Internal Sphincterotomy Research Articles

A Comparative Study of Efficacy of Outcome of Lateral Internal Sphincterotomy versus Subcutaneous Fissurectomy in Chronic Fissure in Ano

Background: Fissure-in-ano is a very common problem across the world which causes considerable morbidity and affects the patient’s quality of life to a greater extent. Anal fissure is a common painful condition affecting the anal canal. The main aim of study was to compare the efficacy of outcome of subcutaneous fissurectomy versus lateral internal sphincterotomy in chronic fissure in Ano. Subjects and Methods: The study was a prospective, parallel group, comparative trial. The study was conducted at Department of General Surgery, Chalmeda AnandRao Institute of Medical Sciences, Karimnagar. The number of patients included in the study was 50. Patients were divided into lateral internal sphincterotomy groups and subcutaneous fissurectomy groups. Patients were followed up regularly for relief of symptoms i.e., pain in the anal region and bleeding from anal region and for complications like incontinence; duration of sitz baths and number of work days lost. Results: The mean age group in the present study was 38.24 9.96 for subcutaneous fissurectomy and 39.2 10.4 for lateral internal sphincterotomy; there was no significant difference in the mean age in either of the groups with P value > 0.05. Conclusion: The current study shows results in favor of subcutaneous fissurectomy with a healing rate of 100% with faster pain-relief and minimal or no complications if performed by the hands of an experienced surgeon.

Lateral internal sphincterotomy (LIS)—still top gun in chronic anal fissure treatment?

Anal fissure is one of the most common proctological complaints. If the fissure persists for more than 6–8 weeks, it is termed a chronic fissure and will most likely need surgical intervention. Surgical partial transection of the internal sphincter muscle, lateral internal sphincterotomy (LIS), is still seen as the gold standard procedure for chronic anal fissure in many parts of the world, especially in the Anglo-American community. In contrast, the German-speaking surgical community favors fissurectomy ± application of Botox, as some studies report high postoperative incontinence rates after LIS. This paper aims to give an overview of the literature on LIS and its outcomes and answer the question, “Is LIS still the gold standard surgical approach for chronic anal fissure?” A literature search for “sphincterotomy,” “internal sphincter,” and “anal fissure” was performed in PubMed. For the purpose of this overview article, randomized controlled trials (RCTs), meta-analyses, up-to-date guidelines, and retrospective cohort studies were taken into account. LIS produces excellent rates of fissure healing (~95%), quick symptom relief, and high patient satisfaction. Incontinence after LIS is mostly described as mild and transient. In the authors’ view, open LIS is therefore rightfully still the gold standard procedure for treatment of chronic anal fissure in the majority of patients. A conservative approach with limited division of internal sphincter muscle is preferred. For patients with preexisting sphincter weakness and an increased risk of incontinence, further preoperative diagnostic assessment (anal manometry, endoanal ultrasound) is recommended. In this high-risk group, alternative surgical options might be preferred.

Comparison of hemorrhoidectomy versus hemorrhoidectomy and internal sphincterotomy in terms of postoperative pain.

Objectives: To compare open hemorrhoidectomy with internal sphincterotomy versus open hemorrhoidectomy alone in terms of frequency of the postoperative pain. Study Design: Randomized Controlled Trial. Setting: Surgical Unit - I, Holy family Hospital, Rawalpindi. Period: For one year i.e. from January 2016 to December 2016. Material & Methods: 250 patients were divided in two equal groups by lottery method. The surgical procedure was performed using standard protocols after obtaining written informed consent. Anal dilatation was done after open hemorrhoidectomy in patients of control group (Group A). In the study group (Group B), the patients were subjected to lateral internal sphincterotomy after completion of classical open hemorrhoidectomy. Postoperative pain score was recorded by using visual analog scale. Difference between both groups for pain was analyzed using chi-square test. Results: There were 68 males and 57 females in Group-A and 61 males and 64 females in Group-B. The mean age of patients in Group-A was 33.10±8.77years and in Group-B was 32.52±9.4years. The mean pain score of patients in Goup-A and Group-B was 2.82±2.51 and 1.59±1.58 respectively (P<0.05). In Group-A, 94 (75.2%) cases had no pain while in Group-B, 116 (92.8%) cases were pain free following the procedure. The difference between both groups was significant i.e. P < 0.05. Conclusion: Open hemorrhoidectomy with internal sphincterotomy is effective in reducing postoperative pain.

