Anoplasty c section

Anoplasty c section DEFAULT

'Unexpected': Taron Threatens Reanna Over Delivery Room Decision in Exclusive Sneak Peek

The tension between exes Reanna and Taron is heating up as the Unexpected stars prepare for the birth of their first baby. In a exclusive of Sunday's all-new episode of the TLC show chronicling unplanned teen pregnancies, the young mother, 15, and her ex, 17, attend a prenatal check-up just two weeks before Reanna's planned C-section.

Reanna's mom, Jessica, 33, explains that her teen will have to undergo a C-section due to a procedure she had as child called an anoplasty, or a surgery "to correct a birth defect involving the rectum and anus," according to MedLine Plus. "So they think if she had the natural birth, it would cause them to have to go in there and reconstruct the work that they did during the anoplasty, and she might not heal correctly," Jessica explains during her confessional.

Because she will be undergoing a scheduled C-section, Reanna has been given the task of determining which one person she will have in the operating room to witness the birth of her child. It's here that things get tricky with Reanna and Taron, who recently broke up due to infidelity on the father-to-be's part, as Reanna would prefer her own mother in the delivery room with her instead of the baby's dad. "She's pretty set on me being in the delivery room with her instead of Taron, because she just thinks that Taron may bring her more stress," Jessica shares. "But I'm hoping that she will change her mind."

Taron is upset at possibly being excluded from his child's birth as well. "I feel like I deserve to be one of the first to hold my child, and I want to be in the delivery room," he says. "I think I deserve to be in there, just because I am the father, that's it."

Reanna doesn't exactly have a ton of sympathy for his ex, telling cameras "he put his self in the situation," but the teen's mother advises her to reconsider. "Using a child as a pawn to get back at someone, that's the worst thing and the most cowardly thing that somebody could do," she tells her daughter, who responds indignantly, "I'm not using it to get back at him."


Taron isn't willing to take this as the start of their co-parenting relationship, however, telling her he hoped his exclusion isn't "a sign of things to come." He adds to the camera as Reanna looks on, "When the baby's born, if Reanna doesn't let me see her, I'd probably have to take her to court to just try to see my baby as much as I can." Unexpected airs Sundays 10 p.m. ET on TLC.


Imperforate anus repair

Imperforate anus repair is surgery to correct a birth defect involving the rectum and anus.

An imperforate anus defect prevents most or all stool from passing out of the rectum. 

How this surgery is performed depends on the type of imperforate anus. The surgery is done under general anesthesia. This means the infant is asleep and feels no pain during the procedure.

For mild imperforate anus defects:

  • The first step involves enlarging the opening where the stool drains, so stool can pass more easily.
  • Surgery involves closing any small tube-like openings (fistulas), creating an anal opening, and putting the rectal pouch into the anal opening. This is called an anoplasty.
  • The child must often take stool softeners for weeks to months.

Two surgeries are often needed for more severe imperforate anus defects:

  • The first surgery is called a colostomy. The surgeon creates an opening (stoma) in the skin and muscle of the abdominal wall. The end of the large intestine is attached to the opening. Stool will drain into a bag attached to the abdomen.
  • The baby is often allowed to grow for 3 to 6 months.
  • In the second surgery, the surgeon moves the colon to a new position. A cut is made in the anal area to pull the rectal pouch down into place and create an anal opening.
  • The colostomy will likely be left in place for 2 to 3 more months.

Your child's surgeon can tell you more about the exact way the surgeries will be done.

The surgery repairs the defect so that stool can move through the rectum.

Risks from anesthesia and surgery in general include:

  • Reactions to medicines
  • Breathing problems
  • Bleeding, blood clots, infection

Risks of this procedure include:

  • Damage to the urethra (tube that carries urine out of the bladder)
  • Damage to the ureter (tube that carries urine from the kidneys to the bladder)
  • Hole that develops through the wall of the intestine
  • Abnormal connection (fistula) between the anus and vagina or skin
  • Narrowed opening of the anus
  • Long-term problems with bowel movements because of damage to the nerves and muscles to the colon and rectum (may be constipation or incontinence)
  • Temporary paralysis of the bowel (paralytic ileus)

Follow instructions on how to prepare your baby for the surgery.

Your baby may be able to go home later the same day if a mild defect is repaired. Or, your baby will need to spend several days in the hospital.

The health care provider will use an instrument to stretch (dilate) the new anus. This is done to improve muscle tone and prevent narrowing. This stretching must be done for several months. 

Most defects can be corrected with surgery. Children with mild defects usually do very well. But, constipation may be a problem.

Children who have more complex surgeries still usually have control of their bowel movements. But, they often need to follow a bowel program. This includes eating high-fiber foods, taking stool softeners, and sometimes using enemas.

Some children may need more surgery. Most of these children will need to be followed-up closely for life.

Children with imperforate anus may also have other birth defects, including problems with the heart, kidneys, arms, legs, or spine.

Anorectal malformation repair; Perineal anoplasty; Anorectal anomaly; Anorectal plasty

Bischoff A, Levitt MA, Peña A. Imperforate anus. In: Wyllie R, Hyams JS, Kay M, eds. Pediatric Gastrointestinal and Liver Disease. 5th ed. Philadelphia, PA: Elsevier; 2016:chap 55.

