Surgery options & recovery — fissure and fistula

If conservative care isn't enough, the next decision is which procedure. The right answer depends on what you have, what's been tried, your continence baseline, and which trade-off you'd rather take.

Fissure procedures

For chronic fissures that haven't responded to topicals (GTN, diltiazem), the choice is typically Botox or LIS.

Botulinum toxin (Botox) injection

A small dose injected into the internal sphincter on either side of the fissure paralyzes the muscle for 2–3 months — long enough for the fissure to heal in a relaxed environment.

• Outpatient, often under sedation. No incision.
• Healing rate: 60–70%. Can be repeated once.
• Recurrence higher than LIS.
• Effect is temporary, so no permanent incontinence risk. Some short-term flatus or seepage during the paralysis window.
• A reasonable choice for younger patients, women with prior obstetric trauma, or anyone with concerns about incontinence.

Lateral internal sphincterotomy (LIS)

The historical gold standard. A small, controlled cut releases the spasm permanently.

• Day case under general or spinal anesthesia.
• Healing rate: above 90%. The most effective treatment.
• Recovery: most return to desk work in 5–7 days.
• Risk: small but real chance of mild flatus or stool incontinence (3–8% in modern series, often transient).
• Modern surgeons individualize the depth of the cut to balance cure rate and continence.

Fistula procedures

Fistulotomy

The simplest, most effective fistula procedure. The tract is opened and laid flat to heal from the bottom up.

• Cure rate: above 90% for low fistulas.
• Wound left open: 4–8 weeks of healing by secondary intention.
• Daily wound care, sitz baths, soft stool needed.
• Limited to fistulas that involve little muscle — high tracts can't safely be done this way.

Mucosal advancement flap

For higher tracts. Healthy rectal tissue is mobilized and used to cover the internal opening; the external part of the tract is opened and curetted.

• Cure rate: 60–80% in expert hands.
• Sphincter is spared.
• Recovery 4–6 weeks; less wound care than fistulotomy because the wound is closed.

LIFT (ligation of intersphincteric tract)

A relatively newer technique that ties off the tract through a small incision between the two sphincters.

• Cure rate: 60–75%.
• Sphincter-sparing.
• Quick recovery, small wound.
• Failures often convert to a low fistula that's then easier to fistulotomize.

Newer / specialized options

• VAAFT (video-assisted): Endoscope visualizes the tract from inside; treatment with cautery and stitching.
• FiLaC (laser closure): Laser fiber threaded through the tract and pulled back, ablating the lining.
• Fibrin glue / fistula plug: Lower cure rates but very low risk; sometimes worth trying first.
• Stem cell therapy (Darvadstrocel/Alofisel): Approved for complex Crohn's-related fistulas in some regions; specialized centers only.

Choosing your surgeon

• Look for a colorectal specialist rather than a general surgeon for anything beyond the simplest cases. Outcomes for complex fistulas track strongly with surgeon volume.
• Ask how many of these specific procedures they do per year.
• Ask about their personal recurrence and continence rates.
• If you have Crohn's, ask whether they coordinate with a gastroenterologist.
• For complex or recurrent fistulas, a second opinion at a high-volume center is worth your time.