INTRODUCTIONFissure in ano is a common benign and painful proctologic disease causing considerable morbidity and affecting the quality of life. 1 The cause of fissure in ano remain to be defined but expected view is a combined effect of constipation (hard stools), internal anal sphincter hypertonia and certain predisposing factors like smoking, alcohol consumption of high fat diet, non-vegetarian diet etc.2-4 Medical management is the first line of treatment in all fissure in ano which aims to regulate the bowel movements by high fiber diet, stool softener, osmotic laxatives and topical medications which consist of local anaesthetic and anti-inflammatory agent which reduces the local pain and irritation. The ideal treatment for reducing the hypertonicity of anal sphincter is debatable and it could be medical or surgical manipulation which remains the cornerstone of the treatment. 2 Lateral internal sphincterotomy, remains the most effective and timetested surgical procedure for treatment of chronic fissure ABSTRACT Background: Fissure in ano is one of the commonest benign and painful proctologic condition encountered in surgical practice treated by conservative line of management. Lateral sphincterotomy is the ideal treatment option for chronic refractory fissure in ano. A newer modality segmental internal sphincterotomy shows good promise in terms of early resolution of symptoms, fissure healing and prevention of anal incontinence involving division of the internal sphincter at two different levels. Methods: In comparative nonrandomized trial patients with chronic fissure in ano satisfying the inclusion and exclusion criteria were allocated to lateral sphincterotomy and segmental internal sphincterotomy groups. The outcome factors were perianal sepsis, pain relief using VAS as assessed on passing the first motion, duration of healing of fissure, assessment of incontinence using Wexner's continence score on 30 th post-operative day. Results: A total of 54 cases were enrolled, of them 31 patients underwent lateral internal sphincterotomy and 23 underwent segmental internal sphincterotomy with the mean age of patient was 34.76 years and a male to female ratio of 1.07:1. The pain score (VAS) on passing stool for the first time postoperatively was 4.5 with lateral sphincterotomy and 3.91 with segmental internal sphincterotomy which was statistically significant (P value < 0.010). The duration of postoperative healing was observed to be 27.94 days and 28.09 days in lateral sphincterotomy and segmental internal sphincterotomy group respectively. The post-operative anal incontinence was evaluated by using Wexner's continence grading after one month which was not statistically significant between two groups. Conclusions: Segmental internal sphincterotomy could be a good surgical modality with its healing effect on fissure in ano and post-operative complications which are similar to standard lateral internal sphincterotomy.

Pilonidal sinus is an infective condition between the natal cleft in young males. Chronic Pilonidal disease normally needs a surgical treatment for eradication of septic focus, which ranges from cutting of the tract to complex rotation flap. Kshar sutra is an age old treatment modality practiced since times of Sushruta. Lack of established evidence in the evidence based scenario is the rationale for current study. It is a tertiary care hospital based case series with inclusion criteria of pain and discharge in and around the natal cleft. Clinically diagnosed as Pilonidal sinus with two openings one in natal cleft and other outside the natal cleft. The patients with multiple sinuses, previous treatment and co-morbid conditions are excluded. The study factor was of Kshar sutra threading of Pilonidal Sinus done under local infiltration of anaesthesia around the tract and changed 2-3 times during entire treatment period on clinical judgement. The outcome factors were duration of cutting open of tract and duration for total healing, number of times Kshar sutra was changed and local complications. A total of 5 cases, all males with median age of 21 years and median presentation duration of 8 months were recruited. The median cutting duration of the tract was 23 days and total tract healing time was 29 days. Kshar sutra was changed 2-3 times during the entire duration of treatment. There was no post-operative complication and recurrence after 20.4 months of follow up. Kshar sutra is a minimal invasive procedure in Pilonidal sinus which has encouraging results but need large sample and an RCT to provide quality evidence.