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BENIGN ANO BENIGN ANO ANO ANO RECTAL RECTAL DISORDERS DISORDERS

By By WAEL KHAFAGY WAEL KHAFAGY

COLORECTAL UNIT COLORECTAL UNIT

Anatomy of Rectum, & Anatomy of Rectum, & Anus Anus

WAEL KHAFAGY WAEL KHAFAGY

n n The origin of the rectum to the level of the The origin of the rectum to the level of the third sacral vertebra. third sacral vertebra.

n n It descends along the curvature of the It descends along the curvature of the sacrum and coccyx and ends by passing sacrum and coccyx and ends by passing through the through the levator levator ani ani muscles. muscles.

n n The rectum differs from the colon in that The rectum differs from the colon in that the outer layer is entirely longitudinal the outer layer is entirely longitudinal muscle, characterized by the merging of muscle, characterized by the merging of the three the three taenia taenia bands. bands.

It measures 12 It measures 12– –15cm in length and lacks a 15cm in length and lacks a mesentery, mesentery, sacculations sacculations, and appendices , and appendices epiploicae epiploicae. .


n n The rectum describes three lateral curves: the The rectum describes three lateral curves: the upper and lower curves are convex to the right, upper and lower curves are convex to the right, and the middle is convex to the left. and the middle is convex to the left.

n n On their inner aspect these On their inner aspect these infoldings infoldings into the into the lumen are known as the valves of Houston. lumen are known as the valves of Houston.

n n The rectum is divided into upper, middle, The rectum is divided into upper, middle, and lower thirds. and lower thirds.

1. 1. The upper third is covered by peritoneum The upper third is covered by peritoneum anteriorly anteriorly and laterally, and laterally,

2. 2. the middle third is covered only the middle third is covered only anteriorly anteriorly, and , and 3. 3. the lower third is devoid of peritoneum. the lower third is devoid of peritoneum.


Waldeyer Waldeyer’ ’s s Fascia Fascia n n The sacrum and coccyx are covered with a strong fascia that is p The sacrum and coccyx are covered with a strong fascia that is part of art of the parietal pelvic fascia. Known as the parietal pelvic fascia. Known as Waldeyer Waldeyer’ ’s s fascia, this fascia, this presacral presacral fascia covers the median sacral vessels. fascia covers the median sacral vessels.

n n The The rectosacral rectosacral fascia is the fascia is the Waldeyer Waldeyer’ ’s s fascia from the fascia from the periosteum periosteum of of the fourth sacral segment to the posterior wall of the rectum. the fourth sacral segment to the posterior wall of the rectum.

Denonvilliers Denonvilliers’ ’ Fascia Fascia n n Anteriorly Anteriorly, the , the extraperitoneal extraperitoneal portion of the rectum is covered with a portion of the rectum is covered with a visceral pelvic fascia, the fascia visceral pelvic fascia, the fascia propria propria Anterior to the fascia Anterior to the fascia propria propria, , or is a filmy delicate layer of connective tissue known as or is a filmy delicate layer of connective tissue known as Denonvilliers Denonvilliers’ ’ fascia. fascia.

n n It separates the rectum from the seminal vesicles and the prost It separates the rectum from the seminal vesicles and the prostate or ate or vagina. vagina.

Lateral Ligament Lateral Ligament n n The distal rectum, which is The distal rectum, which is extraperitoneal extraperitoneal, is attached to the pelvic side , is attached to the pelvic side wall on each side by the lateral ligament, it is composed of the wall on each side by the lateral ligament, it is composed of the pelvic pelvic nerve plexus, connective tissues, and middle rectal artery (if p nerve plexus, connective tissues, and middle rectal artery (if present). resent).




n n MESORECTUM MESORECTUM n n The posterior rectum is devoid of peritoneum and has no The posterior rectum is devoid of peritoneum and has no mesorectum mesorectum. The term . The term mesorectum mesorectum is a misnomer. is a misnomer.

n n Total Total mesorectal mesorectal excision implies the complete excision of all excision implies the complete excision of all fat enclosed within the fascia fat enclosed within the fascia propria propria, down to the , down to the levator levator muscles muscles



Anal Canal Anal Canal

n n It is about 4 cm long, and terminates at the anal verge. (This It is about 4 cm long, and terminates at the anal verge. (This definition differs from that of the anatomist, who designates definition differs from that of the anatomist, who designates the anal canal as the part of the intestinal tract that extends the anal canal as the part of the intestinal tract that extends from the dentate line to the anal verge). from the dentate line to the anal verge).

Relations Relations n n Posteriorly Posteriorly the anal canal is related to its surrounding muscle the anal canal is related to its surrounding muscle and coccyx. and coccyx.

n n Laterally is the Laterally is the ischioanal ischioanal fossa fossa with its inferior rectal vessels with its inferior rectal vessels and nerves. and nerves.

n n Anteriorly Anteriorly in the male is the urethra, and in the female are in the male is the urethra, and in the female are the the perineal perineal body and posterior vaginal wall. body and posterior vaginal wall.


Anal Canal Anal Canal

LINING OF CANAL LINING OF CANAL n n The lining of the anal canal consists of epithelium of different The lining of the anal canal consists of epithelium of different types at types at different levels. different levels.

n n Dentate line. This line is approximately 2 cm from the anal ver Dentate line. This line is approximately 2 cm from the anal verge. ge. n n Longitudinal folds (columns of Longitudinal folds (columns of Morgagni Morgagni), of which there are 6 to 14, are ), of which there are 6 to 14, are known as the. There is a small pocket or crypt at the lower end known as the. There is a small pocket or crypt at the lower end of the of the folds. folds.

n n These crypts are of surgical significance because foreign mater These crypts are of surgical significance because foreign material may ial may become lodged in them, obstructing the ducts of the anal glands become lodged in them, obstructing the ducts of the anal glands and and possibly resulting in sepsis. possibly resulting in sepsis.


MUSCLES OF THE MUSCLES OF THE ANORECTAL REGION ANORECTAL REGION INTERNAL SPHINCTER MUSCLE INTERNAL SPHINCTER MUSCLE n n It is the downward continuation of the circular, It is the downward continuation of the circular, smooth muscle of the rectum becomes thickened smooth muscle of the rectum becomes thickened and rounded at its lower end. and rounded at its lower end.

CONJOINED LONGITUDINAL MUSCLE CONJOINED LONGITUDINAL MUSCLE n n At the level of the At the level of the anorectal anorectal ring, the longitudinal ring, the longitudinal muscle coat of the rectum is joined by fibers of the muscle coat of the rectum is joined by fibers of the levator levator ani ani and and puborectalis puborectalis muscles. The muscles. The conjoined longitudinal muscle so formed descends conjoined longitudinal muscle so formed descends between the internal and external anal sphincters between the internal and external anal sphincters


MUSCLES OF THE MUSCLES OF THE ANORECTAL REGION ANORECTAL REGION EXTERNAL SPHINCTER MUSCLE EXTERNAL SPHINCTER MUSCLE n n It is consists of three divisions: the subcutaneous, superficia It is consists of three divisions: the subcutaneous, superficial, l, and deep portions. and deep portions.

1. 1. The lowest part (subcutaneous fibers) is attached to the The lowest part (subcutaneous fibers) is attached to the skin. skin.

2. 2. The next portion (superficial) is attached to the coccyx by a The next portion (superficial) is attached to the coccyx by a anococcygealligament anococcygealligament. .

3. 3. The deep portion of the external sphincter becomes The deep portion of the external sphincter becomes continuous with the continuous with the puborectalis puborectalis muscle. muscle. Anteriorly Anteriorly, the high , the high fibers of the external sphincter are inserted into the fibers of the external sphincter are inserted into the perineal perineal body, where some merge and are continuous with the body, where some merge and are continuous with the transverse transverse perineal perineal muscles. muscles.

The female sphincter has a natural defect occurring along its The female sphincter has a natural defect occurring along its anterior length. anterior length.

The external sphincter is supplied by the inferior rectal nerve The external sphincter is supplied by the inferior rectal nerve and and a a perineal perineal branch of the fourth sacral nerve. branch of the fourth sacral nerve.



INNERVATION INNERVATION

Sympathetic Sympathetic Innervation Innervation n n The sympathetic fibers to the rectum are derived from L1 The sympathetic fibers to the rectum are derived from L1 3, 3, which pass through the sympathetic chains and leave as a which pass through the sympathetic chains and leave as a lumbar sympathetic nerve that joins the lumbar sympathetic nerve that joins the preaortic preaortic plexus. plexus.

n n The aortic plexus The aortic plexus → → two two hypogastric hypogastric nerves identified at the nerves identified at the sacral promontory. sacral promontory.

n n The The hypogastric hypogastric nerve on each side joins the branches of the nerve on each side joins the branches of the sacral parasympathetic nerves, or sacral parasympathetic nerves, or nervi nervi erigentes erigentes, to form the , to form the pelvic plexus. pelvic plexus.

