From Sushruta's Parikartika (600 BCE) to the Modified Open Lateral Internal Sphincterotomy — a journey across 2,600 years of surgical innovation, culminating in the world's first published prospective series with 100% cure and zero incontinence.
Chronic fissure in ano (CFA) is one of the most painful and debilitating anorectal conditions, characterised by a longitudinal tear of the anoderm distal to the dentate line, associated with hypertonia of the internal anal sphincter (IAS). The management of this condition has evolved over millennia, from Sushruta's ancient herbal preparations and dietary regimens to contemporary pharmacological agents and minimally tailored surgical interventions.
This review traces that evolution comprehensively, cataloguing conservative, pharmacological, and surgical modalities. Special emphasis is placed on the landmark Modified Open Lateral Internal Sphincterotomy (MOLIS) developed by Dr. O. P. Bhandari, which achieves definitive surgical cure through precise partial division of the lower third of the IAS under direct vision — without the risk of incontinence. A prospective series of 153 consecutive patients operated from 2016 to 2025 is presented, demonstrating a 100% cure rate with zero incontinence, zero recurrence, and minimal morbidity — challenging the longstanding concern that sphincterotomy inevitably compromises continence.
Anal fissure, known in Latin as fissura ani, is a longitudinal elliptical tear or ulcer in the squamous epithelium of the anal canal distal to the dentate (pectinate) line. When such a tear persists beyond eight to twelve weeks without healing, it is classified as chronic. Chronic fissures are distinguished from acute fissures by the development of a sentinel skin tag (external component), a hypertrophied anal papilla (internal component), and exposed horizontal fibres of the internal anal sphincter at the floor of the ulcer — the classic triad of chronicity.
Figure 1. Left: Sagittal schematic of the anal canal — the classic triad of chronic fissure (sentinel tag, exposed IAS fibres, hypertrophied papilla). Right: The vicious cycle of chronicity — IAS hypertonia → ischaemia → impaired healing → perpetuation.
The overwhelming majority (90–95%) of chronic fissures occur in the posterior midline, rendered vulnerable by relative hypoperfusion of the posterior anal mucosa. Doppler studies (Schouten et al., 1994) confirmed that blood pressure in the posterior commissure is significantly lower than at any other anal location. The remaining fissures appear anteriorly — predominantly in women with obstetric injury. Lateral fissures are atypical and mandate investigation for Crohn's disease, tuberculosis, STIs, HIV, or malignancy.
The earliest documented management of anorectal conditions appears in the Sushruta Samhita, the foundational text of Ayurvedic surgery attributed to Sushruta of Varanasi (circa 600 BCE). Sushruta described a condition called Parikartika — cutting-like pain of the anus — which closely corresponds to anal fissure. His management comprised sitz baths (avagaha sveda) in warm medicated decoctions of neem, turmeric and sesame oil, dietary regulation emphasising soft lubricating foods, and medicated ghee-based pastes applied to the anal canal. For recalcitrant cases he described kshara sutra (medicated thread) and agnikarma (thermal cautery) — the world's earliest documented anorectal surgical techniques.
The Ebers Papyrus (circa 1550 BCE) references rectal pain and prescribes suppositories of honey, fat, and herbal substances. Hippocrates (460–370 BCE) in On Fistulae and Haemorrhoids described rectal ulceration and advocated gentle manual anal dilation — the world's first recorded description of dilation therapy — alongside warm fomentations and dietary management.
The modern surgical era begins with French surgeon Jean-Louis Récamier (1829), who introduced forcible anal dilation, working on the empirical observation that sphincter stretching relieves pain and promotes healing. Popularised by Peter Lord in 1969 (four-finger dilation under general anaesthesia), subsequent randomised studies revealed unacceptably high incontinence rates (up to 39%) from uncontrolled sphincter disruption — leading to abandonment of this approach.
In 1951, Eisenhammer described the internal sphincterotomy principle. The 19th and early 20th century also saw advocacy for posterior midline internal sphincterotomy (PMIS) — dividing the IAS at the fissure site — which persisted despite well-recognised keyhole deformity, impaired continence (10–28%), and delayed wound healing.
Figure 2. Illustrated timeline of chronic fissure in ano management — 600 BCE to 2025. Each era introduced refinements driven by anatomical understanding, manometric data, and outcomes analysis.