Shanti CM. Surgical conditions of the anus and rectum. In: Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:chap 371.

Updated by: Debra G. Wechter, MD, FACS, general surgery practice specializing in breast cancer, Virginia Mason Medical Center, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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Anorectal anomaly

An anorectal anomaly is a disorder affecting the anus and the rectum, the last part of the digestive system.This page explains about anorectal anomaly, how it can be treated and what to expect when a child comes to Great Ormond Street Hospital (GOSH).

After food has been digested it passes through the small bowel into the large bowel. The faeces (poo) is stored in the rectum until the muscles receive a message from the brain to empty the bowel. The faeces then pass out through the anus.

There are two types of anorectal anomaly – low anorectal anomaly and high anorectal anomaly.

  • A low anorectal anomaly is where the anus is closed over, in a slightly different position or narrower than usual. There may also be a connecting passage to the skin called a fistula.

  • A high anorectal anomaly is where the bowel has a closed end at a high level and does not connect with the anus, or it may connect with another part of the body, usually the bladder, urethra or vagina, through a fistula.

Girls can be affected by a very complex malformation where there is only one opening for the bladder, vagina and bowel. This is called ‘cloaca’ or 'cloacal malformation' and requires more specialist treatment than covered in this information.

What are the symptoms of an anorectal anomaly?

Symptoms may vary according to the type of anorectal anomaly. The child will not be able to pass meconium – the dark faeces passed in the first few days of life – in the usual way. This can cause a swollen abdomen and vomiting.

If the child has an anorectal anomaly with a fistula, the faeces will be able to partially pass out of the body, near the vagina in girls or through the urethra in boys. As the faeces can only be partially removed from the body, this will not relieve the pressure in the abdomen, causing swelling and vomiting. Anorectal anomalies need to be diagnosed quickly as the baby can become very unwell in a short period of time.

How is an anorectal anomaly diagnosed?

An anorectal anomaly is usually diagnosed soon after birth, on examination, when the baby fails to pass meconium at all, or the meconium comes from a different place. Health care professionals use the passing of meconium as part of the standard newborn checking procedure.

The doctor may suggest scans to give a clearer picture of the type of anorectal anomaly and whether there is a fistula. These could include X-rays, ultrasound scans or rarely, MRI scans.

What causes an anorectal anomaly and how common is it?

An anorectal anomaly happens when the bowel does not form properly while the baby is developing in the womb. We do not know exactly what causes this, but it is not due to anything that happened during pregnancy. Research has indicated some possible causes of anorectal anomaly, but these need further investigation.

An anorectal anomaly can be associated with other problems, but the doctor will examine the child closely to check if this is the case. About one in 3,000 babies are born with an anorectal anomaly.

What treatments are available and are there any alternatives?

The treatment depends on the type of anorectal anomaly. All types of anorectal anomaly will need an operation under general anaesthetic. In some cases only one operation (anorectoplasty) will be needed, but most children may need a series of operations.

The first operation is to create a loop stoma (an artificial way of disposing of waste matter) usually in the days after birth. The second is an posterior sagittal anorectoplasty (PSARP) operation to join the bowel to a newly created anus. This usually happens when the child is a few months old and has gained weight.

The final stage is to close up the stoma. This happens when the child’s bowel and anus is working well a few months after the second operation.

The three operations are usually completed by the time the child is six to nine months old. In most cases, the surgeon operates on the child’s bottom, but occasionally an incision in the abdomen might be needed. The second operation referred to as a PSARP (posterior sagittal anorectoplasty). This describes the operation and the approach taken by the surgeons.

There are no alternatives to these operations as the child needs to be able to pass faeces to prevent it building up in the bowel.

What happens before the operation?

Whichever operation is planned, you will receive information about how to prepare the child for the operation in your admission letter and your welcome booklet. The surgeon will explain the operation in detail, discuss any worries you may have and ask your permission for the operation by asking you to sign a consent form. An anaesthetist will also visit you to explain about anaesthetic in more detail. If the child has any medical problems, like allergies, please tell the doctors.

As the child cannot take oral fluids normally due to the blocked bowel, they will need a drip of fluids for a while before the operation. The child will also need a nasogastric tube, which is passed up the nose, down the foodpipe and into the stomach. This will drain off the stomach and bowel contents and vent any air which has built up, which will make the child more comfortable.

What does the operation involve?

Anoplasty – the surgeon will open up the anus (if it was closed over), move the anus (if it was in a slightly different place to usual) or widen the anus (if it was narrower than usual).

Creation of loop stoma – the surgeon will bring the bowel to an artificial opening in your child’s abdomen (stoma).

Posterior sagittal anorectoplasty operation (also called PSARP) – the surgeon will create a new anus and then separate the bowel from the fistula (if there is one) and bring it down to join the newly created anus. They will then close up the fistula. If the fistula is very high, the surgeon may need to make an incision in the child’s abdomen to correct it. The child will continue to use the stoma so that the bowel and anus can rest and heal.

Closure of loop stoma – the surgeon will disconnect the bowel from the stoma and close it to form a fully working bowel.

Are there any risks?