Parasympathetic Parasympathetic Innervation Innervation n n The parasympathetic nerve supply is from the The parasympathetic nerve supply is from the nervi nervi erigentes erigentes, , which originate from 2 which originate from 2 nd nd ,3 ,3 rd rd ,&4 ,&4 th th sacral nerves on either side sacral nerves on either side of the anterior sacral foramina. The third sacral nerve is the of the anterior sacral foramina. The third sacral nerve is the largest of the three and is the major contributor. largest of the three and is the major contributor.


The pelvic plexus The pelvic plexus n n It supplies the prostate, seminal vesicles, corpora It supplies the prostate, seminal vesicles, corpora cavernosa cavernosa, terminal parts of , terminal parts of vasa vasa deferentia,prostatic deferentia,prostatic and membranous urethra, and membranous urethra, ejaculatory ducts. ejaculatory ducts.

n n The pelvic plexus also provides visceral branches The pelvic plexus also provides visceral branches that innervate the bladder, that innervate the bladder, ureters ureters, seminal , seminal vesicles, prostate, rectum, and corpora vesicles, prostate, rectum, and corpora cavernosa cavernosa. .

n n In addition, branches that contain somatic motor In addition, branches that contain somatic motor axons travel through the pelvic plexus to supply the axons travel through the pelvic plexus to supply the levator levator ani ani, , coccygeus coccygeus, and striated urethral , and striated urethral musculature. musculature.

n n The branches of the pelvic plexus along with the The branches of the pelvic plexus along with the blood vessels (neurovascular bundle) that supply blood vessels (neurovascular bundle) that supply the male genital organs. the male genital organs.

n n Both sympathetic and parasympathetic nervous Both sympathetic and parasympathetic nervous


n n Pudendal Pudendal Nerve Nerve The The pudendal pudendal nerve arises from the sacral nerve arises from the sacral plexus (S2 to S4). It leaves the pelvis plexus (S2 to S4). It leaves the pelvis through the greater sciatic foramen, crosses through the greater sciatic foramen, crosses the the ischial ischial spine, and continues in the spine, and continues in the pudendal pudendal canal ( canal (Alcock Alcock’ ’s s canal) toward the canal) toward the ischial ischial tuberosity tuberosity in the lateral wall of the in the lateral wall of the ischioanal ischioanal fossa fossa on each side. on each side.

Three branches are the inferior rectal, Three branches are the inferior rectal, perineal perineal, and dorsal nerves of the penis or , and dorsal nerves of the penis or clitoris. clitoris.


ANAL CANAL ANAL CANAL

Motor Motor Innervation Innervation n n The internal anal sphincter is supplied by both The internal anal sphincter is supplied by both sympathetic and parasympathetic nerves. sympathetic and parasympathetic nerves.

n n The external sphincter is supplied by the inferior The external sphincter is supplied by the inferior rectal branch of the internal rectal branch of the internal pudendal pudendal nerve and nerve and the the perineal perineal branch of the fourth sacral nerve. branch of the fourth sacral nerve.

Sensory Sensory Innervation Innervation n n The sensory nerve supply of the anal canal is the The sensory nerve supply of the anal canal is the inferior rectal nerve. The epithelium of the anal inferior rectal nerve. The epithelium of the anal canal is profusely innervated with sensory nerve canal is profusely innervated with sensory nerve endings, especially in the vicinity of the dentate endings, especially in the vicinity of the dentate line. line.

n n Pain sensation in the anal canal can be felt from Pain sensation in the anal canal can be felt from the anal verge to 1.5cm proximal to the dentate the anal verge to 1.5cm proximal to the dentate line. The anal canal can sense touch, cold, and line. The anal canal can sense touch, cold, and pressure. pressure.


PATIENT HISTORY PATIENT HISTORY

n n Bleeding per Anus Bleeding per Anus n n Pain Pain n n Discharge Discharge n n Perianal Perianal Swelling Swelling n n Pruritus Pruritus n n Prolapse Prolapse n n Incontinence Incontinence n n Loss of Weight Loss of Weight n n Change in the bowel habit (constipation, obstruction, Change in the bowel habit (constipation, obstruction, diarrhea, diarrhea, tensemus tensemus, , dyschazia dyschazia) )

n n Medications (laxative Medications (laxative… ….. ..ect ect) ) n n Family History ( Family History (familal familal polyposis polyposis, colorectal cancer, , colorectal cancer, n n Bleeding tendency Bleeding tendency


EXAMINATION EXAMINATION

ANORECTAL EXAMINATION ANORECTAL EXAMINATION 1 1 Positioning Positioning Inverted prone jackknife position, or left lateral position Inverted prone jackknife position, or left lateral position 2 2 Inspection Inspection

Inspection should precede any other examination, Inspection should precede any other examination, Skin tags, Skin tags, excoriation, and change in color or thickness of the anal verge excoriation, and change in color or thickness of the anal verge and and perianal perianal skin can be detected quickly. A scarred, patulous, or irregular skin can be detected quickly. A scarred, patulous, or irregularly ly shaped anus may give clues to the cause of anal incontinence. shaped anus may give clues to the cause of anal incontinence. Particularly in Particularly in multiparous multiparous women, the anal verge may be pushed down women, the anal verge may be pushed down too far during straining too far during straining— — a feature of the a feature of the perineal perineal descent syndrome. descent syndrome.

3 3 Prolapse Prolapse of the rectum is best demonstrated by asking the patient to of the rectum is best demonstrated by asking the patient to strain while in a lateral position or sitting on the toilet. strain while in a lateral position or sitting on the toilet.

4 4 When the anal verge is pricked with a needle, the external s When the anal verge is pricked with a needle, the external sphincter phincter visibly contracts because of anal reflex. It is useful for testi visibly contracts because of anal reflex. It is useful for testing the ng the sensibility of the anal canal, which may be absent in areas of a sensibility of the anal canal, which may be absent in areas of a previous previous scar or defect, or in patients with an underlying neuropathy. scar or defect, or in patients with an underlying neuropathy.


EXAMINATION EXAMINATION n n Digital Examination Digital Examination n n The index finger should be well lubricated with a lubricant jell The index finger should be well lubricated with a lubricant jelly, and the y, and the finger pressed on the anal aperture to finger pressed on the anal aperture to ‘‘ ‘‘warn warn’’ ’’ the patient. Then the finger the patient. Then the finger should be gradually inserted and swept all around the anal canal should be gradually inserted and swept all around the anal canal to detect to detect any mass or any mass or induration induration. .

n n In men the prostate should be felt. In men the prostate should be felt. n n In women the posterior vaginal wall should be pushed In women the posterior vaginal wall should be pushed anteriorly anteriorly to detect to detect any evidence of a any evidence of a rectocele rectocele. .

n n Anal tone, whether tight or loose, can be easily estimated. Anal tone, whether tight or loose, can be easily estimated. n n A stricture or narrowing from scarring or a defect in the intern A stricture or narrowing from scarring or a defect in the internal or al or external sphincters from a previous operation can be felt. A fib external sphincters from a previous operation can be felt. A fibrous cord or rous cord or induration induration in the anal area and anal canal may indicate a fistulous track. in the anal area and anal canal may indicate a fistulous track.

n n The external sphincter, The external sphincter, puborectalis puborectalis, and , and levator levator ani ani muscles can also be muscles can also be appreciated by digital examination. appreciated by digital examination.

n n The finger should press gently on these muscles for signs of ten The finger should press gently on these muscles for signs of tenderness. derness. n n When a person with good sphincter function is asked to contract When a person with good sphincter function is asked to contract the the muscles, the examiner not only feels the squeeze of the muscle o muscles, the examiner not only feels the squeeze of the muscle on the n the examining finger but also feels the finger pulled forward by the examining finger but also feels the finger pulled forward by the puborectalis puborectalis muscle. muscle.


