Lateral internal sphincterotomy (LIS) for chronic anal fissure by LigaSure™ Small Jaws: a comparison with traditional technique

BACKGROUND: An anal fissure is a small laceration in the tissue (mucosa) that lines the anus. Anal fissures can cause pain and bleeding with bowel movements. Anal fissures can be attributed to constipation or repeated straining: a hard-fecal bolus cut the mucosa of anal canal that is relatively soft at sphincter level. Management and treatment of the disease are controversial. Many studies recommend conservative and medical treatment modalities as the initial options, since they are noninvasive and do not have risks of sphincter injury. Lateral internal sphincterotomy (LIS) is considered the gold standard for treatment of chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. LigaSure™ (Medtronic, Dublin, Ireland) is a bipolar electrosurgical device designed to deliver high current and very low voltage to tissue. It monitors tissue impedance between the jaws of the instrument and continuously adjusts the delivery of energy. We have applied the use of this device to a group of patients complaining about chronic anal fissure in order to verify if there is any advantage in performing it, compared to traditional technique (blade, scissors, electrocautery). METHODS: A group of 436 patients were treated in our institution as proctological day-surgery patients from January 2016 to January 2021. Three hundred fifty-one underwent lateral internal sphincterotomy. As comparative group (CG), we considered the results of the systematic review of Boland et al. whose sphincterotomy group consisted of 349 patients (45% of 775patients) from 9 studies included. RESULTS: Of 351 patients who underwent to LIS pile excision, 322 healed within 9 weeks from treatment (91.73%) compared to 332 (95.1%) of the CG. Sixty-three out 85 (74.1%) of patients with AF + other treatments. In the LIS group the overall recurrence over a period of 6 months for all patients was 17 patients (4.84%) compared with 6.9% (24/349) over a period of 2-6 months follow-up. CONCLUSIONS: The use of LigaSure™ Small Jaw (SJ) (Medtronic) was never reported for anal fissures in literature. LigaSure™ SJ (Medtronic) is a bipolar device which allows to perform the procedure in a reduced time and in a safer way even if differences with traditional techniques are not significant. The costs of the operation are higher in LigaSure group. Literature up today does not report any article about the use of LigaSure™ (Medtronic) for treatment of anal fissures. It could be controversial for the cost of the device but is safer and quicker compared to traditional knife or scissors.