I have posted here a few times and I am very close to making a decision as to whether to pursue LIS or not. I need some feedback from the group on some advice/recommendations that I received from an out-of-state CRS, who has never examined or treated me in the past. I found this particular CRS online and sent him an email regarding my history of chronic rectal pain, most likely the result of some sort of pelvic floor dysfunction, my chronic bowel evacuation difficulties, and the recent development of some recurring fissures. I did tell him that I have only had three diagnosed fissures in the past 5 years, all of which healed with little to no treatment and I had several months between each episode. The following is his recommendation based on the information that I provided to him:
"You have alot of features that tell me that you would benefit positively from sphincterotomy. Recurrent anal fissure disease being the most important. Problems with external hemorrhoid swelling on an intermittent basis and a high resting anal sphincter pressure with evacuation constipation are more minor reasons. Sphincterotomy will get rid of your anal fissure disease, improve swelling of external hemorrhoids and improve a tight sphincter that might aggravate constipation. I would not expect it to totally eliminate external hemorrhoid swelling or evacuation constipation. Any improvement in constipation and straining will help levator spasm. The internal sphincter muscle is an involuntary muscle and is contracted at rest. When a bowel movement comes down and distends the rectum, nerves tell the internal sphincter muscle to relax such that the bowel movement or gas can come down where you can sense what is there. Then, with your external sphincter muscle (voluntary control muscle)., you decide whether to hold it or let it pass. Everything works fine up to that point with a patient who has an anal fissure or high resting anal sphincter pressure. However, when you decide to go, the base of the fissure is the internal sphincter muscle and it spasms causing pain and funneling the anal canal applying pressure to the front and the back and propagating the anal fissure. Sphincterotomy is done by making a small left lateral incision and identifying the internal sphincter muscle and putting a small 1 cm cut in the muscle. This takes pressure off of the front and back of the canal and the fissure heals. Have never seen one not heal. Nor have I seen anyone who has undergone sphincterotomy have recurrent anal fissures going forward. The hemorrhoids sit on top on the internal sphincter and, although it is not well-documented, it has been alot of our impressions in the profession that the internal sphincter spasm forms a concentric ring and aggravates external hemorrhoid swelling. I think it helps patients that have that problem in addition to anal fissure. Some patient have undergone hemorrhoidectomy under these circumstances and gotten worse. Yes, there is a risk of some change in continence, but I really have not seen that. I think a sphincterotomy for you is definitely indicated given the understanding that it will eliminate your anal fissure disease and possibly help some with recurrent external hemorrhoid swelling and evacuation issues. If levator spasm is present , then by helping with evacuation and decreased straining, it might get some better too. Although continence issues have to be mentioned, I really dont think that is an issue. I probably do about 30 of these a year and have been in practice 25 years. Hope this helps."
He went on to say, in future email correspondence, that he would do LIS whether I presented with an active fissure or not, he was not a big fan of botox, he did not feel it necessary to perform a fissurectomy at the same time as LIS, and that I would only need to spend a week, at most, before I could return back home and that most patients feel immediate relief from the procedure. Please let me know what your thoughts are on his comments. Thanks

Hey there,
I think this is very interesting and makes perfect sense. There's a few things that he said that my crs has said too. I'm scheduled for surgery in a few weeks and just had an appointment where we discussed the procedure. She said there would be immediate relief from the spasms, that the fisher would take atleast 6 weeks to heal and that I would need to take it really slow the first week. I'm having skin tag removal with lis but she said with just lis that the recovery would be a little easier. She also said No on a fissurectomy. She said they are old and they don't really make sense. She also said she has never had any cases of incontinence.
Everything this CRS said in the email makes perfect sense to me. I think it would be a good choice to have the lis....But I am new at this fissure game and I haven't had the surgery yet so hopefully some of the others will give you good advice. Take care :)

Your CRS seems to be quite clued up which is hard to find, I agree with what he says, I really think you'll benefit from the LIS, but ultimately that choice is yours, maybe once the spasms are under control (Via LIS) then you might just get relief from the other annoying rectal issues your having, IMHO it's got to be worth a shot, what have you got to lose?
Good luck with your decision

You have suffered for a long time and watever u did hasnt helped you heal.If you are undecided,you can always take a second opinion.LIS has healed many of us here and i only wish i cudve done it earlier.it has given me my life back.It may help you as well but i wud advice for someone to examine you before you go ahead.
Goodluck with watever u decide

Everything your CRS says makes perfect sense to me, and is consistent with everything I have read and everything my CRS has told me.
LIS and hemmorhoidectomy gave me my life back. I had immediate relief from the fissure pain, but the surgical pain was really bad for about a week. Pretty bad for about another week, and then everything was pretty good after that. I'm 8 weeks out now and 100% better.

Thank you all for the input. It seems as though this CRS is knowledgable, but I was concerned that maybe he was too optimistic about the outcome of the procedure. I definitely want a surgeon who is confident, but I'm always a little bit leery of one that seems to be less than realistic about the pros and cons. The only real thing holding me back from surgery is that I developed fissures and hemorrhoids because of difficulty with bowel evacuation and unless I know that this procedure will fix this underlying problem and improve my bowel movements, then how would I know that I wouldn't be right back in this same situation?

mm92599,
Don't you think if it loosens the muscle, that help with bowel evacuation?
I don't know but maybe you can get a second opinion.

Dawn: I agree that it seems as though LIS would loosen things up to allow for easier bowel evacuation, however, I have heard mixed reviews on this. Seems logical, but doesn't always seem to be the case for some people. I'm about 75% leaning toward LIS. This week however, I've developed an extremely painful hemorrhoid that has completely taken over to the point where I don't feel the fissure pain at all. Maybe I just need LIS and hemorrhoidectomy at the same time?

I'm so sorry!! Are you sure it's a hemmroid because I thought the same thing at one time.... and I couldn't walk without holding my butt cheeks apart and it turned out that it was a swollen skin tag that is caused by the fissure. It looks and feels just like a hemm.

Dawn, was your skin tag located near the fissure? I've had external and internal hemorrhoids for several years, but the internal ones are not very bad and don't require treatment and the external ones would usually flare about once ever 6 months and they were very obvious (i.e. looked liked a small grape on the outside of the rectum). I've had a thrombosed hemorrhoid in the same location where I am now feeling the pain, but as of yet, I haven't noticed the "lump", but the pain is the same. The pain is on the opposite side from where my fissure pain is. Very strange. I'm thinking maybe the hemorrhoid is not noticeable or is till forming? How did you know that yours was a skin tag?