Download - Anorectal diseases
COMMON ANAL PROBLEMS
DR.K.R.DHARMENDRA, MS.,DNB.,
GENERAL & LAPAROSCOPIC SURGEON,
AL HAYAT INTERNATIONAL HOSPITAL, MUSCAT.
OUTLINE
• RELEVANT SURGICAL ANATOMY
• HAEMORRHOIDS
• FISSURE IN ANO
• FISTULA IN ANO
SURGICAL ANATOMY OF ANAL CANAL
• THE ANORECTAL RING• PUBORECTALIS MUSCLE• EXTERNAL ANAL SPHINCTER• THE INTERNAL ANAL SPHINCTER• DENTATE LINE• ANAL CUSHIONS
ANORECTAL RING
Marks the junction between rectum & anal canal
Formed by joining of
Puborectalis muscle
Deep External Sphincter
Conjoined Longitudinal muscle
Highest part of internal sphincter
PUBORECTALIS MUSCLE
• Funnel shaped muscle
• Maintains angle between anal canal &
rectum
• Important for continence mechanism
• Innervated by Sacral somatic nerves
West becomes East !!!
EXTERNAL ANAL SPHINCTER
• Single, somatic, voluntary muscle
• Divided by lateral extensions from
longitudinal muscle into 3 portions
• Deep
• Superficial
• Subcutaneous
• Innervated by Pudental Nerve
INTERNAL SPHINCTER• Involuntary muscle
• Thickened distal continuation
of circular coat of rectum
• In a tonic state of contraction
• Receives intrincic non-
adrenergic and non-
cholinergic fibres, stimulation
of which causes release of NO
which induces IS relaxation
DENTATE LINE
• Important surgical landmark
• Represents the site of fusion of
proctodaeum and post-allantoic gut.
• Site of crypts of Morgagni through which
anal ducts that communicate with anal
glands open into anal lumen.
DENTATE LINE Above Pink Mucosa Columnar epithelium Superior Rectal Artery Portal circulation Autonomic Nervous system Painless
Below Parchment coloured mucosa Stratified Squamous epithelium Inferior Rectal Artery Systemic circulation Somatic innervation Painful
ANAL CUSHIONS• Uneven folds of mucosa &
submucosa just above the dentate line
• Left lateral• Right posterior• Right anterior• Contains sub epithelial
meshwork of supporting tissues
• Site of dense arterio venous plexus
HAEMORRHOIDS
• Greek:
haima = blood
Rhoos = flowing
• Latin: pila = a ball
• Definition:
Symptomatic
anal cushions
Piles characteristically lie in 3, 7& 11 o’ clock positions
These are the locations of the terminal branches of superior rectal artery
CAUSES OF HAEMORRHOIDS• Constipation
• Fiber deficient diet
• Straining to pass stool
Shearing forces acting on the anus lead to
caudal displacement of anal cushions.
Fragmentation of supporting structures leads to
loss of elasticity of cushions such that they no
longer retract following defecation.
SYMPTOMS OF HAEMORRHOIDS
• Bright –red , painless bleeding
• Mucus discharge
• Prolapsed mass
• Pain only when prolapsed
BEWARE OF GI SYMPTOMS!!
• Change of bowel habits
• Mucus discharge
• Tenesmus
• Back pain
• Anorexia/ Weight loss
• Abdominal pain
DEGREES OF HAEMORRHOIDS
MX OF HAEMORRHOIDS
• FIRST DEGREE: Conservative[Medical]
• SECOND DEGREE: BARRON’S BANDING
• 3RD & 4TH DEGREE: OPEN
HAEMORRHOIDECTOMY
OR
STAPLED HAEMORRHOIDECTOMY
BARRON’S BANDING
STAPLED HAEMORRHOIDECTOMY
• Introduced by Longo in 1998
• Utilises a purpose designed stapling
gun[PPH]
• Excises a strip of mucosa & submucosa
circumferentially
• Above Dentate Line
STAPLED HAEMORRHOIDECTOMY
EXTERNAL HAEMORRHOIDS
• Arising from superficial
haemorrhoidal plexus
• 5-Day, Painful, Self curing lesion
• Termed as Perianal Haematoma
• Within 48 hours: Evacuate under LA
EXTERNAL HAEMORRHOIDS
FISSURE IN ANO
• A longitudinal split
in the anoderm
of distal anal canal
• Not beyond Dentate line
Aetiology of Anal Fissure
• Strained evacuation of hard stool
• Anal Hypertonicity
• Vascular insufficiency
Clinical Features of Anal Fissure
• Severe anal pain on defecation
• Bright red bleeding
• Sentinel tag
• Discharge, itching
Ectopic site suggests a more sinister cause!!!
• Crohn’s Disease• TB• HIV• Syphilis
• Chlamydia• Chancroid• Lymphogranuloma Venereum• HSV• Cytomegalovirus• Kaposi’s Sarcoma• B cell Lymphoma• Squamous cell carcinoma
Management of Anal Fissure
• Conservative MX:
Stool bulking agents
Stool Softeners
• Local Anaesthetic cream
• 0.2 % Glyceryl Trinitrate
• 2% Diltiazem cream
Operative measures for Anal Fissure
• Lateral Anal Sphincterotomy
• Anal Advancement Flap
FISTULA IN ANO
It is a chronic abnormal
communication lined by granulation
tissue, which runs outwards from the
anorectal lumen to an external
opening on the skin of perineum or
buttock.
Presentation of Anal Fistula
• Intermittent perianal
purulent discharge
• Pain
• Previous episode
of anorectal sepsis
Park’s Classification
“Based on the centrality of intersphincteric anal
gland sepsis, which results in a primary track
whose relation to the External sphincter”
• Intersphincteric
• Trans-sphincteric
• Supra sphincteric
• Extra sphincteric
Goodsall’s Rule
Anterior: Drain straight
Posterior: Drain curved to anorectal midline
Surgical Management
• Fistulotomy
• LIFT Procedure
• Fistula Plug
• Advancement flap
• Setons
FIAT TRIAL
LIFT
• Identify the internal opening
• Incision at intersphincteric groove
• Dissection through intersphincteric plane to find intersphincteric
fistula tract
• Secure suture ligation of intersphincteric fistula tract
• Remove the fistula tract
• Curette fistula tract from external opening
• Suture closure of external sphincter muscle defect
• Closure of intersphincteric wound
Cutting Setons
• Latin: seta = bristle
• High Fistula eradication without functional
impairment
• The enclosed muscle is gradually severed
• Divided muscles do not spring apart
• Fistulous tract is replaced by fibrosis
Synthetic, bioabsorbable scaffold of polyglycolic acid and trimethylene carbonate copolymer
Practice Pearls Squatting is the only natural defecation posture
Proctoscopy is the guide to plan the treatment of piles
Currently Stapled Haemorrhoidopexy is the choice
Proctoscopy is abandoned in acute anal fissure
Pain is the differentiating feature between fissure & piles
Only complicated piles presents with pain
Beware of GI symptoms associated with piles
Hence never hesitate to go for colonoscopy
Majority of external piles don’t need any intervention
Ectopic Fissure smells danger
Rule out Crohn’s Disease in recurrent anal fistula
MRI is essential to locate internal opening
LIFT & Fistula Plug procedures preserves continence
ADHARMENDRAPRESENTATION