Management of chronic anal fissures: a narrative review

Anal fissures are often encountered in surgical practice in both sexes. It is a distressing disease impacting quality of life and causes profound morbidity among those affected. If left untreated, it may lead onto perianal abscess or even malignancy in long standing cases. Surgery is the gold standard management for chronic anal fissures. Recently the widespread use of pharmacologic agents for chronic fissures has increased. The management of chronic anal fissures has migrated to an era of multifaceted approach. This narrative review looks into various studies spanning over a period of 16 years. Various articles were shortlisted and analyzed for efficacy of various treatment methods, their impact in hospital stay, quality of life improvement, recurrence rate and complications among various treatment methods. We concluded from this review, that open lateral internal sphincterotomy is still the gold standard method of treatment for chronic anal fissure. Among pharmacological agents, 2% diltiazem has the best effectiveness with good compliance rate. Modern surgical techniques like VY plasty can be reserved for special situations. We do not recommend the practice of manual anal dilatation.

Comparative study of closed versus open lateral internal sphincterotomy in the management of chronic anal fissure

Background: Anal fissure is a painful tear in distal anal canal extending from just below the dentate line to anal verge. Patient presents with pain during or after defecation and passage of bright red blood per anus. Various studies investigating chronic anal fissures show a large variation in healing rates for different modalities. The present study was carried out to evaluate effectiveness of closed versus open lateral internal sphincterotomy in treatment of patients with chronic anal fissure.Methods: A prospective study was conducted in the Department of Surgery, Pt. B.D. Sharma PGIMS, Rohtak. Group A and group B included 20 patients each with chronic anal fissure and managed by closed and open lateral internal sphincterotomy respectively and effectiveness was evaluated with regards to fissure healing, pain reduction, recurrence and incontinence after surgical treatment.Results: The mean pain scores on visual analogue scale at end of 1 week in group A and group B was not found to be statistically significant, whereas it was found to be statistically significant at 3 week and at 6 weeks. Delayed healing was seen in 1 patient of group B, whereas no patient in group A had delayed healing or absence of healing postoperatively.Conclusions:There was a significant difference between closed and open methods of lateral internal sphincterotomy in terms of relief in post-operative pain but as a whole both techniques did not show any statistically significant difference in terms of fissure healing, postoperative complications or recurrence at 3 months.

Early Outcome of Open versus Closed Lateral Internal Anal Sphincterotomy in the Treatment of Chronic Anal Fissure

Background: Chronic anal fissure is a benign disorder that is associated with considerable discomfort. Surgical treatment in the form of lateral internal sphincterotomy has long been regarded as the gold standard of treatment. Two methods of sphincterotomy are currently practiced: open or closed technique.
 Objective: The objective of this study was to compare the early outcome of closed versus open lateral internal anal sphincterotomy for the treatment of chronic anal fissure, based on the assessment of post-operative pain and complications.
 Methods: A comparative study was conducted at the department of surgery in Dhaka Medical College & Hospital, over a period of 6 months from April 2015 to September 2015. A total of 80 patients were purposefully included in this study and were equally divided into two groups; Group A included 40 patients undergone closed lateral internal anal sphincterotomy and Group B included 40 patients undergone open lateral internal anal sphincterotomy. Patients were followed up postoperatively for 6 weeks to assess any complications. The outcomes were compared between the groups using the Chi-square (x2) test and Student's "t" test.
 Results: Delayed postoperative healing was found in 7.5% patients of the open lateral internal anal sphincterotomy group. The mean pain score and duration of hospital stay were lower in closed lateral internal anal sphincterotomy group.
 Conclusion: Closed lateral internal sphincterotomy is preferred to open technique in the treatment of chronic anal fissure, as it is effective, safe, less expensive, and is associated with low complication rate.
 Journal of Surgical Sciences (2018) Vol. 22 (1): 52-57

The Long-term Effect of Standardized Anal Dilatation for Chronic Anal Fissure on Anal Continence.

