1. Mucosal advancement flap anoplasty
faculty smsmc…richa jain

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

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

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

5. 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

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

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

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

9. 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

10. fissurectomy
Upto fissure apex
Rather than upto dentate line

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

12. 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

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

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

15. 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

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

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

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

19. 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

20. “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.)

21. 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.

22. don`t rock the boat