The foundation of treatment — for acute fissure and as an adjunct in chronic disease — comprises bulking agents (ispaghula husk, methylcellulose), increased dietary fibre and hydration for soft formed stools, warm sitz baths 15–20 minutes post-defaecation (reducing IAS pressure by 30–35% transiently), topical local anaesthetics, and lubricating emollients. These measures address the traumatic perpetuation cycle and achieve healing in up to 50% of acute and 20–30% of chronic fissures.
GTN 0.2–0.4% ointment, a nitric oxide donor and smooth muscle relaxant, was introduced by Loder et al. (1994). It reduces resting anal pressure by 25–35% and promotes mucosal healing. Multiple RCTs demonstrated healing rates of 46–68% vs 30–40% for placebo. The major limiting factor is headache in 20–60% of patients, causing unacceptable discontinuation. Recurrence upon cessation reaches 30–50%. GTN remains the most studied first-line chemical sphincterotomy agent.
Diltiazem 2% ointment and nifedipine 0.2% gel inhibit voltage-gated calcium channels in the IAS, reducing smooth muscle tone without the severe headache of GTN. Meta-analyses suggest healing rates of 65–75% with only 5–10% headache. Oral diltiazem 60 mg twice daily is also effective. Diltiazem is slightly inferior in efficacy to GTN but superior in tolerability — a valuable alternative or second-line agent.
First proposed by Jost and Schimrigk (1993), BTA injection into the IAS causes reversible chemical denervation, reducing resting anal pressure for 8–12 weeks. Dosing: 20–30 U divided between two IAS sites. Healing rates: 60–80%. Advantages: reversibility, avoidance of surgery. Disadvantages: cost, need for repeat injections, recurrence 30–50% at two years, transient minor incontinence in 7–20%.
| Treatment | Mechanism | Healing Rate | Recurrence | Main Side Effect |
|---|---|---|---|---|
| Conservative (fibre, sitz baths) | Stool softening, pressure relief | 20–50% | High | None significant |
| GTN 0.2–0.4% | NO donor → IAS relaxation | 46–68% | 30–50% | Headache (20–60%) |
| Diltiazem 2% | Ca²⁺ channel blocker | 65–75% | 25–40% | Perianal dermatitis (5%) |
| Nifedipine 0.2% | Ca²⁺ channel blocker | 60–75% | 25–45% | Headache (10%) |
| Botulinum Toxin A | Chemical denervation | 60–80% | 30–50% | Transient incontinence (7–20%) |
| Manual Anal Dilation (Lord) | Mechanical sphincter stretch | 75–85% | 15–25% | Incontinence (11–39%) |
| Lateral Internal Sphincterotomy | Surgical IAS division | 95–99% | 1–5% | Incontinence (0–8%)* |
Table 1. Comparative efficacy and safety of treatments for chronic fissure in ano. *Incontinence rate falls to 0% with Bhandari MOLIS technique (Section 5–6). NO = nitric oxide; IAS = internal anal sphincter.
Lateral internal sphincterotomy (LIS) occupies the apex of the therapeutic hierarchy for chronic fissure in ano. Its evolution — from the posterior midline approach to the modern precisely calibrated lateral technique — is a story of progressive refinement driven by manometric understanding and outcomes data.
The earliest sphincterotomy for fissure was in the posterior midline — dividing the IAS at the fissure site. PMIS was plagued by the keyhole deformity (posterior notch causing soiling), delayed wound healing (8–12 weeks), and incontinence rates of 10–28%. By the 1980s, posterior midline sphincterotomy had been largely abandoned in favour of the lateral approach.
M. J. Notaras (1969) described lateral subcutaneous sphincterotomy: a cataract or tenotomy blade inserted into the intersphincteric groove and rotated to divide the IAS — all without a formal skin incision. This "blind" technique offered rapid recovery and reduced wound morbidity. However, the absence of direct vision meant imprecise division, leading to either under-division (recurrence) or over-division (incontinence). Meta-analyses show CLIS carries a somewhat higher incontinence rate than open LIS.
Bennett and Goligher (1976) published open lateral internal sphincterotomy (OLIS): a formal radial incision at the intersphincteric groove, exposing the distal IAS under direct vision, then dividing it from the anal verge to the dentate line. OLIS rapidly became the gold standard — healing rates consistently above 95% — but chief concern remained incontinence: large audits reported minor soiling or gas incontinence in 3–8% and liquid incontinence in 1–2%.
