Anal fissure: Lateral sphincterotomy and Botox

Sphincterotomy
1.Position the patient in lithotomy.
2.Perform a EUA including a digital and rigid sigmoidoscopy. Determine the status of the fissure.
3.Curette the base of the fissure and send the material for histopathology.
4.Identify the intersphincteric groove laterally on the left side while placing the sphincter on stretch using a Pratt or Eisenhammer speculum and make a1.5cm incision after infiltrating with LA.
5.Dissect the internal sphincter to the determined level and place artery forceps to this (should be at the level of the apex of the fissure and no higher than the dentate line). Divide the muscle with scissors. An alternative method is to bring out the length of internal sphincter via the incision and divide with diathermy on the artery forcep.
6.Dress with Unitulle following haemostasis.

Botox
Eisenhammer
Palpate intersphincteric groove.
Inject 25IU into 3 o'clock and 25IU into 9 o'clock positions
Peak onset is 7 days but can work as early as 3 hours