All surgery carries a small risk of bleeding during or after the operation. There is a very small chance that the bowel could leak into the abdominal cavity. This could cause an infection called peritonitis, but we will give the child antibiotics to treat this, should it happen. If the child has a fistula, the urethra or vagina could be damaged when the bowel is disconnected but this is very rare.

There is also a chance the muscles used for bladder and bowel control could be damaged, but this is also very rare. In many cases, the muscles are already affected to some degree before the anomaly is repaired. Every anaesthetic carries a risk of complications, but this is very small. The anaesthetist is an experienced doctor who is trained to deal with any complications.

What happens afterwards?

The child will come back to the ward to recover. We will keep the child as comfortable as possible, by giving regular pain relieving medications. For the first few days, the pain relief will usually be given through a drip and then, when the child is more comfortable, in the form of medicines to be swallowed.

For the first few days, the child will need a drip of fluids until they feel like eating and drinking again. This will also allow the bowel to rest and start to heal. When the surgeon is happy that the area is healing, you can start to feed the child again, starting with small amounts, and increasing the amount as they tolerate it.

If the child has had a new anus created, in some cases, you may be asked to stretch (dilate) it using a probe called a dilator. In many cases, the surgeon will check the area and carry out the first dilatation while the child is under a short general anaesthetic. If further dilatation is needed, your surgeon or stoma nurse specialist will show you how to do this before you go home. You will need to start with a small size dilator and gradually increase the size until the anus is the right size. Most children do not require dilatation.

If the child has had the stoma created, the stoma nurse specialist will teach you how to look after it. We will make sure you feel confident before you go home.

You will be able to go home once the child is feeding well and starting to gain weight. We will contact your health visitor and family doctor (GP) to tell them about the operation.

When you get home

The child’s abdomen may feel sore for a while after the operation, but wearing loose clothes can help. The stitches used during the operation will dissolve on their own so there is no need to have them removed. If possible, keep the operation site clean and dry to let it heal properly. The surgeon will let you know when the child can have a bath, but do not soak the area until the operation site has settled down.

After all the operations, the child may have diarrhoea or constipation. This is an after-effect of the operation and we will discuss this with you at the follow up appointment. Occasionally some children need medicines to help with any bowel problems. After the operation, the child may have a very sore bottom. It is not a good idea to sit your baby upright or do anything that puts pressure on the healing area for several weeks after the operation. Whenever possible, leave the child’s bottom exposed to the air as this will help it heal too.

When the stoma has been closed and your child is in nappies, use nappy cream liberally to prevent nappy rash. Almost all babies develop nappy rash at some point after this operation, usually as a reaction to the bowel starting to work.

You will need to come back to hospital for an outpatient appointment about six weeks after each operation. We will write to you with the appointment date.

You should call your family doctor (GP) or the ward if the child:

  • has serious abdominal pain and/or diarrhoea

  • has serious constipation

Seek urgent medical help if the child:
  • vomits when feeding

  • has a swollen stomach

  • vomits green liquid

  • is not gaining weight

What is the outlook for children with anorectal anomaly?

The outlook for children with anorectal anomaly depends on the type of abnormality. Many children go on to lead normal lives. However, there are a couple of side effects which you should know about should they arise in the future.

The child may need extra bowel training at a later stage to learn when and how to empty their bowels. They may also need some extra help in the form of enemas, washouts or medicines, but these will be explained to you if they are needed.

However, some children continue to have bowel problems for many years after the operations, but this depends on the original severity of the anorectal anomaly. If the child does not have full bowel control by the age of three years, please discuss this with the team at your next clinic appointment.

The child will need regular check ups with your doctor at Great Ormond Street Hospital until they are well. Girls who have had an anorectal anomaly repair may be better having a caesarean section rather than vaginal childbirth. This will put less strain on the operation site and is less likely to cause problems in the future. Your daughter should discuss her previous medical history with her doctor when planning a pregnancy.

Compiled by:

The Specialist Neonatal and Paediatric Surgery department in collaboration with the Child and Family Information Group

Last review date:

August 2016

anal stenosis, anoplasty

Cesarean delivery and anal sphincter injury

Objective: Cesarean delivery has been thought to prevent all obstetric anal sphincter damage. The objective of this study was to determine the relationship between the timing of cesarean during primiparous delivery and injury to the anal sphincter mechanism.

Methods: A prospective observational study was conducted, using a continence questionnaire and anorectal physiology assessment before and six weeks after primiparous delivery. A cohort of 234 women were recruited from the antenatal clinics at the National Maternity Hospital, Dublin. Thirty-four women delivered subsequently by cesarean, and 200 women by spontaneous vaginal delivery.

Results: Thirty-four women underwent cesarean delivery without attempted vaginal delivery: eight prior to labor and 26 during labor, 17 in early labor (cervical dilatation less than 8 cm) and 9 in late labor (dilatation greater than 8 cm). No woman delivered by cesarean had altered fecal continence postpartum. Anorectal physiology was unaltered in women delivered by elective cesarean or cesarean in early labor. Pudendal nerve terminal motor latency was prolonged, anal squeeze pressure increment reduced, but vector symmetry index was unchanged in women delivered by cesarean delivery late in labor, indicating neurologic injury to the anal sphincter mechanism.