Recognition that the extent of IAS division directly correlated with both cure and incontinence drove a shift towards tailored sphincterotomy. Garcia-Aguilar et al. (1996) demonstrated that division to the fissure apex (not the dentate line) was sufficient for cure with lower incontinence risk. Manometric studies confirmed that reducing resting pressure to 75–85 mmHg — not maximal reduction — was the therapeutic target. Intraoperative manometry-guided LIS showed impressive results but added operative complexity.
Figure 3. End-on schematic comparison of the four principal sphincterotomy techniques. The Bhandari MOLIS (D) limits IAS division to the lower ⅓ under direct vision, eliminating the incontinence risk of the preceding techniques.
Dr. O. P. Bhandari developed the MOLIS technique in response to a critical clinical observation: classical open LIS, despite its high cure rates, carried a small but real risk of incontinence — particularly for gas (8%) and soiling (3–5%) — unacceptable in a benign condition affecting working-age adults. His central hypothesis: division of the lower one-third of the internal anal sphincter alone is sufficient to break the hypertonia–ischaemia cycle and achieve healing, without compromising the functional upper sphincter critical for continence.
This hypothesis is supported by Garcia-Aguilar et al. (1996) who showed LIS need only reach the fissure apex (not the dentate line), and by Metcalf and Nicholls' manometric studies showing that a 25–35% reduction in resting IAS pressure restores posterior mucosal perfusion to healing levels. The Bhandari MOLIS achieves precisely this physiological target.
Figure 4. Five-step operative schematic of the Bhandari MOLIS technique. The cardinal innovation — Step 4: calibrated division of exclusively the lower ⅓ IAS under direct haemostatic-forceps vision — eliminates inadvertent over-division and consequent incontinence risk.
The Bhandari MOLIS differs from classical Bennett–Goligher open LIS in four critical respects:
The following videos present live operative demonstrations of the Bhandari MOLIS technique by Dr. O. P. Bhandari, MS, FAIS — Ex Professor of Surgery, PIMS Udaipur, Rajasthan; presently Senior Consultant Surgeon & Proctologist, Chittorgarh, Rajasthan, India.
A prospective observational cohort study was conducted at Dr. Bhandari's surgical practice in Chittorgarh, Rajasthan, India between January 2016 and December 2025. All 153 consecutive patients presenting with chronic fissure in ano (persisting >8 weeks with at least one feature of chronicity) undergoing MOLIS were included. Patients with atypical (lateral) fissures, Crohn's disease, HIV, tuberculosis, or prior anorectal surgery were excluded.
| Variable | Number | Percentage / Range |
|---|---|---|
| Total patients | 153 | — |
| Male | 94 | 61.4% |
| Female | 59 | 38.6% |
| Age range | — | 18–72 years |
| Mean age | — | 38.2 ± 11.4 years |
| Duration of symptoms | — | 3 months – 8 years |
| Posterior midline fissure | 142 | 92.8% |
| Anterior midline fissure | 11 | 7.2% |
| Sentinel skin tag present | 139 | 90.8% |
| Hypertrophied anal papilla | 118 | 77.1% |
| Concomitant haemorrhoids | 38 | 24.8% |
| Prior failed GTN/diltiazem therapy | 128 | 83.7% |
| Prior botulinum toxin injection | 14 | 9.1% |
| Spinal anaesthesia used | 148 | 96.7% |
| Day-case (same-day discharge) | 141 | 92.1% |
Table 2. Demographics and pre-operative characteristics of the 153-patient MOLIS prospective series (2016–2025), Chittorgarh, Rajasthan, India.
| Outcome | Number | Percentage |
|---|---|---|
| Complete fissure healing at 6 weeks | 153 | 100% |
| Complete fissure healing at 4 weeks | 141 | 92.2% |
| Complete resolution of pain at 2 weeks | 149 | 97.4% |
| Return to normal activity within 48 hours | 145 | 94.8% |
| Incontinence — any grade, any type | 0 | 0% |
| Incontinence to solids | 0 | 0% |
| Incontinence to liquids | 0 | 0% |
| Incontinence to gas | 0 | 0% |
| Minor soiling / staining | 0 | 0% |
| Recurrence at 1 year | 0 | 0% |
| Recurrence at 5 years (n=102 followed) | 0 | 0% |
| Wound infection | 3 | 1.9% |
| Haematoma requiring drainage | 1 | 0.65% |
| Urinary retention (requiring catheterisation) | 4 | 2.6% |
| Re-operation for any cause | 0 | 0% |
Table 3. Outcomes of the Bhandari MOLIS prospective series (n=153, 2016–2025). Zero incontinence across all types and grades is the defining achievement.
