الفهرس 
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Abstract
الرAn anal fissure is a linear tear in the mucosa of the anal canal,extend distally from the dentate line to the anal verge . It is usually located in the posterior midline , less frequently in the anterior midline, and rarely in the lateral position of the anal canal It typically causes pain during defaecation which may last for 1–2 h afterwards. The most consistent finding on physical examination is spasm of the anal canal due to hypertonia of the internal anal sphincter. The aetiology of the typical fissure is not clear. Trauma from passing a large or hard stool is a common initiator, but many traumatic fissures heal and others do not. The incidence of anal fissures is around 10–15% of proctological patients. They occur equally commonly in male and female.
Chronicity of a fissure relates to duration of greater than 6 weeks with fibres of the internal anal sphincter visible at the base of the fissure. Associated pathology may include a sentinel ‘pile’ distally and a fibro-epithelial polyp at the apex. The initial approach in the treatment of anal fissures is non-operative. An acute anal fissure may heal spontaneously or in response to medical therapy. Recent innovations in nonsurgical alternatives have included the administration of topical nitrates (glyceryl trinitrate or isosorbide dinitrate) or botulinum toxin (Botox ®) injections targeted to relaxation of the IAS. chronic anal fissures are associated with a raised internal anal sphincter (IAS) pressure and reduced vascular perfusion at the base. Current treatment has aimed at reducing resting anal pressure by diminishing sphincter tone and improving blood supply at the site of the fissure, thus promoting the healing rate.
Therefore, surgical treatment is almost uniformly recommended for such fissures in the chronic state lateral internal anal sphincterotomy (LIS) being the time-honored treatment. LIS lowers the pressure exerted by the IAS, restores normal perfusion of the anoderm, and leads to relief of pain and healing of the fissure. Remaining as the gold-standard treatment of CAF, use of LIS has been increasingly discouraged because of the significant rates of postoperative anal incontinence. Although most episodes are minor and transient, impairment of continence in up to 45 percent of patients has been reported. To alleviate postoperative disturbances of continence, tailoring of the height of the sphincterotomy to the length of the fissure has been suggested as an alternative to dogmatic division of the IAS to the dentate line
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