Endoscopy Endoscopy

n n Anoscope Anoscope n n Sigmoidoscopy Sigmoidoscopy It is an essential part of examination of It is an essential part of examination of all patients with colorectal disorders all patients with colorectal disorders (75% of colorectal cancer occurs (75% of colorectal cancer occurs within this area) within this area)

n n Colonoscopy (Diagnostic and Colonoscopy (Diagnostic and therapeutic) therapeutic)

n n Capsule Capsule Endoscopy Endoscopy


Manometry Manometry and EMG and EMG studies studies

n n Anorectal Anorectal manometry manometry is a means of quantifying the is a means of quantifying the function of the internal and external sphincters function of the internal and external sphincters. . Closed balloon systems and Closed balloon systems and perfused perfused fluid fluid filled open filled open tipped tipped catheters. Air catheters. Air filled balloon systems,& air filled balloon systems,& air filled filled microballoon microballoon manometry manometry ( (cmputerized cmputerized). ).

n n The length of the high The length of the high pressure zone varies between pressure zone varies between 2.5 and 5 cm and is shorter in women than in men. 2.5 and 5 cm and is shorter in women than in men.

n n maximal resting anal pressure (MRAP will range from maximal resting anal pressure (MRAP will range from 65 65 – – 85mmHg , no difference in both sexes) 85mmHg , no difference in both sexes)

n n maximal squeeze anal pressure (MSAP 183 mmHg in maximal squeeze anal pressure (MSAP 183 mmHg in men &. 102 mmHg in women). men &. 102 mmHg in women).

n n Rectoinhibitory Rectoinhibitory anal anal reflex reflexThe The internal sphincter reflex in internal sphincter reflex in response to rectal distention can be elicited by inflation of a response to rectal distention can be elicited by inflation of a rectal balloon. rectal balloon.

n n Balloon Expulsion Test Balloon Expulsion Test n n Saline Continence Test Saline Continence Test


Radiological Radiological

n n Endo Endo rectal US rectal US n n Barium Enema Barium Enema n n Defecography Defecography It is measure the It is measure the anorectal anorectal angle. 92 angle. 92± ±1.5 at 1.5 at rest and 137 rest and 137± ±1.5 during straining, 1.5 during straining, perineal perineal descent, the descent, the presence of a presence of a rectocele rectocele,& ,& intussception intussception & & anismus anismus

n n Fisulography Fisulography n n Colonic Transit Studies Colonic Transit Studies n n Abdominal and pelvic US Abdominal and pelvic US n n CT, MRI CT, MRI n n Computed Computed Tomographycolonography Tomographycolonography (CTC) (virtual (CTC) (virtual colonoscopy) colonoscopy)

n n 99mTc 99mTc Labeled Red Blood Cells Labeled Red Blood Cells n n Positron Emission Tomography Positron Emission Tomography n n Radioimmunoscintigraphy Radioimmunoscintigraphy


Laboratory Laboratory

OCCULT BLOOD TESTING OCCULT BLOOD TESTING n n Guaiac Guaiac Test Test n n Heme Heme Porphyrin Porphyrin Assays Assays n n Immunologic Test Immunologic Test Assessment of Operative Risk Assessment of Operative Risk n n Cardiovascular Status Cardiovascular Status n n Pulmonary Function Pulmonary Function n n Renal Status Renal Status n n Hepatic Function Hepatic Function n n Hematologic Hematologic Status, Status, n n Nutritional Status, Nutritional Status,


HEAMORRHOIDS HEAMORRHOIDS


n n Hemorrhoids are not varicose veins, and not every Hemorrhoids are not varicose veins, and not every one has hemorrhoids. one has hemorrhoids.

n n But everybody has anal cushions. But everybody has anal cushions. n n The anal cushions are composed of blood vessels, The anal cushions are composed of blood vessels, smooth muscle ( smooth muscle (Treitz Treitz’ ’s s muscle), and elastic muscle), and elastic connective tissue in the connective tissue in the submucosa submucosa

n n They are located in the upper anal canal, from the They are located in the upper anal canal, from the dentate line to the dentate line to the anorectal anorectal ring ( ring (puborectalis puborectalis muscle). muscle).

n n Three cushions lie in the following constant sites: left Three cushions lie in the following constant sites: left n n lateral, right lateral, right anterolateral anterolateral, and right , and right posterolatera posterolatera



Theories of hemorrhoids Theories of hemorrhoids

n n Varicose Theory Varicose Theory obslete obslete n n Vascular hyperplasia Theory Vascular hyperplasia Theory obselete obselete n n It is sliding downward of the anal cushions. It is sliding downward of the anal cushions. n n Disruption of the anchoring and flattening action of Disruption of the anchoring and flattening action of the the musculus musculus submucosae submucosae ani ani ( (Treitz Treitz’ ’s s muscle). muscle).

n n Hypertrophy and congestion of the vascular tissue Hypertrophy and congestion of the vascular tissue are secondary. are secondary.

n n Hemorrhoids are associated with straining and with Hemorrhoids are associated with straining and with an irregular bowel habit, a feature compatible with an irregular bowel habit, a feature compatible with the sliding anal lining theory. the sliding anal lining theory.

n n Hard, bulky stools as well as Hard, bulky stools as well as tenesmus tenesmus from from diarrhea cause straining, which is more diarrhea cause straining, which is more

likely to push the cushions out of the anal canal. likely to push the cushions out of the anal canal.


Aetiology Aetiology

n n Chronic constipation has been Chronic constipation has been considered the cause of hemorrhoids, considered the cause of hemorrhoids,

n n Other studies show that patients with Other studies show that patients with hemorrhoids are not necessarily hemorrhoids are not necessarily constipated but tend to have abnormal constipated but tend to have abnormal anal pressure. anal pressure.

n n Pregnancy hormonal changes, Pregnancy hormonal changes, n n Portal hypertension Portal hypertension


PATHOLOGY PATHOLOGY n n External hemorrhoids comprise the dilated vascular External hemorrhoids comprise the dilated vascular plexus that is located below the dentate line and plexus that is located below the dentate line and covered by covered by squamous squamous epithelium. epithelium.

n n Internal hemorrhoids can be divided into categories. Internal hemorrhoids can be divided into categories. 1. 1. Grade 1 internal hemorrhoids are those that bulge into Grade 1 internal hemorrhoids are those that bulge into the lumen of the anal canal and may produce painless the lumen of the anal canal and may produce painless bleeding. bleeding.

2. 2. Grade 2 internal hemorrhoids are those that protrude at Grade 2 internal hemorrhoids are those that protrude at the time of a bowel movement but reduce the time of a bowel movement but reduce spontaneously. spontaneously.

3. 3. Grade 3 internal hemorrhoids are those that protrude Grade 3 internal hemorrhoids are those that protrude spontaneously or at the time of a bowel movement and spontaneously or at the time of a bowel movement and require manual replacement. require manual replacement.

4. 4. Grade 4 internal hemorrhoids are those that are Grade 4 internal hemorrhoids are those that are permanently prolapsed. permanently prolapsed.


CLINICAL CLINICAL

n n Bleeding Bleeding n n Mucosal Mucosal prolapse prolapse n n Chronic states of Chronic states of prolapse prolapse predispose to mucous predispose to mucous and fecal leakage, resulting in and fecal leakage, resulting in pruritus pruritus and and excoriation of the excoriation of the perianal perianal skin. skin.

n n Pain per se is not a symptom of uncomplicated Pain per se is not a symptom of uncomplicated hemorrhoids. It may indicate associated disease, hemorrhoids. It may indicate associated disease, such as anal fissure, such as anal fissure, perianal perianal abscess. abscess.

n n Prolapsed, strangulated hemorrhoids present as an Prolapsed, strangulated hemorrhoids present as an acute problem, with the symptom of pain acute problem, with the symptom of pain associated with discharging, edematous, tender, associated with discharging, edematous, tender, irreducible hemorrhoids. Gangrene and infection irreducible hemorrhoids. Gangrene and infection with sloughing and secondary bleeding with sloughing and secondary bleeding


Examination Examination

n n Inspection may reveal variable degrees of Inspection may reveal variable degrees of perianal perianal skin abnormalities, protrusion of internal skin abnormalities, protrusion of internal hemorrhoids, or normal appearance. hemorrhoids, or normal appearance.

n n Straining Straining n n P.R. Asking the patient to strain while the P.R. Asking the patient to strain while the examiner examiner’ ’s index finger is in the s index finger is in the anorectum anorectum, an , an enterocele enterocele can be detected. rectal and anal canal can be detected. rectal and anal canal neoplasms neoplasms and will enable and will enable

n n assessment of the tone of the anal sphincter. assessment of the tone of the anal sphincter. n n Anoscopy Anoscopy is performed to rule out a coexisting anal is performed to rule out a coexisting anal fissure. fissure.

n n Sigmoidescopy Sigmoidescopy n n Colonscopy Colonscopy


TREATMENT TREATMENT

n n DIET AND BULK DIET AND BULK FORMING AGENTS FORMING AGENTS n n OFFICE, OUTPATIENT, AND MINOR OFFICE, OUTPATIENT, AND MINOR

PROCEDURES PROCEDURES 1. 1. Rubber Band Rubber Band Ligation Ligation 2. 2. Infrared Photocoagulation Infrared Photocoagulation 3. 3. Electrocoagulation Electrocoagulation 4. 4. Sclerotherapy Sclerotherapy 5. 5. Cryotherapy Cryotherapy


n n Anal Stretch Anal Stretch n n Lateral Internal Lateral Internal Sphincterotomy Sphincterotomy n n Hemorrhoidectomy Hemorrhoidectomy 1. 1. Closed Closed hemorrhoidectomy hemorrhoidectomy 2. 2. Excision and Excision and Ligation Ligation 3. 3. Laser Laser Hemorrhoidectomy Hemorrhoidectomy 4. 4. PPH PPH 5. 5. Ligature Ligature 6. 6. Harmonic scalpel Harmonic scalpel


FISSURE FISSURE


Definition: Definition: A fissure A fissure in in ano ano is a painful is a painful linear ulcer situated in the anal canal linear ulcer situated in the anal canal and extending from just below the and extending from just below the dentate line to the margin of the anus. dentate line to the margin of the anus.

n n In the acute phase, the lesion is often In the acute phase, the lesion is often a crack in the epithelial surface but a crack in the epithelial surface but causes much pain and spasm. causes much pain and spasm.


n n Affects both sex equally (women, Affects both sex equally (women, 51.1%; men, 49.9%). 51.1%; men, 49.9%).

n n Posterior fissure in 73.5%, the Posterior fissure in 73.5%, the anterior in 16.4%, and in both in anterior in 16.4%, and in both in 2.6%. 2.6%.

n n Anterior midline in 45% of women and Anterior midline in 45% of women and 15% of men. 15% of men.