Conclusion: Cesarean delivery performed in late labor, even in the absence of attempted vaginal delivery, does not protect the anal sphincter mechanism.


C section anoplasty

Cesarean delivery for the prevention of anal incontinence

Effects of interventions

Reported crude incontinence rates varied greatly between reports from 1.14% (Hannah 2002) to 25.7% (Varma 2006) to 48% (Guise 2008). This variation is troubling. Variation is also often seen in prevalence studies, where apparently similar populations report widely varying rates of anal incontinence (Nelson 2004), but in no case in those reports was it as high as in the reports cited above. This may be due to variations in ascertainment techniques and the age of the assessed populations. For instance the (Hannah 2002) participants had just had babies and were clearly much younger than those assessed in (Varma 2006), who were between 40 and 69 years old. Yet in a similarly aged population to Varma 2006, Fornell 2004 presents fecal incontinence prevalence as low as 1% for solid faeces in urinary continent women. Further discussion of problems related to disease ascertainment is presented in Discussion. Comparison of rates across studies are therefore not done, though comparative rates within studies, especially when age adjustment is performed, should be more reliable than rates across studies. Results for each of the outcomes are shown in the Forest plots. In addition, summary statistics of effect are not reported as these are all non‐randomised studies, or in one case, a randomised study reported as treated (Hannah 2002; Hannah 2004) because of a cross over rate of 52.1% after randomisation.

1.Comparison: Caesarean delivery versus vaginal delivery (all studies) 

 Outcome: Anal incontinence


1.11 Of the 22 studies shown in Forest plot 1.1, fecal incontinence by delivery mode, only two show a significant protective effect of CD (MacArthur 2001;Guise 2008). The (MacArthur 2001) assessed continence only 3 months post partem and in a follow up study of the same participants, the difference in prevalence of incontinence comparing CD and VD disappeared (MacArthur 2005) (OR=1.04, 0.72‐1.50), an effect also seen in comparing the early and late reports of (Hannah 2002; Hannah 2004). (Guise 2008) is a subset of (Guise 2007), the primiparous mothers from that survey, with adjustment for age, many delivery related factors and exclusion of women who reported an anal incontinence prior to the pregnancy, allowing a calculation of incidence. Also unlike the 2007 study, the more recent publication allows direct comparison of CD and VD. The protective effect of CD was very significant (OR=0.7, 0.62‐0.78) and the population large (5491), apparently giving great weight to the study. However the continence assessment tool used, the "NIH definition" of incontinence, merged both flatus and faeces. Any episode of incontinence since delivery up to three months was queried and apparently even a single episode in the early post‐partum period would classify that mother as incontinent. The incidence of incontinence in CD was 39% and in VD, 48%, levels of incontinence otherwise only seen in nursing homes (Nelson 1998). All other included studies showed prevalence numbers, despite their variation, much smaller than this, some less than 1%, especially for CD (Chaliha 2001). This adds great emphasis to the importance of continence assessment at a time remote from the delivery of the baby. In addition it also stresses the need for an assessment tool that can be more uniformly utilized in future studies and especially one that discloses a sustained disorder rather than a single event at a traumatic time.


1.2 There are no studies that show a significant benefit of CD over VD with regard to incontinence of flatus. As mentioned above, two studies merged flatus and faeces into a single outcome variable (Guise 2008; Lal 2003) and the data from both these studies has been entered in comparison 1.1, incontinence of faeces.

2. Subgroup Comparison: Caesarean delivery versus vaginal delivery (by subgroups of quality or emergency or elective)

2.1 Incontinence of faeces in the 7 best studies. Seven studies adjusted for age, avoided misclassification or overlap of delivery mode, and assessed incontinence at an appropriate time (Abramov 2005; Altman 2007; Goldberg 2003; MacArthur 2005; MacLennan 2000; Varma 2006; Melville 2005). A validated instrument for the detection of anal incontinence was used in four of these studies (Abramov 2005; Altman 2007; Goldberg 2003; Melville 2005). None of these studies showed a significant benefit of CD over VD and aside from (Abramov 2005), the odds ratios are closely clustered around 1.0.

2.2   Emergency CD versus Elective CD

Six studies allowed comparison of elective versus emergent CD (Abramov 2005; Guise 2007; Guise 2008; Lal 2003; MacArthur 1997; MacArthur 2005). An important factor in separating the effects of pregnancy from labor is whether the CDs were done electively or in a women in labor, emergently. MacArthur presents only 3 month continence data for primips. (Odds Ratio for fecal incontinence = 0.99; 95 per cent confidence interval = 0.62‐1.52) and all women (1.14; 0.49‐2.65) (MacArthur 2001), and Abramov (Abramov 2005) a more prolonged follow‐up in discordant twins (1.07; 0.05‐24.1). (Lal 2003) had an OR of 1.57; CI 0.381‐6.486, among 184 women having either emergent or elective CDs and (MacArthur 1997) had an OR of 0.134; CI=0.007‐2.428. In none of these studies was there a significant difference in fecal incontinence between women having emergency or elective CDs. For (Guise 2007) and (Guise 2008, looking only at primiparous mothers from the 2007 population), the odds ratios were 0.92; 0.57‐1.51 and 1.20; 0.92‐1.56 respectively.