PurposeFor the past several decades, internal anal sphincterotomy has generally been considered to be the standard operation for an anal fissure. However, wound complications inherent in this operation forced surgeons to look for an alternative form of treatment. The aim of our study was to evaluate the long-term outcome of anal dilatation for chronic anal fissure, especially possible negative impact on anal sphincter function.MethodsThe study was approved by the local Institutional Review Board and given a waiver of written consent. A phone call survey was undertaken among a group of consecutive patients who had an anal dilatation by standardized technique for chronic anal fissure for the period between 2000 and 2016. The survey included medical, obstetrical and surgical-related data, Wexner fecal incontinence score, recurrence of the anal fissure, and the need for additional medical intervention. Five hundred 48 patients were identified after limitations of age, concomitant pathology, and procedures that were applied to the hospital computerized database. Eighty-five patients (group A) agreed to participate in the survey and 463 patients did not.ResultsThere were no differences between groups in demographic information and medical records data; therefore, group A may well represent a satisfactory sample of the whole group. The interval between the procedure and the survey was 6.8 ± 2.7 years. The Wexner incontinence score was 0 in 94% of patients.ConclusionAnal dilatation, performed in a systematic and standardized way, has a successful outcome with no complications and has no clear long-term negative impact on anal sphincter function.

Comparison between Lord Dilitation Versus Lateral Internal Sphincterotomy for Management Post Hemorrhoidectomy Pain and Stenosis

Hemorrhoidectomy is usually associated with significant pain during the postoperative period. The spasm of internal sphincter seen to play an important role in the origin of pain. This study was designed to evaluate the effectiveness of lateral internal sphincterotomy or Lord dilatation of anal sphincter after hemorrhoidectomy in regarding the maximum resting pressure of the anal canal, accelerating wound healing and decrease postoperative pain when resting and defication. The patients with profound or diagnosed hemorrhoid (n = 79), visited to the Alfayha teaching hospital during April 2016 to June 2017 were enrolled in the present study. The informed consent was taken from each patient before enrollment. Seventy nine patients were admitted in the hospital complaining from anal stenosis and pain after different method of hemorrhoidectomy. The patients underwent hemorrhoidectomy with unhealed wound and severe pain after defication one month ago. They were divided into the two groups viz. patients treated with lateral internal sphincterotomy (n = 40) or lord dilatation surgery (n = 39). In the present study the ratio of lateral internal sphincteroctomy to lords dilatation surgery were found to be 2.761. The occurrence of the hemorrhoid was found to be higher in male than females (2.95:1). The higher number of patients were from 21-30 age group. About 69.2% of male patients ere operated by lord dilatation, while 33 (82.5%) of male patients managed by lateral internal sphinctertomy. Around 12 females (30.8%) managed by lord dilatation and 7 (17.5%) female patients managed by lateral internal sphincterotomy. Out of total patients, 43 were suffering from diabetes mellitus where, 16 were operated by the lard dilation and 27 were operated with lateral internal sphincterotomy. Around 22 suffering steroid problem out of which 17 were operated by the lard dilation and 5 were operated with lateral internal sphincterotomy. About 3 patients were suffering malignancy (2 in lard dilation and 27 in lateral internal sphincterotomy surgery). The present study concluded that the lord dilatation is significant improve wound healing after hemorrhoidectomy and decrease pain.

Comparison between Lord Dilitation Versus Lateral Internal Sphincterotomy for Management Post Hemorrhoidectomy Pain and Stenosis

Comparison between Lord Dilitation Versus Lateral Internal Sphincterotomy for Management Post Hemorrhoidectomy Pain and Stenosis

Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure.

Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy. This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received. In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group. LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Surgical Sphincter Saving Approach and Topical Nifedipine for Chronic Anal Fissure with Hypertonic Internal Anal Sphincter.