PATHOGENESIS PATHOGENESIS

n n rectal distention rectal distention →→ →→ reflex relaxation of the reflex relaxation of the internal sphincter. internal sphincter.

n n In patients with anal fissures, this In patients with anal fissures, this relaxationis relaxationis followed by an abnormal followed by an abnormal ‘‘ ‘‘overshoot overshoot’’ ’’ contraction contraction→ → sphincter spasm sphincter spasm and pain during defecation. and pain during defecation.

n n Lateral internal Lateral internal sphincterotomy sphincterotomy → → the the pressure dropped by 50% to normal levels pressure dropped by 50% to normal levels and the fissures healed with no change in and the fissures healed with no change in pressure over a 12 pressure over a 12 month follow month follow up. up.


PATHOGENESIS PATHOGENESIS

n n The vessels passing through the The vessels passing through the sphincter muscle are subject to sphincter muscle are subject to contusion during periods of increased contusion during periods of increased sphincter tone and that the resulting sphincter tone and that the resulting decrease in blood supply might lead to decrease in blood supply might lead to a a pathogenetically pathogenetically relevant ischemia at relevant ischemia at the posterior the posterior commissure commissure. .


DIAGNOSIS DIAGNOSIS

n n Inspection Inspection : : n n Gentle separation of the buttocks usually Gentle separation of the buttocks usually reveals the fissure; however, spasm may reveals the fissure; however, spasm may keep the anal orifice closed, and the finding keep the anal orifice closed, and the finding of spasm of a sphincter is suggestive of a of spasm of a sphincter is suggestive of a fissure. fissure.

n n The coexistence of large hemorrhoids or The coexistence of large hemorrhoids or skin folds may hide the ulcer. skin folds may hide the ulcer.

n n The triad of a chronic fissure includes a The triad of a chronic fissure includes a sentinel pile, an anal ulcer, and a sentinel pile, an anal ulcer, and a hypertrophied anal papilla, with the sentinel hypertrophied anal papilla, with the sentinel pile. pile.


DIAGNOSIS DIAGNOSIS

n n Palpation Palpation n n The digital examination is uncomfortable, with The digital examination is uncomfortable, with maximal tenderness usually elicited . maximal tenderness usually elicited .

n n In fact, the pain may be so intense that a In fact, the pain may be so intense that a complete digital examination cannot be performed complete digital examination cannot be performed during the initial examination. However, it is during the initial examination. However, it is essential that the examination be performed later essential that the examination be performed later to exclude other lesions of the lower rectum such to exclude other lesions of the lower rectum such as carcinoma or a polyp. as carcinoma or a polyp.

n n With a chronic fissure, With a chronic fissure, induration induration of the base and of the base and the lateral edges, as well as a hypertrophied anal the lateral edges, as well as a hypertrophied anal papilla, may be palpable. papilla, may be palpable.


Anoscopy Anoscopy

n n With an acute fissure, With an acute fissure, anoscopic anoscopic examination is examination is usually impossible because of the severe pain. usually impossible because of the severe pain.

n n With a chronic fissure, the ulcer itself will be noted With a chronic fissure, the ulcer itself will be noted as a triangular as a triangular shaped slit in the anal canal, with shaped slit in the anal canal, with the floor being the internal sphincter. the floor being the internal sphincter.

n n Just proximal to the ulcer, the hypertrophied anal Just proximal to the ulcer, the hypertrophied anal papilla may be identified. papilla may be identified.

n n A chronic fissure may be associated with anal A chronic fissure may be associated with anal stenosis stenosis of varying severity, of varying severity,

n n Anoscopy Anoscopy may also demonstrate other conditions may also demonstrate other conditions such as internal hemorrhoids or such as internal hemorrhoids or proctitis proctitis. .


DIAGNOSIS DIAGNOSIS

n n A biopsy should be performed on any A biopsy should be performed on any fissure that fails to heal after fissure that fails to heal after treatment. treatment.

n n Such biopsy may reveal unsuspected Such biopsy may reveal unsuspected Crohn Crohn’ ’s s disease or an implanted disease or an implanted adenocarcinoma adenocarcinoma. .

n n Squamous Squamous carcinoma of the anal canal carcinoma of the anal canal may be confused with fissure may be confused with fissure in in ano ano. .


DIFFERENTIAL DIFFERENTIAL DIAGNOSIS DIAGNOSIS 1. 1. ANORECTAL SUPPURATION ANORECTAL SUPPURATION 2. 2. PRURITUS ANI PRURITUS ANI 3. 3. FISSURES IN INFLAMMATORY FISSURES IN INFLAMMATORY

BOWEL DISEASE BOWEL DISEASE 4. 4. CARCINOMA OF ANUS CARCINOMA OF ANUS 5. 5. SPECIFIC INFECTIOUS PERIANAL SPECIFIC INFECTIOUS PERIANAL

CONDITIONS CONDITIONS 6. 6. HEMATOLOGIC CONDITIONS HEMATOLOGIC CONDITIONS


Fissure Fissure in in Ano Ano vs. Anal vs. Anal Abrasion Abrasion Fissure Abrasion Fissure Abrasion

ـــــــــــــــــــــــــــــــــــــــــــــــــــ ـــــــــــــــــــــــــــــــــــــــــــــــــــ ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــDeep ulcer Superficial ulcer Deep ulcer Superficial ulcer Sentinel pile No sentinel pile Sentinel pile No sentinel pile Anal papilla No anal papilla Anal papilla No anal papilla Overhanging edges Flat edges Overhanging edges Flat edges Associated scarring No associated scarring Associated scarring No associated scarring Rarely lateral May be lateral Rarely lateral May be lateral Chronic condition Transient condition Chronic condition Transient condition

(1 (1– –2 d) 2 d) Often treated surgically Not treated surgically Often treated surgically Not treated surgically


TREATMENT TREATMENT

ACUTE FISSURE ACUTE FISSURE n n The aim of treatment of an acute fissure The aim of treatment of an acute fissure in in ano ano is to break is to break

the cycle of a hard stool, pain, and reflex spasm. the cycle of a hard stool, pain, and reflex spasm. n n Avoidance of constipation by ingestion of bulk Avoidance of constipation by ingestion of bulk forming forming

foods. foods. n n simple measures such as warm baths simple measures such as warm baths n n Anesthetic ointments Anesthetic ointments n n suppositories that contain anesthetics, analgesics, suppositories that contain anesthetics, analgesics,

astringents, anti astringents, anti inflammatory agents (usually inflammatory agents (usually hydrocortisone), hydrocortisone),

n n Nitroglycerin GTN Nitroglycerin GTN n n Calcium channel blocker e.g. Calcium channel blocker e.g. Diltiazem Diltiazem, , Nifedipine Nifedipine n n Botulinum Botulinum Toxin (BT) Toxin (BT) n n Sympathetic Sympathetic Neuromodulators Neuromodulators. . n n Surgery: Surgery: Dilatation Dilatation


CHRONIC FISSURE CHRONIC FISSURE

n n Fissure that persists for at least 6 Fissure that persists for at least 6– –8 weeks. 8 weeks. n n Pathologic anatomic point of view features of Pathologic anatomic point of view features of chronicity chronicity include exposure of the internal sphincter, include exposure of the internal sphincter, induration induration of of the fissure edges, development of a large sentinel pile, the fissure edges, development of a large sentinel pile, and hypertrophied anal papilla. and hypertrophied anal papilla.

n n Classic Classic Excisionwith Excisionwith division of varying amounts of division of varying amounts of sphincter muscle sphincter muscle

n n V V Y Y Anoplasty Anoplasty (Advancement Flap Technique) (Advancement Flap Technique) n n Internal Internal Sphincterotomydivision Sphincterotomydivision of the lower half of the of the lower half of the internal sphincter in the posterior midline (incontinence internal sphincter in the posterior midline (incontinence due to the due to the ‘‘ ‘‘keyhole keyhole’’ ’’ deformity created by a posterior deformity created by a posterior internal internal sphincterotomy sphincterotomy). ).

n n Lateral Lateral sphincterotomy sphincterotomy ( open or closed) ( open or closed) n n Tailored lateral Tailored lateral sphincterotomy sphincterotomy in female in female

WAEL KHAFAGY WAEL KHAFAGY Fissurectomy

WAEL KHAFAGY WAEL KHAFAGY VY anoplasty. Prone position

Anal Fistula Anal Fistula


n n Definition: Definition: It is an opening It is an opening between between perianal perianal skin and the cavity skin and the cavity of the anal canal or rectum. of the anal canal or rectum.