2.3   Elective CD versus VD

Four studies presented analyses that compare elective CD versus VD (Abramov 2005; Lal 2003; MacArthur 1997; MacArthur 2001), again addressing the same issue raised in comparison 2.2, whether combining elective and emergent CD in comparisons to VD might obscure a benefit of CD when done electively. There was no significant advantage of elective CD over VD in any of these four studies.

2.4 The association of pregnancy delivered by any method with fecal incontinence compared to women who have never delivered a baby is shown in this Forest plot. These are derived from the four studies (Fritel 2007; MacLennan 2000; Melville 2005; Varma 2006), encompassing 1796 nulliparous women and 7686 women who have had a baby by any delivery method. (MacLennan 2000; Varma 2006) both show a significant increase in risk of fecal incontinence in parous women.

The number needed to treat results are shown in Table 1. There was great variation between studies, in some cases with inverted numbers, that is VDs would have to be done to prevent a case of anal incontinence relative to CD (negative numbers in the Table). Summary calculations are not presented for two reasons. First summary risk data are not calculated since all included studies are observational studies. Second the prevalence risk of incontinence in the control population (VD) varied widely between studies suggesting cultural/methodological/clinical differences in these studies that would make them hard to compare. The internal validity within each study of the VD/CD comparison and NNT should not be affected by this variation.

The fecal incontinence prevalence decreased in follow‐up studies for instance from 9.6% (MacArthur 2001) in the whole cohort at 3 months to 3.6% (MacArthur 2005) at 6 years The same disappearance of an apparent insignificant benefit of CD in preservation of anal continence was found in the follow up study of the Term Breech Trial (Hannah 2002, Hannah 2004). In the (MacArthur 2005) study and the mothers of twins study (Goldberg 2003), there was an insignificant trend towards increased incontinence risk with CD (see NNT in Additonal Tables). Among the studies where follow‐up is also published, data from both the initial reports and longer follow up data are presented in the Forest plots for (Hannah 2002; Hannah 2004; MacArthur 2001; MacArthur 2005).

EMCrit Vertical C Section

Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation


Chronic anal fissure’s (CAF) etiopathogenesis remain unclear. CAF of the posterior commissure (CAPF) are often characterized by internal anal sphincter (IAS) hypertonia. The treatment of this disease aimed to reduce IAS hypertonia. Due to the high rate of anal incontinence after LIS, the employment of sphincter preserving surgical techniques associated to pharmacological sphincterotomy appears more sensible. The aim of our study is to evaluate the long-term results of fissurectomy and anoplasty with V–Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection for CAPF with IAS hypertonia. We enrolled 45 patients undergone to fissurectomy and anoplasty with V–Y cutaneous flap advancement and 30 UI botulinum toxin injection. All patients were followed up for at least 5 years after the surgical procedure, with evaluation of anal continence, recurrence rate and MRP (Maximum resting pressure), MSP (Maximum restricting pressure), USWA (Ultrasound wave activity). All patients healed within 40 days after surgery. We observed 3 “de novo” post-operative anal incontinence cases, temporary and minor; the pre-operative ones have only temporary worsened after surgery. We reported 3 cases of recurrences, within 2 years from surgery, all healed after conservative medical therapy. At 5 year follow-up post-operative manometric findings were similar to those of healthy subjects. At 5 years after the surgical procedure, we achieved good results, and these evidences show that surgical section of the IAS is not at all necessary for the healing process of the CAPF.


Chronic anal fissure (CAF) is one of the most frequent proctological disease, its clinical features are post-defecation bleeding, itching and pain, which can last from few minutes–hours. CAF most frequently occur at the posterior commissure (CAPF) [1], nevertheless, to present the etiopathogenesis of the disease remains unclear. CAPF are characterized, more often than CAF at the anterior commissure, by internal anal sphincter (IAS) hypertonia. To date, the role of this latter feature is unknown, and we still wonder whether it is a cause or a consequence of CAF disease. During the last few decades, the treatment of this disease aimed to reduce IAS hypertonia with medical or surgical techniques. Surgical lateral internal sphincterotomy (LIS) represents nowadays the gold standard treatment for CAFs, which are refractory to the pharmacological therapy; this surgical procedure is burdened by low rate of post-operative complications and high healing rate. The great disadvantage of the latter procedure is the high rate of anal incontinence, which can occur in up to 30–40% of cases. A recent meta-analysis [2] evaluating long-term incidence of anal incontinence after LIS, showed an overall continence alteration risk of 14%; however, on severity analysis, flatus incontinence and soilage/seepage were much commoner than frank incontinence to liquid or solid stool.

Anal incontinence has a strong impact on the quality of life of patients and it can be more disabling than CAF itself [3]; as a matter of fact, patients tend to bear better the recurrence than the fecal incontinence [4].

To preserve the anatomical and functional integrity of the sphincterial system as well as to reduce the anal incontinence incidence, the surgical procedures mostly used for the treatment of CAPF are fissurectomy alone or fissurectomy and pharmacological sphincterotomy, which can be associated with cutaneous and mucous flap.

The aim of our study is to evaluate the results of fissurectomy and anoplasty with V–Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection, at 5 years after the sphincter-saving surgical procedure, as a treatment for CAPF with IAS hypertonia.

