hypotonic sphincter Why do in chr painless fissure where spasm is not the cause of ulcer Poor ext sphincter….another issue Fissure still causes post op pain

Your attention please Goligher Notaras Rudd Boulos Pernikoff Garcia Hananel and gordon Nyam and pemberton

In many large series on lis Reported soiling upto20% Incontinence to flatus35% Accidents 5% Recurrence or persistence0 to 11% Healing 89 to 100%

maap Has low morbidity and High cure rates Is applicable in fissures recurring after LIS Or not responding to chemical sphincterotomy

A relative life is miserable…comparison Of maap and lis is not justified b/c of large no. of pts reqd to reach any statistically valid conclusions assessing cure or incontinence to be the primary end points

“Comparison of Anal advancement flap versus Lateral Sphincterotomy for the treatment of Chronic Anal Fissure " Submitted to Rajasthan University of Health Sciences Jaipur For the degree of M.S. (General Surgery) 2016 Submitted by: Dr. Manish Under the Supervision and Guidance of Dr. Richa Jain Associate Professor & Unit Head Department of Surgery SMS Medical College & Hospital Jaipur (Raj.)

omg !!!!!!! Sample size was calculated 85 subjects for each of two groups at alpha error 0.05 and power 80% assuming resolution of symptoms achieved in 90% after AAF and 72% of patients after LIS (as per seed article).  So for the study purpose 85 cases were to be taken for each of the two groups.

don`t rock the boat