The spaces of the anus and rectum. 1. Pelvirectal space. 2, Ischioanal (ischiorectal) space. 3,

Intersphincteric spaces. 4, Subcutaneous space. 5, Central space. 6, Submucous space .


n n Different theories were reported about Different theories were reported about persistence of fistula in persistence of fistula in ano ano include: include:

1 1 Cryptoglandular Cryptoglandular theory theory 2 2 Epethialisation Epethialisation 3 3 Presence of foreign body: Presence of foreign body: 4 4 Specific infections: (IBD, TB, Specific infections: (IBD, TB,


Diagram showing the possible courses of spread of sepsis from the diseased anal gland in the

intersphincteric space.


Classification of anal fistula Classification of anal fistula

n n According to the site of their internal According to the site of their internal opening they can be classified into: opening they can be classified into:

1. 1. Low Low level fistula level fistula, the internal , the internal opening open into the anal canal opening open into the anal canal below the below the anorectal anorectal ring. ring.

2. 2. High High level fistula level fistula, the internal , the internal opening open into the anal canal at opening open into the anal canal at or above the or above the anorectal anorectal ring . ring .


Classification of anal fistula Classification of anal fistula

According to the relation to external and internal According to the relation to external and internal sphincters Parks classified fistulas into: sphincters Parks classified fistulas into:

– – Intersphincteric Intersphincteric fistula, originates from abscess fistula, originates from abscess in in intersphincteric intersphincteric anal gland and runs between anal gland and runs between internal and external sphincters along the plane internal and external sphincters along the plane of longitudinal muscle fibers. of longitudinal muscle fibers.

– – Transsphincteric Transsphincteric fistula have a primary track that fistula have a primary track that passes through the external sphincter at varying passes through the external sphincter at varying levels into the levels into the ischiorectal ischiorectal fossa fossa Such fistula may Such fistula may be uncomplicated, consisting only of the primary be uncomplicated, consisting only of the primary track, or may have a blind high track which may track, or may have a blind high track which may terminates below or above the terminates below or above the levator levator ani ani muscles. muscles.

– – Suprasphincteric Suprasphincteric fistula have a primary track fistula have a primary track running up to a level above running up to a level above puborectalis puborectalis and then and then curl down through the curl down through the levators levators and and ischiorectal ischiorectal fossa fossa to reach the skin. to reach the skin.

– – Extrasphincteric Extrasphincteric fistula run without relation to fistula run without relation to the sphincters. the sphincters.


Diagram demonstrating the three planes in which sepsis may spread circumferentially.


Parks (1976) classification

Intersphincteric fistula. The tract passes through the

internal sphincter and in the intersphincteric plane

Transsphincteric fistula. The tract passes through both the

internal and external sphincters, into the ischiorectal

fossa, and to the skin


Suprasphincteric fistula. The tract courses above the puborectalis muscle after initially passing cephalad as an intersphincteric fistula. It then traverses downward through the ischiorectal fossa to the skin


Transsphincteric fistula with supralevator extension. Drainage of the extension

into the rectum is contraindicated

Extrasphincteric fistula. The internal opening is above the level of the levator ani muscle, and the tract passes to the skin deep to the external sphincter

in the ischiorectal space



Examination of Anal fistulas involves five Examination of Anal fistulas involves five essential points: essential points:

1. 1. The location of external opening. The location of external opening. 2. 2. The location of internal opening. The location of internal opening. 3. 3. The course of primary track. The course of primary track. 4. 4. The presence of secondary The presence of secondary

extension. extension. 5. 5. The presence of other diseases The presence of other diseases

complicating the fistula. complicating the fistula.



n n Digital assessment of the primary track by expert Digital assessment of the primary track by expert proctologist is about 85% accurate. proctologist is about 85% accurate.

n n Examination under anesthesia is considered as a routine Examination under anesthesia is considered as a routine examination of anal fistula. examination of anal fistula.

1. 1. It is carried by It is carried by proctoscope proctoscope so internal opening can be so internal opening can be seen easily (as dimpling or as scar tissue if the opening seen easily (as dimpling or as scar tissue if the opening is not patent) is not patent)

2. 2. Gentle downward retraction of the dentate line which Gentle downward retraction of the dentate line which may expose openings hidden by prominent valves or may expose openings hidden by prominent valves or papillae. papillae.

3. 3. Digital massage of the track may reveal the site of the Digital massage of the track may reveal the site of the internal opening as a bead of pus. internal opening as a bead of pus.

4. 4. A probe can be used through the entire length of the A probe can be used through the entire length of the track and must inserted gently to avoid false passage. track and must inserted gently to avoid false passage.

5. 5. Introduce certain agents through the track as saline, Introduce certain agents through the track as saline, hydrogen peroxide and dyes such as hydrogen peroxide and dyes such as methylene methylene blue and blue and indigo carmine. indigo carmine.


The location of external opening and its distance from anal verge and their relations to the course of the track were hypothesized by Goodsall and known as Goodsall’s rule.

It states that if an imaginary transverse line bisects the anus, external opening anterior to the line will connect to an internal opening by a short, direct fistulous track. External opening posterior to the line will join tracts that curve toward an internal opening in the posterior midline (Goodsall and Miles 1990).


Goodsall’s rule. The usual relationship of primary and secondary fistula orifices is diagrammed. The internal (primary orifice) is marked.

A, The rule predicts that if a line is drawn transversely across the anus, an external opening (B) Anterior to this line will lead to a straight radial tract, whereas an external opening that lies posterior to the line will lead to a curved tract and an internal opening in the posterior commissure. The long anterior fistula is an exception to the rule.


Exception to this rule include anteriorly located opening more than 3 cm from anal verge, which usually opens in the posterior midline and may be anterior extension of posterior horseshoe fistula. Other exception is fistula associated with other diseases especially Crohn’s disease and malignancy.


Anterioposterior view fistulography showing fistulas tract non branching opening in the anal canal below the intertrochantric line.


2) Anorectal Ultrasonography 3) MRI



A

B

A

B C

Coronal view (STIR) left transsphincteric active track is seen start from the ischiorectal fossa traversing the external and then the internal sphincter. (A) Puborectales muscle, (B) Active transsphincteric

track, (C) Ischiorectal fossa abscess cavity.


Anal manometry: Anal manometry is not a routine method for evaluating anal fistula.

Introduction


Treatment Principles of fistula surgery:

Treatment of fistulas is aimed at draining sepsis, defining and eradicating fistulous tracts whilst preserving sphincter integrity and function (Gordon, 1999).

Fistulotomy and drainage: Fistulotomy means laying open and allowing to heal by secondary intention. It should be used only when a significant degree of incontinence would not result. Intersphincteric and low transsphincteric tracks are probably best treated by this method.


Fistulectomy and coring out: Fistulectomy means to excises rather than to incise the fistula track. It has advantage of low rate of recurrence but it leads to greater tissue loss with delayed healing and more risk of incontinence (Kronborg, 1985).

Setons: A seton is used as a drain for the primary track, but use of the seton to transect the muscle carries a significant risk of incontinence Setons may be classified as loose, tight or chemical according to their different properties and modes of action (Fleshman et al., 1999).

Introduction


The critical aspects of management by the cutting seton must first be getting rid of acute sepsis before sphincter division and secondly the speed with which the seton cuts through the sphincter (Peter and Robin, 2001).

Advancement flaps: The rectal advancement flap achieves healing of the fistula in a shorter time, & avoiding any sphincter division.


Introduction

VY apanoplasty (Gordon, 2007)


External opening of anal fisulta.


Detection of the internal opening by hydrogen peroxide injection.


Probing of the anal fisulta.


Coring fistulectomy with saving the external sphincter.


Application of seton.


Appearance of the puborectalis muscle with external sphincter.


Tightening of the seton around sphincter complex.

REROUTING IN THE REROUTING IN THE TREATMENT OF ANAL TREATMENT OF ANAL

FISTULA FISTULA


External opening of the anal fistula.


Detection of the internal opening (diseased crypt) using hydrogen peroxide injection.


Coring fistulectomy


Continuing coring fistulectomy.


Continuing coring fistulectomy.


Fistula rerouting by application of seton around

internal sphincter.


Meticulous Repair of fistulous

opening in the external sphincter


The appearance of the external sphincter repair


Final step in rerouting technique of fistula

PILONIDAL SINUS PILONIDAL SINUS



n n The term The term ‘‘ ‘‘pilonidal pilonidal sinus sinus’’ ’’ ( (pilus pilus, , meaning hair, and meaning hair, and nidus nidus, meaning , meaning nest) to describe the chronic sinus nest) to describe the chronic sinus containing hair and found between the containing hair and found between the buttocks. buttocks.

n n It is called It is called ‘‘ ‘‘jeep disease jeep disease’’ ’’ because it because it is more frequent in military personnel is more frequent in military personnel who entered training & driving trucks, who entered training & driving trucks, tanks, and jeeps. tanks, and jeeps.


n n Pilonidal Pilonidal sinus is a chronic sinus is a chronic subcutaneous abscess in the natal subcutaneous abscess in the natal cleft, which spontaneously drains cleft, which spontaneously drains through the openings. through the openings.