The role of augmented internal anal sphincter (IAS) tone in the genesis of posterior chronic anal fissure (CAPF) is still unknown. Lateral internal sphincterotomy is the most employed surgical procedure, nevertheless it is burdened by high risk post-operative anal incontinence. The aim of our study is to evaluate results of sphincter saving procedure with post-operative pharmacological sphincterotomy for patients affected by CAPF with IAS hypertonia. Methods: We enrolled 30 patients, undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement; all patients received topical administration of nifedipine 0.3% and lidocaine 1.5% ointment-based therapy before and for 15 days after surgery. The primary goal was patient's complete healing and the evaluation of incontinence and recurrence rate; the secondary goal included the evaluation of manometry parameters, symptom relief and complications related to nifedipine and lidocaine administration. Results: All wounds healed within 40 days after surgery. We didn't observe any de novo postoperative anal incontinence case. We reported 2 cases of recurrences, healed after conservative therapy. We didn't report any local complications related to the administration of the ointment therapy; with whom all patients reported a good compliance. Conclusions: Fissurectomy and anoplasty with V-Y cutaneous advancement flap and topical administration of nifedipine and lidocaine, is an effective treatment for CAPF with IAS hypertonia.

Comparative study of Glyceryl Trinitrate ointment versus lateral internal sphincterotomy in management of Chronic anal fissure.

Objectives: To compare efficacy of topical 0.2% glyceryl trinitrate ointment with lateral internal sphincterotomy in treatment of patients with chronic anal fissure. Study Design: Randomized Control Trial. Setting: Department of General Surgery, DHQ Teaching Hospital, Sahiwal. Period: From 20 September 2016 to 31 December 2017. Material & Methods: A total number of 60 patients included in this study and divided into two groups GTN and LIS group through computer generated randomization method. Three main outcome variables were assessed in this study; pain relief, healing of fissure and recurrence. SPSS version was used to analyze data. P value ≤ 0.05 was considered as significant. Results: A total number of 60 patients included in this study. Relief of pain GTN and LIS was (95%) and (86.7%) respectively. Fissure healing GTN and LIS was noted as (88.3%) and (83.3%) respectively. Recurrence was not found in any patient of the present study. Relief of pain was statistically significant. Conclusion: Topical application of GTN ointment for relief of pain is safe and effective method for relief of chronic anal fissure but pain relief is slow. On other hand lateral internal sphincterotomy is first line treatment and treatment of choice for chronic anal fissure when performed by an experienced surgeon.

Treatment of Chronic Anal Fissure

Chronic anal fissure is a non healing ulcer in the anoderm appearing as a painful tear below the dentate line. There are debates about the efficacy of different treatment options for chronic anal fissure. This review aims to evaluate existing and newer treatment modalities. Aspects of chronic anal fissure aetiology and pathogenesis are also reviewed. Glyceryl trinitrate (GTN) ointment, Diltiazem ointment can be used as first line and Botulinum toxin (BTX) injection as second line pharmacological treatment. The effects of these chemicals are not permanent with higher fissure recurrence rates. Lateral internal sphincterotomy is the operative treatment of choice for fissures with high anal tone. Flap anoplasty should be done for fissures with normal anal tone especially in female patients. Both surgical procedures can be used as primary treatment option. The newer treatment options like gonyautoxin, controlled balloon anal dilatation, closed anal spand fissurotomy need more research. Perineal support device can be used as an adjunct to other treatment modalities.
 Journal of Surgical Sciences (2015) Vol. 19 (2) : 67-71

Fissurectomy with posterior midline internal sphincterotomy and anoplasty in the management of chronic posterior anal fissures

ObjectiveThe objective of this study was to evaluate the efficacy and safety of fissurectomy with posterior midline internal sphincterotomy and mucosal anoplasty in the management of chronic posterior anal fissures in terms of symptomatic relief and complications. Methods160 patients (male 74, female 86) aged 23–75 years (mean age, 38 years) were diagnosed having chronic anal fissures. Eighty patients from among them were randomly chosen for fissurectomy with posterior midline internal sphincterotomy and anoplasty (FPMISA), and the other 80 patients were chosen for lateral internal sphincterotomy (LIS). However, patients with acute anal fissures, fissures due to Crohn's disease, ulcerative colitis, tuberculosis, anterior fissures and hypotonic sphincter were excluded from this study. Symptomatic relief, postoperative healing and complications such as incontinence, keyhole deformity and recurrence were studied for a follow-up period of 18–24 months between September 2016 and December 2018. ResultsNone of the patients had bleeding per anum, except minor postoperative pain. In the FPMISA group, wound healed in 74 patients (92.5%) in 2–4weeks. However, 6 patients (7.5%) developed a keyhole deformity with a serosanguinous discharge duo to bacterial infection, which ultimately healed taking further 2 weeks. Transient incontinence to flatus (6.25%) and faeces (3.75%) were seen. None of the treated patients reported recurrence. On the other hand, in the LIS group of patients, wound healed in 90%, taking about 4–6 weeks. There was no significant difference in incontinence. ConclusionFissurectomy with posterior midline internal sphincterotomy and mucosal anoplasty is safe with minimal complications. It is still a dependable alternative treatment for chronic posterior anal fissures. The fear of keyhole deformity can be well addressed with the added anoplasty.

