<p> Robert C. Wright, MD, PS</p><p>Informed Consent – Anal Fissurectomy and/or Lateral Internal Sphincterotomy</p><p>Your symptoms and physical exam suggest that you have an anal fissure. An anal fissure is a tear in the tissue overlying the anus. A small fissure can usually be treated with conservative measures, including Sitz baths and stool softeners. When conservative measures fail to resolve the anal fissure, alternative treatments are offered. An anal fissure is an ongoing nuisance, but poses no major health threat. Surgery is considered when the anal fissure remains painful and troublesome. Description of the Procedure Surgical treatment of an anal fissure can usually be performed without admission to the hospital. The fissure is usually excised. A small cut is then made on the right side of the anus, and a portion of the internal sphincter muscle is cut. An anesthetic pad is left in the anal canal.</p><p>Alternatives for Treatment 1. Conservative treatment – an excellent first treatment modality if the fissure is small. 2. Anal dilatation – has a higher complication and failure rate than a sphincterotomy because it tears the internal sphincter muscle in an uncontrolled fashion. </p><p>Benefits of Treatment Surgical therapy offers a safe, convenient and low risk treatment of an anal fissure. Coupled with the aggressive use of stool softeners and a high residue duet, this treatment assures a reasonably low recurrence rate. </p><p>Risks/Complications of Treatment 1. Recurrence – a new fissure may develop, particularly if diet and bowel habits are not changed. 2. Pain – a sense of discomfort in the rectum will be experienced for several days following the operation. Pain medicine helps but will not completely eliminate the pain. This usually resolves spontaneously. 3. Bleeding – heavy rectal bleeding will happen occasionally after surgery, sometimes as late as one or two weeks after the procedure is performed. Notify the surgeon if this occurs. This may require an additional procedure to stop the bleeding. 4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia, sore throat, or potential death, in rare cases. 5. Incontinence – incontinence of stool or gas is uncommon but possible following this procedure. This may require another surgery to correct. 6. Infection – the surgery site may occasionally become infected. Occasionally, this may be severe enough to require major to correct. On occasion, a patient has died from not seeking early treatment for an infection following perianal surgery. You should notify your surgeon immediately should you develop increasing pain, fever, or drainage from the anus or rectum following surgery.</p><p>Anticipated Recovery/Expected Rehabilitation Recovery is quite variable, depending on the individual. Most people experience pain, and are not able to resume normal work activities for a week or two after surgery. </p><p>(see other side) Consent for Treatment</p><p>I understand my condition to be an anal fissure. I have read and understand the above explanation of the procedure required to treat my anal condition. My surgeon has answered my questions, and I choose to proceed with surgery.</p><p>I understand that every operation may yield unexpected finding. I give the surgeon permission to act on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding that complications may arise from that action.</p><p>I understand that while most people with an anal fissure benefit from an anal fissurectomy, I may not. My condition may not improve, and it may worsen. No absolute guarantee can be made.</p><p>HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you invite to attend the surgery will be informed of the surgical finding, your surgical status, and anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or may not remember these important details.</p><p>PRINT NAME OF PATIENT ______</p><p>SIGNATURE ______DATE ______</p><p>WITNESS ______DATE ______</p><p>SURGEON ______DATE ______</p><p>RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ______</p><p>I waive the right to read this form, and do not want to be educated and informed of treatment risks; nonetheless, I understand the need for this surgery and grant permission to the surgeon to proceed on my behalf. </p><p>SIGNATURE ______DATE ______03/01 consent</p>