Aetiology Aetiology

n n The congenital theory, the remnant of the The congenital theory, the remnant of the medullary medullary canal, and the canal, and the infolding infolding of the surface of the surface epithelium. In the modern era, the congenital epithelium. In the modern era, the congenital theory still has its proponents. reasoned that hairs theory still has its proponents. reasoned that hairs in the in the pilonidal pilonidal sinuses are identical in length, sinuses are identical in length, diameter, color, and orientation. diameter, color, and orientation.

n n The acquired theory is now widely accepted. The The acquired theory is now widely accepted. The affected hair follicles become distended with keratin affected hair follicles become distended with keratin and subsequently infected, leading to and subsequently infected, leading to folliculitis folliculitis and and the formation of an abscess that extends down into the formation of an abscess that extends down into the subcutaneous fat. the subcutaneous fat.


n n Karydakis Karydakis, believes that the shaft of , believes that the shaft of loose hair inserts into the depth of the loose hair inserts into the depth of the natal cleft in the midline of natal cleft in the midline of sacrococcygeal sacrococcygeal area . Once one hair area . Once one hair inserts successfully, other hairs can inserts successfully, other hairs can insert more easily. Foreign body tissue insert more easily. Foreign body tissue reaction and infection follow, and the reaction and infection follow, and the primary sinus of primary sinus of pilonidal pilonidal disease disease forms. forms.


Patholgy Patholgy

n n It is subcutaneous fibrous tract that may be It is subcutaneous fibrous tract that may be lined with lined with squamous squamous epithelium. A small epithelium. A small abscess cavity and branching tracts may abscess cavity and branching tracts may come off the primary tract. As a rule, hair come off the primary tract. As a rule, hair follicles are not identified. follicles are not identified.

n n Hairs, if seen, sticking out of the secondary Hairs, if seen, sticking out of the secondary opening are in the abscess cavity that the opening are in the abscess cavity that the body tries to spit out. body tries to spit out.

n n Most sinus tracts (93%) run Most sinus tracts (93%) run cephalad cephalad; the ; the rest (7%) run rest (7%) run caudad caudad. .


PILONIDAL ABSCESS PILONIDAL ABSCESS

n n Midline wound in the Midline wound in the intergluteal intergluteal cleft heals cleft heals poorly and slowly. poorly and slowly.

n n Drainage of a Drainage of a pilonidal pilonidal abscess almost always abscess almost always can be performed with the patient under can be performed with the patient under local anesthesia in the clinic, office, or local anesthesia in the clinic, office, or emergency room. emergency room.

n n A longitudinal incision is made lateral to the A longitudinal incision is made lateral to the midline in the midline in the coccygeal coccygeal area from the area from the wound. wound.

n n The hairs around the wound should be The hairs around the wound should be shaved for at least a couple of months. shaved for at least a couple of months.


PILONIDAL SINUS PILONIDAL SINUS

Treatment of Treatment of pilonidal pilonidal sinus can be done in sinus can be done in one of several ways: one of several ways:

1. 1. Nonoperative Nonoperative treatment, treatment, 2. 2. Lateral incision and excision of midline Lateral incision and excision of midline

pits, incision and pits, incision and marsupialization marsupialization, , 3. 3. Wide local excision with or without primary Wide local excision with or without primary

closure, excision and closure, excision and a a Z Z plasty,or plasty,or b b advancing flap operation advancing flap operation

( (Karydakis Karydakis procedure). procedure).


Nonoperative Nonoperative Treatment Treatment

n n Complete healing after drainage of Complete healing after drainage of abscess abscess and and curretage curretage. .

n n Shaving all hairs within the natal cleft, Shaving all hairs within the natal cleft, 5 cm from the anus to the 5 cm from the anus to the presacrum presacrum. .

n n Injecting phenol into the sinus Injecting phenol into the sinus (60%) (60%)


Lateral Incision and Lay Lateral Incision and Lay Open of Midline Sinus Tracts Open of Midline Sinus Tracts

n n Excision of the midline pits, although small, Excision of the midline pits, although small, frequently is slow to heal. to this unhealed draining frequently is slow to heal. to this unhealed draining site. site.

n n The operation was performed in the clinic under The operation was performed in the clinic under local anesthesia without sedation. local anesthesia without sedation.

n n The patient washed the wound at shower and The patient washed the wound at shower and lightly packed it with mesh gauze once or twice lightly packed it with mesh gauze once or twice daily. daily.

n n Hypertrophic Hypertrophic granulation signifies improper packing granulation signifies improper packing and requires cauterization with silver nitrate sticks. and requires cauterization with silver nitrate sticks.

n n The packing should not be tight but the mesh The packing should not be tight but the mesh gauze should touch on the entire subcutaneous gauze should touch on the entire subcutaneous wound. wound.


Excision and Z Excision and Z Plasty Plasty Advantage: Advantage:

1. 1. It Fills out and flattens the natal crease, It Fills out and flattens the natal crease, 2. 2. directs the hair points away from the midline, directs the hair points away from the midline, 3. 3. largely prevents maceration, largely prevents maceration, 4. 4. reduces suction effects in the soft tissues of the reduces suction effects in the soft tissues of the buttocks, and buttocks, and

5. 5. minimizes friction between their adjacent surfaces. minimizes friction between their adjacent surfaces.



Excision and Z Excision and Z Plasty Plasty n n The excision is carried down to the The excision is carried down to the subcutaneous tissue. The limbs of the subcutaneous tissue. The limbs of the Z are cut to form a 30 angle with the Z are cut to form a 30 angle with the long axis of the wound. long axis of the wound.

n n Subcutaneous skin flaps are raised, Subcutaneous skin flaps are raised, and the flaps are transposed and and the flaps are transposed and sutured sutured

n n A closed suction drain is placed under A closed suction drain is placed under the full the full thickness flaps. Z thickness flaps. Z plasty plasty thus thus avoids the midline wound, which is the avoids the midline wound, which is the main cause of slow healing and main cause of slow healing and recurrences. recurrences.


Advancing Flap Operation Advancing Flap Operation Karydakis Karydakis Procedure Procedure

n n A A ‘‘ ‘‘semilateral semilateral’’ ’’ excision is made over the excision is made over the sinuses all the way down to the sinuses all the way down to the presacral presacral fascia. fascia.

n n Mobilization is carried to the opposite side so Mobilization is carried to the opposite side so that the entire flap can be advanced toward that the entire flap can be advanced toward the other side on closure. the other side on closure.

n n A closed suction drain is placed. A closed suction drain is placed. n n This technique avoids the midline wound. This technique avoids the midline wound.



Rhomboid Excision with Rhomboid Excision with Transposition of Flap Transposition of Flap

n n A rhomboid is outlined to encompass the A rhomboid is outlined to encompass the pilonidal pilonidal sinuses in the midline. sinuses in the midline.

n n The rhomboid excision is made down to the sacral The rhomboid excision is made down to the sacral periosteum periosteum in the midline and to the in the midline and to the gluteal gluteal fascia fascia laterally. laterally.

n n The flap is then transposed to cover the rhomboid The flap is then transposed to cover the rhomboid wound. wound.

n n A suction drain is placed under the flap and the wound A suction drain is placed under the flap and the wound is closed with sutures is closed with sutures

n n The advantage of rhomboid excision with transposition The advantage of rhomboid excision with transposition of flap is appealing because it is easy to perform and the of flap is appealing because it is easy to perform and the results are as good as any other more complicated flaps. results are as good as any other more complicated flaps.



GLUTEUS MAXIMUS GLUTEUS MAXIMUS MYOCUTANEOUS FLAP MYOCUTANEOUS FLAP

n n the procedure is rather extensive for a the procedure is rather extensive for a simple disease. simple disease.

n n For unhealed wounds For unhealed wounds



BASCOM BASCOM’ ’S FLAP (CLEFT S FLAP (CLEFT CLOSURE) CLOSURE)

n n For unhealed wounds For unhealed wounds


Rectal Rectal prolapse prolapse


PEDIATRIC RECTAL PEDIATRIC RECTAL PROLAPSE PROLAPSE n n Rectal Rectal prolapse prolapse is the protrusion of a few or all is the protrusion of a few or all layers of the rectal mucous membrane through the layers of the rectal mucous membrane through the anus. anus.

n n Prolapse Prolapse of the rectum may involve only the of the rectum may involve only the mucosa, or it may involve all layers of the rectum mucosa, or it may involve all layers of the rectum protruding through the anus ( protruding through the anus (procidentia procidentia). ).

n n Most cases of childhood Most cases of childhood prolapse prolapse occur in patients occur in patients younger than 4 years. Equal in both younger than 4 years. Equal in both sexe sexe

n n Pediatric rectal Pediatric rectal prolapse prolapse is more common in tropical is more common in tropical and underdeveloped countries, where diarrhea and and underdeveloped countries, where diarrhea and parasitic infection play much greater roles. parasitic infection play much greater roles.