Materials and methods

We enrolled 45 patients, all affected by idiopathic and non-recurrent CAPF with hypertonic IAS, who underwent fissurectomy and anoplasty with V–Y cutaneous flap advancement and 30 UI botulinum toxin injection, from January 2011 until January 2015. All patients were followed up for at least 5 years after the surgical procedure. The patients’ outcome data were retrieved from a prospectively monitored database.

Pre-operative manometric evaluation was performed after a reasonable period of suspension of all medical therapy influencing IAS tone. The manometric evaluation was carried out by a manometric sensor (2.1 mm external diameter) with four circle orifices and a latex microbaloon at its extremity (Marquat C87; Boissy, St-Leger, France). The machine was connected to a polygraph (Narco; Byosystem MMS 200, Houston TX) using the station pull-through method with perfusion of normal saline and the patient lying on the right side. At manometric evaluation, maximum resting pressure (MRP) and maximum squeeze pressure (MSP) were defined as the maximum pressure detected, respectively, on resting and after voluntary contraction. Ultraslow wave activity (USWA) was defined as pressure’s waves with frequency of less than 2/min and an amplitude greater than 25 cm H2O [5].

Data collected on healthy subjects by our anorectal pathophysiological laboratory showed [6] that the normal values of MRP and MSP were, respectively, 68.1 ± 12.3 mmHg mmHg and 112 ± 36,2 mmHg; USWA was detected in the 10% of patients. In accordance to Jones et al. [7], normal range of MRP was 45–85 mmHg; so that CAAF with hypertonic IAS were defined as those with MRP values > 85 mmHg. Manometric follow-up was performed at 12 and 60 months after the surgery.

All patients underwent fissurectomy and anoplasty with V–Y skin flap advancement lying in a gynecological position under spinal or general anesthesia. To expose the anal canal we used four Kocher pliers placed at 3, 6, 9 an 12 h to avoid employing anal retractors; an Eisenhammer retractor or a speculum have been gently introduced just in case of necessity.

After injection of 5 ml of local anesthetic solution (100 mg hydrochloride mepivacaine an 0.025 mf l-adrenaline), the fibrotic edges were excised with a scalpel until normal non-fibrotic anodermal tissue showed sufficient bleeding. The sentinel skin tag and hypertrophied papilla at the level of dentate line were excised when present according to Gupta and Kalaskar [8]. The tissue at the base of the fissure was curetted until there were clean muscle fibers of the IAS. There was no use of diathermy and careful attention was payed to avoiding damages of the IAS. Standard advancement anoplasty was performed using a flap of healthy skin tissue which was mobilized and then advanced with its blood supply to fill in the defect. The flap was secured without tension to the anal canal and the skin was closed tension free in a V–Y manner with interrupted rapid absorbable suture behind the advancement flap. Once the fissurectomy and anoplasty was performed, the botulinum toxin (BT) A (Botox, Allergan, Westport, Ireland) store at − 20 °C and diluted in saline to 50 UI/ml was injected into IAS with a 27-gauge needle. Each patient received a total of 30 UI of BT: 15 UI injected at 3 h in gynecological position and 15 UI injected at 9 h. None of the patients assumed concomitant oral medications that could interfere with the action of type A BT (aminoglycosides, baclofen, dantrolene, diazepam) and there was no known hypersensitivity to any component of BT formulation. All procedures were carried out by the same senior surgeon (GDV). Before surgery, all patients received a small volume of phosphate–saline enema. Metronidazole was administered intravenously in a dose of 500 mg 1 h before surgery. Subsequently, it was administered per os at the dosage of 250 mg for 7 days, three times daily.

During the first 2 weeks after the surgery, patients took variable doses of psyllium fibers. A laxative preparation (sennosides) was given orally to subjects who had not yet passed stools 3 days after surgery. Enema, suppositories and all rectal manipulation were avoided. Immediately after surgery, all patients received 100 mg of diclofenac intramuscularly for analgesia and were instructed to take only 100 mg of nimesulide tablets when needed. The primary goal of the study was the patient’s complete healing and the evaluation of incontinence and recurrence rate; the secondary goal included the evaluation of MRP, MSP, USWA, symptom relief (bleeding, itching and pain) and recording pro forma of the immediate an long time complications related to flap (anal stenosis, keyhole deformity, urinary retention, related side effects of BT). A complete healing was defined as a complete epithelialization of the advancement skin flap. Both duration and intensity of pain post-defecation were evaluated. Pain intensity was scored with a visual analogical scale (VAS) from 0 to 10, where 0 corresponded to no pain and 10 to the worst pain conceivable. Anal incontinence was assessed pre-operatively and after 1, 3, 6, 12 and 60 months from surgery using the Pescatori grading system [9]: A incontinence for flatus and mucus; B for liquid stool; C for solid stool; 1 for occasional; 2 for weekly and 3 for daily. Patients were discharged 24 h after surgery, afterwards they were examined until they were completely healed and they were also followed up at 1, 12 and 60 months following the surgical procedure. Independently of the scheduled appointments, patients were seen on request.

Statistical analysis

Continuous variables were expressed as a mean with standard deviation and qualitative data as absolute frequencies, MRP values were also given as median and range. Student’s t test with Welch correction was used to analyze the differences of pain score and pain duration at each registration point. Values of P < 0.05 were considered statistically significant.


