Background: Fissure in ano is a prevalent and painful condition, typically treated by lateral internal sphincterotomy (LIS) after conservative measures fail. Dilip's transmucosal internal sphincterotomy (TMIS) introduces a simplified approach that reduces the risk of damaging the external sphincter, making it particularly suitable for less experienced surgeons. This innovation offers a less invasive method with minimal risk of incontinence, providing a safer, more accessible option.
Impact of innovation: TMIS simplifies the LIS process, offering a tailored approach that eliminates the need for extensive dissection. This method allows surgeons complete control over the internal sphincter bundle, facilitating a precise, customizable cut without the risks associated with traditional LIS, especially in obese patients where the intersphincteric groove is not visible, leading to potentially harmful blind incisions.
Technology materials and methods: The procedure is performed under saddle block anesthesia with the patient in lithotomy position. A distinctive approach involving the use of retractors and stay sutures allows the internal sphincter to be made prominent and secured without extensive dissection. The division of the internal sphincter is achieved through a minimal mucosal incision, requiring no closure and significantly reducing postoperative pain and complications.
Preliminary results: Between December 2020 and February 2022, 124 patients received TMIS, showing significant benefits with a median operative time of 7 minutes and low post-operative pain. With a 2.5% infection rate effectively managed and a 3% transient incontinence rate, the majority healed within 9 weeks. Recurrence was rare at 1.6%.
Conclusions and future directions: TMIS presents significant advantages over traditional LIS, including reduced pain, lower risk of complications such as hematoma, abscess, or fistula formation, and the absence of painful postoperative nodules. TMIS's success suggests it should be incorporated into surgical education, offering a less daunting, more reproducible method for treating fissure-in-ano, especially beneficial for junior surgeons and improving patient outcomes.
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