Anatomic considerations Anatomic considerations 1. 1. Vertical course of the rectum Vertical course of the rectum 2. 2. Straight surface of the sacrum and coccyx, Straight surface of the sacrum and coccyx, 3. 3. Relatively low position of the rectum in relation to Relatively low position of the rectum in relation to

other pelvic organs, other pelvic organs, 4. 4. Increased mobility of the sigmoid colon, Increased mobility of the sigmoid colon, 5. 5. Relative lack of support by the Relative lack of support by the levator levator ani ani muscle, muscle, 6. 6. Loose attachment of the rectal mucosa to the Loose attachment of the rectal mucosa to the

underlying underlying muscularis muscularis, , 7. 7. Absence of Houston valves in about 75% of infants. Absence of Houston valves in about 75% of infants.


Predisposing factors & Causes Predisposing factors & Causes 1. 1. Increased intra Increased intra abdominal pressure abdominal pressure Straining due to Straining due to constipation, toilet training, protracted coughing ( constipation, toilet training, protracted coughing (pertussis pertussis), ), excessive vomiting excessive vomiting

2. 2. Parasitic Parasitic Trichuriasis Trichuriasis (whipworm), (whipworm), Entamoeba Entamoeba histolytica histolytica; ; and and Giardia Giardia

3. 3. Neoplastic Neoplastic disease Polyps disease Polyps 4. 4. Malnutrition Malnutrition Loss of Loss of ischiorectal ischiorectal fat reduces fat reduces perirectal perirectal support. support.

5. 5. Cystic fibrosis Cystic fibrosis – – This accounts for about 11% of rectal This accounts for about 11% of rectal prolapse prolapse. . – – Sweat test is diagnostic. Sweat test is diagnostic.

6. 6. Ulcerative colitis 7. Ehlers Ulcerative colitis 7. Ehlers Danlos Danlos Syndrome Syndrome 8. 8. Rectal neoplasm Rectal neoplasm 9. 9. Previously repaired Previously repaired anorectal anorectal anomaly anomaly


n n Consider Consider intussusception intussusception. . – – Findings upon a digital examination of the Findings upon a digital examination of the anus and rectum can differentiate anus and rectum can differentiate prolapse prolapse of an of an intussusception intussusception from from prolapse prolapse of the rectum. If an of the rectum. If an intussusception intussusception prolapses prolapses, a finger can be , a finger can be passed into a space between the anal passed into a space between the anal wall and the mucosa of the protruding wall and the mucosa of the protruding mass. mass.

– – With With prolapse prolapse, inserting a finger into this , inserting a finger into this space is not possible. space is not possible.


LAB LAB

n n Sweat chloride test Sweat chloride test – – Cystic fibrosis should be ruled out in patients Cystic fibrosis should be ruled out in patients who present with rectal who present with rectal prolapse prolapse. .

n n Stool for ova and parasites, culture: Rectal Stool for ova and parasites, culture: Rectal prolapse prolapse has been associated with has been associated with Escherichia coli Escherichia coli; antibiotic ; antibiotic associated colitis; associated colitis; Entamoeba Entamoeba histolytica histolytica; ; and and Giardia Giardia, , Salmonella, Salmonella, Shigella Shigella, , and and Trichuris Trichuris species. species.

n n proctosigmoidoscopy proctosigmoidoscopy to rule out rectal to rule out rectal polyps. polyps.


Conservative Conservative management management

– – Prolapsed rectum should undergo manual Prolapsed rectum should undergo manual reduction. reduction.

– – If the If the prolapse prolapse immediately recurs, it may be immediately recurs, it may be reduced again and the buttocks taped together reduced again and the buttocks taped together for several hours. for several hours.

– – Conservative management is started in children Conservative management is started in children younger than 4 years and in children older than younger than 4 years and in children older than 4 years who have 4 years who have noncomplicated noncomplicated, , nonrecurrent nonrecurrent rectal rectal prolapse prolapse. .

– – Treating the cause and reducing straining. with Treating the cause and reducing straining. with dietary modification and stool softeners to dietary modification and stool softeners to reduce straining. reduce straining.

– – Infectious diarrhea or parasitic infestation should Infectious diarrhea or parasitic infestation should be appropriately treated. be appropriately treated.


Surgical treatment Surgical treatment n n Currently, more than 130 operative procedures Currently, more than 130 operative procedures exist for the treatment of rectal exist for the treatment of rectal prolapse prolapse. .

n n Circumferential injection Circumferential injection procedures (90 procedures (90 100% 100% success rate): Injection procedures use either success rate): Injection procedures use either phenol in oil, isotonic sodium chloride, D50, or ethyl phenol in oil, isotonic sodium chloride, D50, or ethyl alcohol as a alcohol as a sclerosant sclerosant to promote adhesion to promote adhesion formation, which stabilizes the rectum. Possible formation, which stabilizes the rectum. Possible complications include injury to nerves, injury to complications include injury to nerves, injury to surrounding tissue, and possible injury from surrounding tissue, and possible injury from sclerosing sclerosing agents that may be carcinogenic. agents that may be carcinogenic.

n n Thiersch Thiersch operation operation (90% success rate): Known (90% success rate): Known as a sling procedure, this operation uses synthetic as a sling procedure, this operation uses synthetic materials to surgically create a materials to surgically create a perianal perianal sling to sling to support the rectum. support the rectum.


Surgical therapy Surgical therapy

n n Lockhart Lockhart Mummery operation Mummery operation (approximately 100% (approximately 100% success rate): Mesh gauze packing is placed temporarily in success rate): Mesh gauze packing is placed temporarily in the the retrorectal retrorectal space to promote adhesions that stabilize the space to promote adhesions that stabilize the rectum. rectum.

n n Cauterization treatment Cauterization treatment (approximately 80% success (approximately 80% success rate): In this procedure, the prolapsed rectum is cauterized in rate): In this procedure, the prolapsed rectum is cauterized in a linear fashion extending to the a linear fashion extending to the submucosa submucosa in 4 quadrants. in 4 quadrants. This produces This produces perirectal perirectal inflammation and scarring that inflammation and scarring that prevents prevents prolapse prolapse. .

n n Abdominal Abdominal rectopexy rectopexy (75% success rate): (75% success rate): Endoscopic Endoscopic or or open approach is possible. The open approach is possible. The perirectal perirectal tissues are attached tissues are attached to the to the presacral presacral area to assure correct anatomical positioning area to assure correct anatomical positioning and tissue adherence. and tissue adherence.

n n Ekehorn Ekehorn rectopexy rectopexy (100% success rate): A suture is placed (100% success rate): A suture is placed in the rectal in the rectal ampulla ampulla through the lowest part of the sacrum to through the lowest part of the sacrum to induce inflammation and adhesions. This induces adhesions induce inflammation and adhesions. This induces adhesions between the rectal wall and between the rectal wall and perirectal perirectal wall to effectively wall to effectively perform a perform a sacrorectopexy sacrorectopexy. .

Adult Adult prolapse prolapse


n n Three different clinical entities are often combined Three different clinical entities are often combined and called rectal and called rectal prolapse prolapse: full : full thickness rectal thickness rectal prolapse prolapse, mucosal , mucosal prolapse prolapse, and internal , and internal prolapse prolapse (internal (internal intussusception intussusception). Treatment of these 3 ). Treatment of these 3 entities differs. entities differs.

n n Full Full thickness rectal thickness rectal prolapse prolapse is the most is the most commonly recognized type and is defined as commonly recognized type and is defined as protrusion of the full thickness of the rectal wall protrusion of the full thickness of the rectal wall through the anus. through the anus.

n n In mucosal In mucosal prolapse prolapse, , only the rectal mucosa (not only the rectal mucosa (not the entire wall) protrudes from the anus. the entire wall) protrudes from the anus.

n n Internal Internal intussusception intussusception may be a full thickness may be a full thickness or a partial rectal wall disorder, but the prolapsed or a partial rectal wall disorder, but the prolapsed tissue does not pass beyond the anal canal and tissue does not pass beyond the anal canal and does not pass out of the anus. does not pass out of the anus.


Rectal Rectal prolapse prolapse is the protrusion of the is the protrusion of the entire thickness of the rectal wall entire thickness of the rectal wall through the anal sphincter. There through the anal sphincter. There are two theories concerning the are two theories concerning the etiology: etiology:

1. 1. sliding hernia through a defect in the sliding hernia through a defect in the pelvic fascia pelvic fascia

2. 2. Circumferential Circumferential intussusception intussusception of of the rectum the rectum 6 6 8 cm from anal verge 8 cm from anal verge


Classification Classification

1. 1. Incomplete (mucosal Incomplete (mucosal prolapse prolapse) ) 2. 2. Complete (full Complete (full thickness wall thickness wall

prolapse prolapse): ): A A First degree (high or early, First degree (high or early,

‘‘ ‘‘concealed, concealed,’’ ’’ ‘‘ ‘‘invisible invisible’’ ’’); ); B B Second degree (externally visible on Second degree (externally visible on

straining, straining, sulcus sulcus evident between evident between rectal wall and anal canal); rectal wall and anal canal);

C C Third degree (externally visible) Third degree (externally visible)


n n Peaks fourth and seventh decades of Peaks fourth and seventh decades of life, life,

n n More in women (80 More in women (80 90%). 90%).