This study includes 15 women and 30 men. At the time of surgical procedure, the median age of the patient was 39 years (range 18–72). Bowel function was normal in 13 patients, 26 patients suffered from constipation and 6 from diarrhea; bowel function was assessed according to the updated Rome diagnostic criteria. Seven women were nulliparous, 4 gave natural birth and all of them underwent an episiotomy and 4 patients gave birth throughout a caesarean section. Clinical features of AF are reported in Table 1.

Full size table

Healing fissure and relief of symptoms

We achieved complete wound healing, in all patients, within 40 days after surgery. Intensity and duration of post-defecation pain was significantly reduced with respect to the pre-operative values starting from the first defecation (P < 0.001) (Fig. 1). None of the patients complained about pain, bleeding or itching 40 days after surgery. Analgesics consumption decreased significantly after first defecation.

Intensity and duration of pain related to defecation after fissurectomy and anal advancement. Star statistically significant difference from the pre-operative values: P < 0.001

Full size image


We recorded 3 cases of pre-operatory anal incontinence (6.6%), 2 cases were type A1 and one was type A2 according to Pescatori grading system. In 2 of these patients, anal incontinence resulted worsened at 1 month follow-up after surgery, while at 3 month follow-up, the grading score was similar than the pre-operative recorded one, Table 2. We observed only 3 “de novo” anal incontinence cases but in all of them the alteration was minor and temporary, Table 3.

Full size table

Full size table


We reported only 3 cases of recurrences, 2 women and 1 man, the site of the recurrences was always different from the primary location. All of them occurred within 2 years from surgery and all were characterized by the persistence of IAS hypertonia. All patients underwent a medical treatment consisting in implementation of fibers in the diet, employ of local products containing nifedipine or lidocaine and anal dilators. All patients responded to the conservative treatment with a complete healing.

Manometry findings

Pre-operative values of MRP were significantly higher as compared with healthy subjects (101 ± 15 mmHg; P = 0.001), whereas MSP values were only slightly increased (125 ± 16.8 mmHg; P = n.s.).

At 12 months and 60 months after surgery MSP values did not significantly differ as compared both with pre-operative levels and healthy control subjects.

At 12 month follow-up, MRP values were significantly lower as compared with pre-operative values (P < 0.001). As compared with healthy controls, MRP values had still increased (P < 0.01). At 60 months, MRP values were similar compared with healthy control subjects (P = n.s.).

Pre-operative, the presence of USWA was detected in 11 of 45 (24.4%). A comparison among healthy subjects and patients with CAPF showed a significant difference (P < 0.001).

At 12 month follow-up, the detected rate of USWA was lower in comparison to pre-operative values (P < 0.05) but they were not significantly higher as compared with healthy subjects. At 60 month follow-up the USWA values of CAPF patient were not statistically significantly different form the ones of healthy subjects.

Complications and follow-up

There were no cases of urinary retention, anal stenosis or keyhole deformity. No necrosis of the transposed flap was observed. We did not report any local complications related to the injection of the BT. The only complications recorded post-operatively were of slight entity and in no case required further surgery; in particular, 3 infections were detected in the donor site and a partial break down of the flap occurred in one case.


The results of our study show that fissurectomy and anoplasty associated with the injection of BT, as treatment for patients affected by CAPF with IAS hypertonia, allows an immediate resolution of clinical symptoms as well as a fast healing of the wounds. We recorded a low rate of recurrence (6.7%); we observed only 3 “de novo” case of post-operatory anal incontinence, which were temporary and of slight entity; patients who were already suffering experienced a temporary worsening. Moreover, MRP values started significantly reducing from 12 months [10] after the procedure to reach, at 60 months after surgery, values which were similar to healthy subjects.

Fissurectomy is the most common surgical procedure used to preserve structural and functional integrity of the IAS. It consists in the in the excision of the CAF and it can be associated with the removal of the hypertrophied anal papilla and skin tags. Fissurectomy, as a wound debridement, removes the bradytrophic scar tissue and produces fresh wound edges, creating an acute fissure. Fissure excision without interfering with the IAS was first reported by Ashton in 1854, it was recognized to be an effective therapy for CAF, but it was abandoned due to its complications, such as keyhole deformity, which can lead to fecal incontinence [11]. Nevertheless, it has been recently reconsidered as a valid treatment for CAF both in children and adults [12]. This latter surgical procedure has been associated with pharmacological sphincterotomy to improve its results, as well as reduce its complications [15,16,17,18,19,20]. After surgical fissurectomy, with or without association with chemical sphincterotomy [13, 15, 21,22,23,24,25,26], we observe a complete second intention wound healing, even after 10 weeks and the rate of failure con reach the 34% [24]. The rate of recurrence reaches up to the 37% in some series [22]. The high rate of recurrence and healing failure of fissurectomy might be related to the fact that this surgical procedure leaves a naked ischemic area, whose previous blood supply arrives from some branches of rectal inferior arteries, which cross the hypertonic IAS fibers [27,28,29]; in this regard the employ of drugs enabling to reduce the IAS tone aims to improve the blood supply of the naked area.