Results of tailored lateral sphincterotomy for chronic fissure in-ano

Background: Fissure-in-ano is one of the common and most painful anorectal conditions encountered in surgical practice. Inspite of several conservative treatment options, surgical treatment in the form of lateral anal sphincterotomy remains the gold standard of treatment for chronic anal fissure, however it is associated with the significant rate of incontinence. This study reviews using a tailored lateral sphincterotomy by selecting the height of internal sphincter to be divided with aim of preserving more sphincter and hence reducing the incontinence rates.Methods: The study was carried out in 50 patients who were diagnosed clinically as chronic anal fissure attending Surgery department of ESIC medical college and hospital, Kalburagi over a period of 6 months from January 2019 to August 2019. Tailored left lateral internal sphincterotomy was performed in all patients. The date was recorded and analysed. Early post-operative follow-up was maintained every week for four weeks or till the fissure healed. Complications mainly incontinence rate was assessed.Results: Common age group was third and fourth decade of life. Pain (100%) was the commonest symptom. Majority of the patients (96%) had posterior fissure. Postoperatively about 97% patients had complete pain relief. Only one patient (2%) in the study reported incontinence to flatus during the first follow-up visit and had minor incontinence and other minimal complications were found.Conclusions: Tailored lateral anal internal sphincterotomy is safe and effective surgical procedure for the management for chronic anal fissure with lower rate of incontinence rate compared to gold standard lateral internal sphincterotomy.

Treatment for Anal Fissure: Where do we stand in 2020?

Anal fissure is arguably the most painful common anorectal disorder. The severity of pain is disproportionate to the size of the lesion (often 8–10 mm located in the posterior midline of the anal canal). Numerous surgical procedures have been advocated but Lateral Internal Sphincterotomy (LIS) has become the standard of care and the procedure of choice. Due to concerns regarding fecal incontinence (FI) following LIS various chemicals have been applied to the anal canal in hope of finding an alternative “chemical” or “pharmacological sphincterotomy”. Large numbers of studies in the literature suffer from being non-randomized case series with short follow-ups and with variable outcome measures. In 2020, LIS is the most reliable treatment for chronic anal fissure associated with almost immediate pain relief, lasting results, a very low recurrence rate, and a very small rate of postoperative FI.

1522 Energy Therapy—An Alternative Treatment of Anal Fissures

INTRODUCTION: Energy Therapy has been a well known non-surgical, minimally invasive treatment option for symptomatic grades I and II internal hemorrhoids. This treatment has not yet been studied in anal fissures refractory to medical therapy. Anal fissures, like hemorrhoids, can severely disrupt the quality of life for patients. Currently, only a few non-surgical treatments are available for anal fissures which involve conservative and supportive measures that include: increasing dietary fiber intake, stool softeners, sitz baths, topical analgesics or vasodilators. The gold standard for chronic anal fissures (CAF) refractory to medical therapy is treatment with internal sphincterotomy. Unfortunately with this treatment there is a chance of relapse and a risk of anal incontinence. We propose the use of hemorrhoid energy therapy (HET) with bipolar cautery as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management. CASE DESCRIPTION/METHODS: 53 year old obese heterosexual man presented with bright red blood per rectum for two months managed outpatient for chronic constipation. Rectal examination revealed a large clot with anal tenderness and few internal hemorrhoids. Colonoscopy revealed 3 internal non-bleeding hemorrhoids and slow oozing bleeding anterior anorectal fissure. The anal fissure exhibited characteristics of chronicity with base exposing to the internal anal sphincter, hypertrophic anal papilla and sentinel pile. HET therapy with bipolar cautery was applied to the bleeding anal fissure. The tissue consisting of anal fissure in bowel wall was compressed in a parallel fashion and bipolar radiofrequency energy was delivered until the temperature reached 55 C or 131 F (5-20 seconds) for approximately 1.5 to 2 seconds. DISCUSSION: The delivery of energy to a targeted region with temperatures between 50 to 55 C along with compression of the tissue can help obtain homeostasis for bleeding or CAF along with change of histology to mild scarring with fibrosis and occlusion of blood supply which would result in healing of the fissure. This intervention using bipolar cautery which could be an alternative treatment as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management prior to considering surgery. Our patient was followed up 2 years after the procedure with no recurrences of anal fissures or rectal bleeding, and reported improved quality of life with no complications from the procedure.