PREDISPOSING FACTORS PREDISPOSING FACTORS

n n History of straining associated with History of straining associated with intractable constipation and another 15% intractable constipation and another 15% experienced diarrhea. experienced diarrhea.

n n Additional contributory causes of anatomic Additional contributory causes of anatomic or neuromuscular deficit included or neuromuscular deficit included pregnancy, previous operations, and pregnancy, previous operations, and neurologic neurologic disease. disease.

n n Psychiatric illness Psychiatric illness suggested that the pelvic suggested that the pelvic floor weakness is secondary to nerve floor weakness is secondary to nerve entrapment or nerve stretching, which leads entrapment or nerve stretching, which leads to a muscular deficiency and complete to a muscular deficiency and complete procidentia procidentia. .

n n Progressive systemic sclerosis Progressive systemic sclerosis


PATHOLOGIC ANATOMY PATHOLOGIC ANATOMY

n n The anatomic defects described as occurring with The anatomic defects described as occurring with prolapse prolapse of the rectum include the following: of the rectum include the following:

(i) (i) a defect in the pelvic floor with a defect in the pelvic floor with diastasis diastasis of the of the levator levator ani ani muscles and a weakened muscles and a weakened endopelvic endopelvic fascia, fascia,

(ii) (ii) an abnormally deep cul an abnormally deep cul de de sac of Douglas, sac of Douglas, (iii) (iii) a redundant a redundant rectosigmoid rectosigmoid colon, colon, (iv) (iv) a patulous weak anal sphincter, and a patulous weak anal sphincter, and (v) (v) loss of the normal horizontal position of the loss of the normal horizontal position of the

rectum caused by its loose attachment to the rectum caused by its loose attachment to the sacrum and pelvic walls. sacrum and pelvic walls.


PHYSIOLOGIC PHYSIOLOGIC DYSFUNCTION DYSFUNCTION Pre Pre existing fecal incontinence ranges from existing fecal incontinence ranges from 35% to 100% of cases. 35% to 100% of cases.

1. 1. secondary to sphincter damage of internal secondary to sphincter damage of internal anal sphincter by the anal sphincter by the prolapse prolapse itself. itself.

2. 2. idiopathic fecal incontinence( Loss of idiopathic fecal incontinence( Loss of rectal anal inhibitor reflex) rectal anal inhibitor reflex)

Chronic Constipation Chronic Constipation


CAUSES CAUSES n n Conditions with increased intra Conditions with increased intra abdominal pressure abdominal pressure

– – Constipation Constipation – – Diarrhea Diarrhea – – Benign Benign prostatic prostatic hypertrophy hypertrophy – – Chronic obstructive pulmonary disease (COPD) Chronic obstructive pulmonary disease (COPD) – – Cystic fibrosis Cystic fibrosis – – Pertussis Pertussis ( (ie ie, whooping cough) , whooping cough)

n n Pelvic floor dysfunction Pelvic floor dysfunction n n Parasitic infections Parasitic infections

– – Amebiasis Amebiasis – – Schistosomiasis Schistosomiasis

n n Neurologic Neurologic disorders disorders – – Previous lower back or pelvic trauma/lumbar disk disease Previous lower back or pelvic trauma/lumbar disk disease – – Cauda Cauda equina equina syndrome syndrome – – Spinal tumors Spinal tumors – – Multiple sclerosis Multiple sclerosis



History History n n Constipation (15 Constipation (15 65%) 65%) n n Fecal incontinence (28 Fecal incontinence (28 88%) 88%) n n Mucus drainage Mucus drainage n n Protruding anal mass Protruding anal mass n n Rectal bleeding Rectal bleeding Physical Physical n n Protruding rectal mucosa Protruding rectal mucosa n n Thick concentric mucosal ring Thick concentric mucosal ring n n Sulcus Sulcus noted between anal canal and rectum noted between anal canal and rectum n n Solitary rectal ulcer (10 Solitary rectal ulcer (10 25%) 25%) n n Decreased anal sphincter tone Decreased anal sphincter tone


n n Barium enema: Redundant colon Barium enema: Redundant colon n n Defecography Defecography (& (&vedio vedio): to determine if the rectum ): to determine if the rectum intussuscepts on defecation. intussuscepts on defecation.

n n Anal rectal Anal rectal manometry manometry is to evaluate the anal is to evaluate the anal sphincter muscles. sphincter muscles.

n n Colon transit time ( Colon transit time (Sitz Sitz marker study) in a patient marker study) in a patient with constipation and rectal with constipation and rectal prolapse prolapse to help to help determine the need for colonic resection. determine the need for colonic resection.

n n Rigid Rigid proctosigmoidoscopy proctosigmoidoscopy should be performed to should be performed to assess the rectum for solitary rectal ulcers (10 assess the rectum for solitary rectal ulcers (10 25%). 25%).

n n Biopsies should be taken to confirm solitary rectal Biopsies should be taken to confirm solitary rectal ulcers ulcers


Medical therapy Medical therapy

n n No medical treatment is available for No medical treatment is available for rectal rectal prolapse prolapse. However, always first . However, always first treat internal treat internal prolapse prolapse medically with medically with bulking agents, stool softeners, and bulking agents, stool softeners, and suppositories or enemas. suppositories or enemas.

n n Biofeedback may be helpful if Biofeedback may be helpful if paradoxical pelvic floor contraction paradoxical pelvic floor contraction also exists. also exists.


Surgical therapy Surgical therapy The following specific issues were addressed. The following specific issues were addressed. 1. 1. Whether surgical intervention is better than no treatment. Whether surgical intervention is better than no treatment. According medical fitness According medical fitness 2. 2. Whether an abdominal approach to surgery is better than a Whether an abdominal approach to surgery is better than a perineal perineal approach. approach.

There were no detectable differences in recurrent There were no detectable differences in recurrent prolapses prolapses between abdominal and between abdominal and perineal perineal approaches, although approaches, although there was a suggestion that fecal incontinence was less there was a suggestion that fecal incontinence was less common after abdominal procedures. common after abdominal procedures.

3. 3. Whether one method for performing Whether one method for performing rectopexy rectopexy is better is better than another than another. .

There were no detectable differences between the methods There were no detectable differences between the methods used for fixation during used for fixation during rectopexy rectopexy. Division rather than . Division rather than preservation of the lateral ligaments was associated with preservation of the lateral ligaments was associated with less recurrent less recurrent prolapse prolapse but more postoperative constipation but more postoperative constipation although these findings were found in small numbers. although these findings were found in small numbers.


Surgical therapy Surgical therapy .4. .4. Whether laparoscopic access is better than open access Whether laparoscopic access is better than open access for operation. for operation.

There were too few data with which to compare laparoscopic There were too few data with which to compare laparoscopic with open operation. with open operation.

5. 5. Whether resection should be included in the procedure. Whether resection should be included in the procedure. Bowel resection during Bowel resection during rectopexy rectopexy was associated with lower was associated with lower rates of constipation. rates of constipation.

6. 6. What is the ideal Surgical procedure. What is the ideal Surgical procedure. Each procedure has advantages and disadvantages. The Each procedure has advantages and disadvantages. The particular method of repair used by a surgeon depends on particular method of repair used by a surgeon depends on his previous training and exposure to a certain technique, his previous training and exposure to a certain technique, which is modified by his own personal experience. which is modified by his own personal experience.


Surgical therapy Surgical therapy Abdominal procedures Abdominal procedures

n n These procedures are typically performed in These procedures are typically performed in younger, healthier patients. The choice of younger, healthier patients. The choice of abdominal procedure is often dictated by abdominal procedure is often dictated by the extent of the associated constipation the extent of the associated constipation and by the surgeon's preference. and by the surgeon's preference.

n n Anterior resection Anterior resection n n Marlex Marlex rectopexy rectopexy n n Suture Suture rectopexy rectopexy n n Resection Resection rectopexy rectopexy


Surgical therapy Surgical therapy Perineal Perineal procedures procedures

n n Perineal Perineal procedures have a higher recurrence procedures have a higher recurrence rate but a lower morbidity rate and are often rate but a lower morbidity rate and are often performed in the elderly population or in performed in the elderly population or in patients who have a contraindication to patients who have a contraindication to general anesthetic. general anesthetic.

n n Anal encirclement ( Anal encirclement (Thiersch Thiersch wire) wire) This This procedure is no longer performed procedure is no longer performed

n n Delorme mucosal sleeve resection Delorme mucosal sleeve resection This This procedure is often used for small procedure is often used for small prolapses prolapses

n n Altemeier Altemeier perineal perineal Rectosigmoidectomy Rectosigmoidectomy n n Surgery for mucosal Surgery for mucosal prolapse prolapse

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