The employ of a skin graft after fissurectomy was first described by Ruiz-Moreno in 1968.The use a flap to cover up for the naked area after fissurectomy is designed to relocate on this area healthy and fresh blood supplied tissue, perfused by other arterial districts. Another possible advantage of using a flap might be represented by the enlarging effect on the cutaneous circumference of the anal canal, which reduces the risk of splitting.

Several surgical techniques for the use of flaps have been described, we number among them the employ of skin or mucous flaps, skin ones are most frequently hired. Various type of skin flaps are known, such as sliding skin grafts, house advancement flap, V–Y advancement anoplasty, island advancement flap and rotation flaps [31,32,33,34,35].

Surgical procedures that involve the employment of flap guarantee shorter healing period and lower incidence of non- healed wound or recurrence and a minimal interference with the anal continence than the ones observed after surgical fissurectomy itself with or without association with pharmacological sphincterotomy [14, 30, 36, 37]. Fissurectomy associated with anoplasty is a surgical procedure employed for both patients with hypertonic IAS and normotonic IAS [35, 38]. Under the light of the brilliant results of this surgical procedure, some authors suggest using fissurectomy with anal advancement flap as the first line therapy for CAF [30, 39,40,41].

At the best of our knowledge, the association of fissurectomy with anoplasty and pharmacological sphincterotomy has been cited in one of our series [38, 42] and subsequently in a study published by Halahakoon et al. [43].

In this study, we associated the injection of BT in the IAS to the fissurectomy and anoplasty with V–Y skin advancement flap, to temporarily reduce the IAS pressure [44]. BT A prevents release of acetylcholine at the presynaptic nerve endings and blocks the neuromuscular transmission, thus causing a chemical enervation of the sphincter muscles. Nevertheless, this procedure is not free of risks, most frequently observed complications are peri-anal thrombosis, infections and anal incontinence. In this regard, we noticed that patients affected by pre-operative anal incontinence, experienced an immediate post-operatory worsening of the alteration, which diminished to pre-operatory level straight after 6 months; even for the 3 “de novo” cases, that we observed in the study, anal incontinence has been temporary and of slight entity but related to the BT action. The only surgical related complications we were able to record were of slight entity and they never required further surgery. Moreover, we recorded 3 cases of recurrence, which have not occurred at the same site as the original lesion and all healed with medical therapy; this might be because of the durability of the advancement flap [30].

However, during the fissurectomy with or without advancement flap, some steps may compromise the integrity of IAS. Therefore, it is mandatory to perform it with a scalpel to avoid excision or cauterization of the IAS fibers. It’s also useful not to use anal retractors, unless necessary and used for a brief period of time. In their prospective randomized clinical Zimmermann et al. [45] showed that trans anal advancement flap for high trans sphincteric fistula results in a significant reduction of MRP values and increase of anal incontinence rate after use of Park retractor when compared with the use of Scott retractor. Van Tets et al. [46] conducted a study in patients who underwent closed hemorrhoidectomy and showed that the reduction of MRP values was greater when a Park retractor was used; they also suggested that overstretching of anal sphincter by a Parks retractor may lead to small nerve branches rupture and consequently to the denervation of IAS fibers. As a matter of fact, in animal studies [47], it has been shown that prolonged stretching may cause local necrosis of external anal sphincter fibers. In view of these latter findings in our study we reached a good exposure of the anal canal just using 4 Kocher pliers placed at 3,6,9 and 12 h in gynecological position or just rarely using an anal retractor.


At 5 years after the surgical procedure we achieved good results and observed that post-operative manometric findings were similar to those of healthy subjects; these evidences show us the surgical section of the IAS is not at all necessary for the healing process of the CAPF.

In conclusion, further randomized trials comparing fissurectomy alone versus fissurectomy associated with graft and drugs enabling the reduction of IAS tone are needed to better define their role in the treatment of CAPF with IAS hypertonia.

Availability of data

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.


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Open access funding provided by Università degli Studi di Palermo within the CRUI-CARE Agreement. All authors contributed to the study. D’Orazio B. and Di Vita G. conceived, devised and designed the manuscript. Geraci G., and Corbo G. collected the case and iconography. D’Orazio B. and Geraci G. wrote the manuscript and participated in the sequence alignment. Di Vita G., Geraci G., Sciumé C. and Martorana G. revised and approved the final manuscript and its conclusions. No further acknowledgement are needed.


No financial support has been obtained in the preparation of this study.

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  1. General Surgery Unit, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Via Liborio Giuffrè, 5, 90127, Palermo, Italy

    Beatrice D’Orazio, Girolamo Geraci, Carmelo Sciumé, Giovanni Corbo & Gaetano Di Vita

  2. Postgraduate Medical School in General Surgery, University of Palermo, Palermo, Italy

    Beatrice D’Orazio & Giovanni Corbo

  3. General and Oncological Surgery Unit, Fondazione Istituto G. Giglio, Cefalù, Italy

    Guido Martorana

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Correspondence to Gaetano Di Vita.

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D’Orazio, B., Geraci, G., Martorana, G. et al. Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation. Updates Surg73, 1575–1581 (2021).

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  • Proctology
  • Anal fissure
  • Fissurectomy
  • Anoplasty
  • Sphincterotomy
  • Botulinum toxin

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