Fissurectomy with sphincterotomy

At a glance

Fissurectomy with sphincterotomy is a combined surgical procedure where the surgeon removes the chronic fissure tissue (fissurectomy) and makes a small, controlled cut in the internal sphincter muscle (sphincterotomy) during the same operation. It addresses both the damaged tissue and the muscle spasm that prevented healing.

This guide covers why the procedures are combined, what having multiple fissures means, what to expect from recovery when both are done together, and questions worth discussing with your surgeon.

If you are looking for information about fissurectomy alone or with botox, see our fissurectomy guide. If you want to understand LIS surgery specifically, see our LIS surgery recovery guide.

Why surgeons combine the two procedures

A chronic anal fissure involves two problems:

1. Tissue damage — the fissure itself becomes scarred, fibrotic, and unable to heal. A sentinel pile (skin tag) may form at the outer edge, and hypertrophied papilla may develop at the inner end.
2. Sphincter spasm — the internal sphincter muscle is in a state of chronic spasm, which restricts blood flow to the area and prevents the tissue from healing.

Each procedure targets one of these problems:

• Fissurectomy removes the damaged tissue — the chronic fissure, sentinel pile, and fibrotic edges — creating a fresh wound that the body can actually heal.
• Sphincterotomy (typically lateral internal sphincterotomy, or LIS) divides a small portion of the sphincter muscle, permanently reducing the spasm and improving blood flow.

Doing both together means the surgeon removes the tissue that could not heal and simultaneously creates the conditions for the new wound to heal properly. The logic is straightforward: remove the problem and fix the environment in one operation rather than two.

When surgeons typically recommend the combined approach

The combined procedure tends to be considered when:

• The fissure has been chronic for a significant period and conservative treatments (GTN, diltiazem, botox) have not resulted in lasting healing
• There is substantial scarring, sentinel pile, or hypertrophied papilla that needs removal
• The surgeon assesses that sphincter spasm is a significant contributing factor and a permanent reduction in tone would benefit healing
• The patient does not have factors that make sphincterotomy less advisable (such as pre-existing continence concerns or previous anal surgery)
• There are multiple fissures that need to be addressed

Not every chronic fissure requires both procedures. Some respond well to fissurectomy with botox, which provides temporary sphincter relaxation without a permanent cut. The decision between the approaches is a conversation between you and your surgeon.

Multiple fissures: what people describe

Some people learn during assessment that they have more than one fissure. This is less common than a single fissure and can be surprising or alarming.

What to know:

• Having more than one fissure may prompt additional investigation. Your surgeon may want to rule out conditions that can cause multiple fissures, such as Crohn’s disease. This does not mean you have Crohn’s — it means your surgeon is being thorough.
• Multiple fissures can be removed in the same procedure. The fissurectomy addresses each fissure site, which means a larger wound area but a similar healing process.
• The recovery approach is the same. Open wound care, sitz baths, soft stools, and time. The wounds heal simultaneously.
• People describe the emotional impact of learning they have multiple fissures. It can feel like a bigger problem than expected. In practical terms, the combined procedure addresses all the fissures at once, which is more efficient than staged approaches.

What the procedure involves

The combined procedure is typically done as day surgery under general or regional anaesthesia.

The fissurectomy component:

• The surgeon excises the chronic fissure tissue, sentinel pile, and any hypertrophied papilla
• The wound is left open intentionally — open wounds in this location heal more reliably than closed ones
• If there are multiple fissures, each is addressed

The sphincterotomy component:

• A small, controlled cut is made in the internal sphincter muscle, typically at the lateral (side) position
• This permanently reduces the resting tone of the sphincter
• The cut is small — typically a few millimetres — but the effect on muscle function is meaningful

Duration: The combined procedure usually takes 20 to 45 minutes. Preparation and recovery time in the hospital is longer than the surgery itself.

Going home: Most people go home the same day, a few hours after the procedure. You will need someone to take you home.

Recovery: what people describe

Recovery from the combined procedure involves managing both the open wound from the fissurectomy and the healing from the sphincter cut. People generally describe this as one recovery process rather than two separate ones, because the healing happens simultaneously.

Days 1 to 3: the hardest window

• The wound area is sore. People describe a raw, surface-level pain — different from fissure pain.
• Sitting can be uncomfortable. Many people lie on their side or use a cushion.
• The first bowel movement is anxiety-inducing but typically more manageable than expected, especially if stools are soft.
• Pain relief as prescribed during this period is important. People consistently advise staying ahead of the pain.

Days 4 to 14: gradual improvement

• The wound begins to settle. Pain decreases noticeably for most people.
• A routine develops: sitz baths, careful wound hygiene, managing bowel movements.
• Many people describe a turning point around day five to seven where things feel more manageable.
• The sphincter relaxation from the sphincterotomy component begins to be noticeable — bowel movements may feel different as the muscle tone adjusts.

Weeks 2 to 4: returning to activities

• Many people return to work and daily activities during this window.
• The wound is visibly healing. Pain with bowel movements continues to decrease.
• Some people notice changes in gas control during this period — less warning time or slight urgency. This is related to the sphincterotomy and is usually temporary.
• Occasional setbacks are normal — a harder bowel movement can temporarily irritate the wound.

Weeks 4 to 8: wound closure

• The fissurectomy wound continues to close by granulation — healing from the bottom up.
• Most people report feeling substantially better by this stage.
• Any early continence changes are typically resolving.
• Full wound closure varies. Some people heal by week four; others take the full eight weeks or slightly longer.

Months 2 to 3 and beyond

• The wound has closed for most people.
• The sphincter has adapted to its new resting tone.
• Bowel habits have normalised.
• People describe the return to normal life — eating without calculation, sitting without planning, using the bathroom without fear.

What helps during recovery

The recovery aids for the combined procedure are consistent with what people describe for either procedure alone:

• Soft stools — stool softeners and fibre are described as essential, not optional. Started before surgery if possible and continued for at least four to six weeks.
• Sitz baths — warm water for 10 to 15 minutes after bowel movements. Universally described as the most soothing part of recovery.
• Gentle wound hygiene — keeping the area clean with water rather than aggressive wiping. A peri bottle or bidet is frequently recommended.
• Rest in the first week — people who took the time describe easier recoveries than those who tried to push through.
• Pain relief as directed — particularly in the first few days. Scheduled rather than reactive.
• Fibre and hydration — supporting the stool softeners with dietary fibre and plenty of water.
• Loose clothing — avoiding anything tight or irritating around the wound site.
• A recovery journal — tracking symptoms, wound progress, and bowel movements to share at follow-up.

What to discuss with your surgeon

People who have been through this procedure describe wishing they had asked more questions beforehand. Some that others have found helpful:

• Why are you recommending both fissurectomy and sphincterotomy rather than fissurectomy with botox?
• How many fissures will you be removing, and does that change the recovery?
• What is the risk of continence changes with the sphincterotomy in my specific case?
• What does the wound look like after, and how will I know it is healing normally?
• How long should I take off work?
• What stool management should I start before the procedure?
• If this does not work, what would the next step be?
• What outcomes do you see in your practice with this combined approach?

Write your questions down. It is easy to forget in the moment.

When to contact your doctor

Contact your surgical team if you experience:

• Heavy bleeding that is not slowing
• Fever or signs of infection — redness, swelling, warmth, discharge
• Pain that is worsening after the first few days rather than gradually improving
• Difficulty with bowel or bladder control that concerns you
• Any symptom that does not feel right

If you experience heavy bleeding, fever, or sudden severe pain, seek medical care promptly.