Botulinum Toxin Vs Lateral Internal Sphicterotomy for Anal Fissures

A prospective study of 60 patients with anal fissures that aims to compare between two different types oftreatment ( Botulinum toxin A injection BTA and lateral internal sphincterotomy LIS ) regarding pain-relief,healing rates and side effects and to establish a systematic method to be followed in the treatment.

Comparative Study of Lateral Internal Sphincterotomy vs Glyceryl Trinitrate Ointment for Fissure in Ano

Aim To compare and find out the effectiveness of lateral internal sphincterotomy as well as glyceryl trinitrate in the treatment of anal fissure. Materials & Method A prospective study of 100 patients at the surgery department of a medical college and tertiary health care centre, over a period of 6 months that included cases of fissure in ano in the age group of 18 yrs and 70 years. They were randomly assigned to two different groups. One for surgery and the other for medical management with GTN. Each group had 50 patients in it. Results The pain relief of the patients after the surgical operation was fast and very satisfactory. On follow up at 2 weeks post operatively, pain and other symptoms were present in only 10patients (20%). Whereas the pain relief in medical management group was not fully satisfactory and it took more time.. and it was only temporary and how ever on follow up at 2 weeks, 15 patients came with recurrent pain and other symptoms.(30%). On follow up at 8 weeks, in both groups,all the 100 patients were symptoms free (100%) in this study. The complications that were observed during this study were soiling in 5 patients (10%) and incontinence to flatus in 2 patients (4%) in the surgical group and headache in 10 patients (20%) and peri anal itching in 4 patients (8%) in the medical management group.. how ever there was no recurrence of anal fissure observed in this study group. Conclusion From the above study, it is proved that lateral internal sphincterotomy is by far the best operation for pain relief and rapid cure for fissure in ano

Prospective comparative study between lateral sphincterotomy and subcutaneous fissurectomy with topical 2% diltiazem gel in the treatment of chronic fissure in ano

Background: Anal fissure is defined as an ulcer in the anoderm usually in the posterior midline, less frequently in the anterior midline and rarely in the lateral position of the anal canal. Different treatment modalities include non-invasive pharmacological therapies, lateral internal sphincterotomy (LIS) which is the gold standard for treatment and new therapies that include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Thus, aim of the study was to compare the efficacy of outcome of lateral internal sphincterotomy and subcutaneous fissurectomy with topical 2% Diltiazem gel in the treatment of chronic fissure in ano.Methods: 50 patients with chronic fissure in ano attending OPD of Department of General Surgery, KVGMCH, Sullia were randomly selected and divided into Group A (n=25): Lateral internal sphincterotomy (control group) and Group B (n=25): Subcutaneous fissurectomy + topical 2% Diltiazem Gel (test group).Results: Patients of Group B showed much less mean duration of absenteeism (2.88 weeks) compared to Group A. Comparison between Group B and Group A showed statistically significant differences in pain relief (P<0.0001), complications (p=0.03), mean duration of sitz baths (p<0.0001), absenteeism (p<0.0001) respectively.Conclusion: Hence Subcutaneous fissurectomy with topical 2% Diltiazem gel is a better surgical option for chronic fissure in ano than conventional Lateral internal sphincterotomy.