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canal examined circumferentially. A pedunculated polypoid mass is present at the 11:00 position, anteriorly, and a healed superficial fissure is noted posteriorly. Along side the posterior fascia there is a broad-based chronic external hemorrhoidal skin tag which protrudes at the anus and it is a source of chronic irritation. No active thrombosed external hemorrhoids nor prolapsing internal hemorrhoids are noted at this time aside from these mentioned above. Dissection began first at the base of the polyp, or a chromic suture was placed proximally and the base of the polyp was excised, and after hemostasis with electrocautery, the mucosal edges are reapproximated with the chromic suture. In a similar fashion, the external hemorrhoid posteriorly is also excised and care was taken to include the bed of the recently healed fissure in that excision. Again, mucosal edges are reapproximated with chromic suture. No other significant mucosal abnormalities detected, but after removal of the anoscope digital exam was repeated, and there seems to be a rather stenotic ring of scar tissue at the level of the sphincter muscle. For that reason, and because the patient has a history of fissure, a lateral sphincterotomy was performed on the patient's left side, with division of a portion of the sphincter muscle with electrocautery
 
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