OT notes · General Surgery

Fissurectomy for chronic anal fissure

Usual anaesthesia
Saddle block (low spinal) or short general anaesthesia, with or without pudendal block
Position
Lithotomy (prone jackknife is an alternative)
Setting
elective

Operative note template for fissurectomy of a chronic anal fissure, with or without an added sphincter procedure, with a filled example for a chronic posterior fissure treated by fissurectomy and tailored lateral internal sphincterotomy under saddle block.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding from the wound
  • pain and delayed wound healing
  • incontinence to flatus or soiling, more if a sphincterotomy is added
  • keyhole deformity of the anal canal
  • recurrence of the fissure
  • retention of urine after spinal anaesthesia
  • infection, abscess or fistula
  • biopsy may show another cause such as Crohn's disease, tuberculosis or cancer

Pre-operative details for this operation

  1. Fissure detailssite by clock position (lithotomy), duration, acute or chronic
  2. Signs of chronicitySentinel tagHypertrophied anal papilla / fibroepithelial polypRaised fibrosed edgesInternal sphincter fibres visible in base
  3. Medical treatment trieddrug (for example diltiazem 2% ointment), duration, response
  4. Continence history and risk factorsprevious anal surgery, vaginal deliveries or obstetric tear, existing soiling
  5. Features of a secondary fissureNoneOff-midline / multiple / painlessCrohn's disease, tuberculosis, HIV, carcinoma to be considered
  6. Rectal preparationEnema givenNot given

Anaesthesia and position

  1. AnaesthesiaSaddle blockSpinalShort GAPudendal block with sedation
  2. PositionLithotomyProne jackknife

Operative findings

  1. Fissureposition, length in cm, depth, how far up towards the dentate line
  2. Sentinel tag / anal papillapresent or absent, size
  3. Sphincter tone under anaesthesiaHighNormalLow
  4. Associated lesionsNoneFissure abscessSubcutaneous fistulaHaemorrhoids
  5. Proctoscopy of rectumnormal / other finding

Procedure (steps)

  1. Skin preparation and drapingantiseptic used
  2. Anal canal lubricated and examinedlignocaine jelly; Parks speculum or anoscope
  3. Sentinel tag excisedExcisedNot present
  4. Fissure excisedelliptical excision of fibrosed edges and base down to internal sphincter, up to but not above the dentate line
  5. Hypertrophied papilla / fibroepithelial polyp excisedExcisedNot present
  6. Associated abscess or subcutaneous fistulaNoneLaid open and edges excised
  7. Sphincter procedure addedNone (sphincter preserved)Lateral internal sphincterotomy, closedLateral internal sphincterotomy, openSphincterotomy in fissure floorBotulinum toxin injectionside (clock), length cut relative to fissure length, or drug dose and sites
  8. Advancement flapNot doneDonetype of flap, suture used
  9. HaemostasisPressure 3 minutesBipolar cauterySuture
  10. Long-acting local infiltrationNot givenGivendrug, strength, volume

Closure, drains and dressing

  1. Fissurectomy woundLeft openCovered by advancement flap
  2. Sphincterotomy woundLeft openClosed with absorbable sutureNot applicablesuture and size if closed
  3. Anal pack / dressingGauze padAnal packTamponwhen it is to be removed

Specimens and implants

  1. Fissure with tag and papilla sent for HPEto exclude carcinoma, tuberculosis, Crohn's disease
  2. Swab for cultureNot takenTaken (reason)

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Watch for bleedingcheck pad; inform surgeon if soaked
  2. Urinewatch for retention after spinal; time of first void
  3. Diet and fluidshigh-fibre diet, 6 to 8 glasses of fluid a day
  4. Stool softener / bulk agentdrug and dose; avoid constipation and straining
  5. Sitz bathwarm plain water, frequency
  6. Analgesiadrug, dose, frequency; avoid opioid if possible (constipation)
  7. Pack / dressing removalnext morning or with first bowel movement
  8. Discharge and follow-upday care or next day; HPE report and wound check date

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. V.D., 34 years, chronic posterior anal fissure for 5 months with sentinel tag and hypertrophied papilla, not healed after 8 weeks of diltiazem 2% ointment, no soiling, no previous anal surgery.

Case details

Date: 03/07/2026. Elective, day care. OT 4.

In OT 09:00. Saddle block 09:08. Procedure started 09:20. Completed 09:45.

Surgeon: Dr A. (2nd-year resident, General Surgery). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: chronic posterior midline fissure with sentinel tag and hypertrophied papilla, failed 8 weeks of topical diltiazem 2%.

No soiling or incontinence. No previous anal surgery. No diarrhoea, weight loss or fever. HIV non-reactive.

Rectum cleared with enema night before and morning of surgery.

Consent: general, procedure-specific and anaesthesia consent taken in Marathi. Risk of flatus incontinence with sphincterotomy and recurrence explained.

WHO checklist sign in and time out done. Inj cefoxitin 2 g IV at 09:10, within 60 min before starting.

Anaesthesia and position

Saddle block. Lithotomy position. Parts painted with povidone-iodine and draped.

Anal canal lubricated with 2% lignocaine jelly. Parks speculum inserted.