Figure 5. Key outcomes bar chart — Bhandari MOLIS prospective series (n=153, 2016–2025). The defining combination of 100% healing with 0% incontinence has not been achieved in any previously published LIS series.
| Study | Year | n | Technique | Cure Rate | Incontinence |
|---|---|---|---|---|---|
| Notaras | 1969 | 99 | Closed LIS | 97% | 7% |
| Bennett & Goligher | 1976 | 50 | Open LIS | 98% | 6% |
| Garcia-Aguilar et al. | 1996 | 357 | Tailored LIS | 97% | 6–8% |
| Arroyo et al. | 2004 | 260 | Open LIS | 98% | 3.8% |
| Renzi et al. | 2008 | 279 | Open LIS | 98% | 3.2% |
| Mousavi et al. | 2009 | 160 | Open LIS | 97% | 2.5% |
| Bhandari (MOLIS) | 2016–2025 | 153 | Modified Open LIS | 100% ★ | 0% ★ |
Table 4. Comparison of Bhandari MOLIS with landmark published LIS series. No prior series has reported simultaneous 100% cure and 0% incontinence across a prospective cohort of this size.
The management of chronic fissure in ano has witnessed a remarkable arc of development across millennia — from the intuitive dietary and herbal wisdom of Sushruta to the precisely calibrated surgical anatomy of modern sphincterotomy. The central physiological insight — that internal anal sphincter hypertonia creates a cycle of ischaemia and impaired healing which must be interrupted for cure — remains as valid today as when first articulated by Eisenhammer (1951) and quantified by Schouten et al. (1994).
The transition from forcible (and unpredictable) manual anal dilation, through the elegant but visually blind closed LIS of Notaras, to the open LIS of Bennett and Goligher, represented progressive moves towards visual control and calibrated intervention. The Bhandari MOLIS represents the logical culmination of this progression: direct visual identification, haemostatic-forceps elevation, and sharp division of precisely the lower one-third of the IAS — the minimum effective intervention to achieve the manometric goal.
The achievement of zero incontinence in 153 consecutive cases is remarkable. Historical studies with open LIS uniformly report incontinence rates of 2–8%, attributable to two mechanisms: (1) inherent variability of the "to the dentate line" division, which in patients with shorter anal canals may divide more IAS proportionally than intended; and (2) operator-to-operator variability in estimating the dentate line level in an anaesthetised, contracted sphincter. The Bhandari MOLIS eliminates both sources by using the anatomically consistent lower third of the IAS (measured from the palpable anal verge) as the division endpoint.
Chronic fissure in ano is a condition whose management has been refined across 2,600 years of surgical and pharmacological innovation. From the sitz baths and ghee applications of Sushruta's Samhita, through the digital dilation of Hippocrates, the forcible dilation of Récamier, the posterior midline sphincterotomy of the 20th century, and the lateral sphincterotomy revolution of Notaras and Bennett, the field has relentlessly pursued a therapy that combines definitive cure with preservation of sphincter function.
Pharmacological chemical sphincterotomy — GTN, diltiazem, nifedipine, and botulinum toxin — offers reversible, non-surgical options with acceptable healing rates in mild disease, but is limited by high recurrence and modest long-term cure rates. Lateral internal sphincterotomy remains the gold standard with 95–99% healing and 1–5% recurrence.
The Modified Open Lateral Internal Sphincterotomy (MOLIS) developed by Dr. O. P. Bhandari achieves what classical LIS has sought but not consistently delivered: complete cure of chronic fissure in ano with absolute preservation of continence. The 153-patient prospective series (2016–2025) demonstrates 100% healing and 0% incontinence — the best published results in modern LIS literature. The technique's key innovation — precise visual identification and limited division of the lower one-third of the IAS under direct haemostatic-forceps control — provides a reproducible, anatomically logical approach that eliminates the incontinence risk inherent in less precisely defined sphincterotomy techniques.
This series invites prospective multicentre validation and, in time, reappraisal of the standard definition of "optimal" lateral internal sphincterotomy for chronic fissure in ano.
21 peer-reviewed citations spanning 2,600 years of literature on chronic fissure in ano management.