Lateral Internal Sphincterotomy

CPT 46080
Approach Open
Add-on / Variant CPTs
  • 46200 — Fissurectomy (if fissure excised separately)
  • 46255 — Hemorrhoidectomy, internal and external (if concurrent)
  • 46505 — Chemodenervation of internal anal sphincter (botulinum toxin injection)
Preoperative Diagnosis:

Chronic anal fissure, [posterior / anterior / lateral], with hypertonic internal anal sphincter

Postoperative Diagnosis:

Same

Procedure Performed:

Lateral internal sphincterotomy [open / closed technique], [right / left] lateral position

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/PA name]

Anesthesia:

[General / MAC / spinal / local with sedation]

Indications:

Patient presents with [chronic posterior anal fissure / recurrent fissure] refractory to conservative management including [topical nitroglycerin / diltiazem / sitz baths / botulinum toxin]. [Duration: X months.] Exam demonstrates [hypertonic sphincter / sentinel skin tag / exposed internal sphincter fibers / indurated fissure base.] Anorectal manometry [performed / not performed], [elevated resting sphincter pressure]. Risks including fecal incontinence (especially in women / multiparous patients), infection, hematoma, and recurrence discussed in detail. Consent obtained.

Findings:

[Posterior / lateral] chronic anal fissure with [sentinel tag / hypertrophied anal papilla / exposed internal sphincter.] Hypertonic internal anal sphincter confirmed on exam under anesthesia. Internal sphincter [divided to dentate line / divided to level of fissure apex]. [Fissurectomy performed / fissure not excised.] Good relaxation of anal tone confirmed after release.

Description of Procedure:

The patient was positioned in the [prone jackknife / lithotomy] position. [General / spinal / local with sedation] anesthesia was administered. The perianal area was prepped and draped in sterile fashion.
Exam under anesthesia confirmed [hypertonic sphincter / posterior chronic fissure / sentinel skin tag]. An anal retractor was placed and the fissure inspected.
[OPEN TECHNIQUE:] A [1 cm / radial] incision was made at the [right / left] lateral position at the intersphincteric groove. The internal anal sphincter was identified between the internal and external sphincter fibers. The internal sphincter was divided under direct vision from the intersphincteric groove to the level of the [dentate line / fissure apex] using [curved scissors / electrocautery]. Division confirmed by palpation. Sphincter fully released.
[CLOSED TECHNIQUE:] A [15-blade / tenotomy blade] was inserted at the intersphincteric groove laterally and rotated to divide the internal sphincter from the dentate line to the level of the fissure apex under digital guidance.
[Fissurectomy was performed using sharp excision of the fissure base and sentinel tag, creating a healthy wound base.]
Hemostasis achieved. No packing placed. Lidocaine-based local anesthetic infiltrated for postoperative pain control. Patient tolerated the procedure well.

Complications:

None

Specimens:

[Sentinel tag / fissure margin sent to pathology / None]

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

Patient taken to PACU. Discharged to home with stool softeners, sitz baths, and topical analgesia.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Chronic anal fissure, [posterior / anterior], with hypertonic internal anal sphincter
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Lateral internal sphincterotomy, [open / closed technique], [right / left] lateral
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General / MAC / spinal / local with sedation]

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a chronic [posterior] anal fissure refractory to conservative management including [topical nitroglycerin / diltiazem / botulinum toxin injection / sitz baths] over *** months. Exam demonstrates hypertonic internal sphincter with [sentinel skin tag / exposed sphincter fibers / indurated fissure base]. Risks including fecal incontinence, infection, hematoma, and recurrence were discussed at length. Informed consent obtained.

FINDINGS: Posterior chronic anal fissure with sentinel skin tag and hypertrophied anal papilla. Hypertonic internal sphincter confirmed under anesthesia. Internal sphincter divided to [dentate line / fissure apex]. Anal tone relaxed after release. [Fissurectomy performed.]

DESCRIPTION OF PROCEDURE:
Patient in [prone jackknife / lithotomy] position; perianal area prepped in sterile fashion. Exam under anesthesia confirmed hypertonic sphincter and posterior chronic fissure. Anal retractor placed. [OPEN: Radial incision at [right / left] intersphincteric groove; internal sphincter identified and divided under direct vision from groove to dentate line using curved scissors; division confirmed by palpation.] [CLOSED: Tenotomy blade inserted at intersphincteric groove and rotated to divide internal sphincter under digital guidance to dentate line.] [Fissurectomy: sentinel tag and fissure base sharply excised.] Hemostasis achieved. Local anesthetic infiltrated. No packing. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Sentinel tag / fissure margin to pathology / None]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU. Discharged home with stool softeners, sitz baths, and topical analgesia.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Concurrent hemorrhoidectomy

Separately billable. Document hemorrhoid classification, excision technique, and closure of each column. Add CPT 46255 or 46262. Avoid excess sphincter division when combining procedures.

Botulinum toxin injection (non-surgical alternative)

CPT 46505. Performed under anesthesia or in clinic. Document injection site (intersphincteric vs. intrasphincteric), units used, and bilateral vs. unilateral injection. Recurrence rate higher than LIS.

Posterior midline sphincterotomy (keyhole deformity risk)

Historically performed but now largely abandoned due to keyhole deformity and incontinence risk. Document if performed for unusual anatomy. Lateral approach strongly preferred.

Charting Tips
  • Document technique explicitly (open vs. closed LIS)
  • State level of sphincter division (to dentate line vs. to fissure apex)
  • Note fissure characteristics (posterior vs. anterior, chronic vs. acute, with or without sentinel tag)
  • Document anal tone before and after division to confirm adequate release
  • In female patients and multiparous women, document incontinence risk counseling explicitly
  • Fissurectomy is not required for healing but, if performed, document it separately
Billing Tips
  • Bill 46080 for sphincterotomy, anal, internal (lateral internal sphincterotomy): 2.46 wRVU, 10-day global. This code covers both open and closed LIS techniques. The approach does not change the code. Document the technique used.
  • Concurrent hemorrhoidectomy at the same session is separately billable. LIS and hemorrhoidectomy are not bundled. Add 46255 (hemorrhoidectomy with fissurectomy), 46250, or 46262 as appropriate. Document both procedures in the operative note.
  • Fissurectomy (excision of the fissure itself) performed without sphincterotomy uses CPT 46200. If both fissurectomy and sphincterotomy are performed, 46080 covers the sphincterotomy; consider whether to add 46200 or bundle under 46080. Confirm with your billing team.
  • Botulinum toxin injection for anal fissure (alternative or adjunct) is billed with 46505 (chemodenervation of internal anal sphincter). This is distinct from 46080 and used when injection is the primary treatment. Document injection site, units, and purpose.
  • 10-day global period: wound checks and routine postoperative care within 10 days are bundled. Patients are typically seen at 2-4 weeks for fissure healing assessment. This visit is outside the global period and separately billable with a standard E/M.