Procedure

Findings: 1.5 cm chronic fissure at 6 o'clock with raised fibrosed edges and internal sphincter fibres in its base. 1 cm sentinel tag at the outer end, 0.5 cm hypertrophied papilla at the inner end. Sphincter tone high. No abscess or fistula. Rectum normal on proctoscopy.

Sentinel tag excised. Fibrosed edges and base of the fissure excised as an ellipse down to the internal sphincter, not going above the dentate line. Hypertrophied papilla excised.

Tailored closed lateral internal sphincterotomy at 3 o'clock: intersphincteric groove felt, No. 15 blade passed flat between anoderm and internal sphincter, turned towards the sphincter and the lower internal sphincter cut up to the length of the fissure only, with the left index finger as a guard. Defect felt.

Pressure for 3 minutes at the stab site. Fissurectomy base dry.

5 ml of 1% methylene blue with 0.25% bupivacaine (1:5) injected intradermally around the wound below the dentate line.

Closure

Fissurectomy wound left open. Sphincterotomy stab left open. Gauze pad applied.

Specimens

Fissure with tag and papilla sent for HPE in formalin.

End of procedure

Estimated blood loss 15 ml.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to day-care ward in stable condition. Pulse 76/min, BP 120/80 mmHg.

Post-op orders

Check pad for bleeding on return to ward and before discharge. Inform surgeon if soaked.

Note time of first void. If unable to pass urine with a palpable bladder, catheterise (retention is a known risk after fissurectomy and spinal anaesthesia).

Oral fluids once recovered from the block, then normal diet with high fibre and 6 to 8 glasses of fluid a day.

Ispaghula husk at bedtime and lactulose syrup as per unit protocol. Avoid straining.

Warm plain-water sitz bath after each motion and twice daily.

Tab paracetamol 1 g 6-hourly. Warned that urine may look blue-violet for a few days (methylene blue).

Discharge in the evening if voided and no bleeding. Review with HPE in 1 week.

Signature

Dr A., JR-2, General Surgery. Reg. no. ________. 03/07/2026, 10:00.

Must document for this operation

  • Position of the fissure by clock face, with the patient position stated. A clock position means nothing unless the reader knows if it was lithotomy or jackknife, and off-midline fissures need a different work-up.
  • Whether a sphincter procedure was added, which one, the side and how much was cut. Incontinence after anal surgery is a common complaint, and the note is the only record of how much sphincter was divided.
  • Pre-operative continence and obstetric history. It shows the risk was weighed before any sphincter was cut and gives a baseline if continence changes.
  • That the specimen was sent for HPE (histopathology). A chronic anal ulcer can be carcinoma, tuberculosis or Crohn's disease, and the pathologist needs the specimen to find it.
  • Drug and dose of any botulinum toxin or long-acting local anaesthetic used. Doses of these drugs must be traceable, and blue urine after methylene blue can alarm the ward if it is not written.

Common mistakes in these notes

  • Writing 'fissurectomy done' with no mention of the tag, papilla or depth of excision.
  • Giving a clock position without the patient position.
  • Not recording whether the internal sphincter was cut.
  • No record of pre-operative continence.
  • Forgetting the urine retention watch after spinal anaesthesia.

Indian practice and paperwork

  • Bio-Medical Waste Management Rules 2016 put excised human tissue in Yellow category (a) human anatomical waste, and discarded formalin is chemical waste. Write where the specimen went. (DGHS/CPCB Guidelines for Management of Healthcare Waste as per BMW Rules 2016)
  • NABH standard COP.14(e) (5th edition) requires the operative note to be written before the patient is transferred out of recovery. (NABH Hospital Accreditation Standards 5th ed. (April 2020), COP.14 OE e)
  • NABH requires informed consent in a language the patient understands. For fissure surgery, the risk to continence should be part of that consent. (NABH Hospital Accreditation Standards 5th ed. (April 2020), PRE.4(c))

Sources

  • Singla SK, Mital K. Operative Manual of Minimally Invasive and LASER Ano-proctology: Tips and Tricks to Improve Outcomes. Springer Nature Singapore; 2025, Ch 9 Fissure in Ano: Lateral Partial Internal Sphincterotomy; Ch 10 LIS and LASERS, pp. 78-87.
  • Operative Techniques in Surgery (Mulholland MW, ed.). Wolters Kluwer; 2015. Part 4, Operative Techniques in Colon and Rectal Surgery, Ch 45, Surgical Management of Anal Fissures (Albo D), pp. 1325-1331.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee Brothers; 2014, Ch 25 Anorectal Surgeries: treatment of anal fissure, pp. 1027-1030.
  • Gvalani AK. Manual of Instruments and Operative Surgery. 2nd ed. CBS Publishers & Distributors, Ch 35, Surgery for anal fissure, pp. 227-228.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 15 Surgery of the anus and perineum: anal fissures, pp. 312-314.
  • Bratzler DW, et al. ASHP/IDSA/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013;70:195-283. Table 1: cefoxitin 2 g adult dose, redose at 2 h; start within 60 min before incision. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf
  • NHS. How and when to take paracetamol for adults (1 g per dose, at least 4 hours apart, not more than 4 g in 24 hours). www.nhs.uk/medicines/paracetamol-for-adults/how-and-when-to-take-paracetamol-for-adults/

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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