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Surgery of the anorectum Surgery of the anorectum and the perianal region in and the perianal region in
small animalssmall animals
Surgery of the anorectum Surgery of the anorectum and the perianal region in and the perianal region in
small animalssmall animals
Dr. T. Németh, Dr. T. Németh, DVM, PhD, DipECVSDVM, PhD, DipECVS
Associate Professor and Head of SurgeryAssociate Professor and Head of Surgery
Dr. T. Németh, Dr. T. Németh, DVM, PhD, DipECVSDVM, PhD, DipECVS
Associate Professor and Head of SurgeryAssociate Professor and Head of Surgery
SurgicalSurgical anatomyanatomy((AnorectumAnorectum))
SurgicalSurgical anatomyanatomy((AnorectumAnorectum))
Zona cutaneaZona cutanea–– Circumanal glandsCircumanal glands–– Anal sacsAnal sacs
Zona intermediaZona intermedia Zona columnarisZona columnaris Linea anorectalisLinea anorectalis
Surgical anatomySurgical anatomy(Perineum)(Perineum)
m. coccygeusm. coccygeus m. levator anim. levator ani m. sphincter ani ext.m. sphincter ani ext. m. sphincter ani int.m. sphincter ani int. m. obturatorius int.m. obturatorius int. a., v. pudenda int.a., v. pudenda int. n. pudendusn. pudendus
General diagnostic considerations of General diagnostic considerations of the anorectal and perianal diseases I.the anorectal and perianal diseases I.
AnamnesisAnamnesis–– generally chronic historygenerally chronic history–– tenesmus in defecationtenesmus in defecation–– fecal deviationfecal deviation–– local signs local signs (pruritus, formal deviation…)(pruritus, formal deviation…)
–– General signs General signs (alimentary, septicus…)(alimentary, septicus…)
General diagnostic considerations of General diagnostic considerations of the anorectal and perianal diseases II.the anorectal and perianal diseases II.
Physical examinationPhysical examination–– inspectioninspection
–– palpationpalpation superficialsuperficial
rectal (RDP)rectal (RDP)
2
General diagnostic considerations of General diagnostic considerations of the anorectal and perianal diseases the anorectal and perianal diseases
III.III.
SupplSuppl. . examinationsexaminations–– BloodworkBloodwork, , urinalysisurinalysis ((gengen. . statestate))
–– FineFine needleneedle aspirateaspirate//cytologycytology ((tumourstumours))
–– XX--rayray / / pospos. . contrastcontrast rectogrrectogr., ., cystogrcystogr. . ((rectalrectal fistulationfistulation, , perinealperineal herniahernia))
–– RectoscopyRectoscopy ((rectalrectal tumourstumours))
–– US US ((perinealperineal herniahernia//prostateprostate, , perinealperineal tumourtumour//lnnlnn.).)
–– CT / MRICT / MRI
General considerations of anorectal General considerations of anorectal and perianal surgery I.and perianal surgery I.
Preoperative dutiesPreoperative duties–– evacuation of rectum (enema)evacuation of rectum (enema)
–– antimicrobial prophylaxisantimicrobial prophylaxis enteralenteral
parenteralparenteral
General considerations of anorectal General considerations of anorectal and perianal surgery II.and perianal surgery II.
SurgerySurgery–– atraumatic handling atraumatic handling
–– preservation of ext. anal sphincter anipreservation of ext. anal sphincter ani
–– monophil suture materialsmonophil suture materials
General considerations of anorectal General considerations of anorectal and perianal surgery III.and perianal surgery III.
PostoperativePostoperative dutiesduties–– ParenteralParenteral / / enteralenteral feedingfeeding / / dietdiet
–– analgesiaanalgesia
–– contcont. of . of antibacterialantibacterial therapytherapy
–– protectionprotection of of operationoperation site (site (collarcollar, , cleaningcleaning))
Most important diseases of the Most important diseases of the regionregion
Anal/rectal prolapsAnal/rectal prolaps
Anal sacculitisAnal sacculitis
Perianalis fistulaPerianalis fistula
Anal and rectal tumoursAnal and rectal tumours
Anal/rectal prolapsAnal/rectal prolaps
IncidenceIncidence–– result of diseases with defecation tenesmus of result of diseases with defecation tenesmus of
frequent defecationfrequent defecation
–– commonly in combination with commonly in combination with intussusceptionintussusception
3
Anal/rectal prolapsAnal/rectal prolaps
DiagnosisDiagnosis–– assesment of vitality of assesment of vitality of
the prolapsed gutthe prolapsed gut
–– reponability (?)reponability (?)
–– diagnosis of the primary diagnosis of the primary disease (enteritis)disease (enteritis)
Anal/rectal prolapsAnal/rectal prolaps
TherapyTherapy–– Treatment of primary Treatment of primary
diseasedisease
–– 1. reposition 1. reposition purse purse string suturestring suture
–– 2. reposition 2. reposition colopexycolopexy
–– 3.3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
TherapyTherapy–– Treatment of primary diseaseTreatment of primary disease–– 1. reposition 1. reposition purse string suturepurse string suture
–– 2. reposition 2. reposition colopexycolopexy
–– 3. 3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
TherapyTherapy–– Treatment of primary diseaseTreatment of primary disease–– 1. reposition 1. reposition purse string suturepurse string suture
–– 2. reposition 2. reposition colopexycolopexy
–– 3. 3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
TherapyTherapy–– Treatment of primary diseaseTreatment of primary disease–– 1. reposition 1. reposition purse string suturepurse string suture
–– 2. reposition 2. reposition colopexycolopexy
–– 3. 3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
TherapyTherapy–– Treatment of primary Treatment of primary
diseasedisease
–– 1. reposition 1. reposition purse purse string suturestring suture
–– 2. reposition 2. reposition colopexycolopexy
–– 3. 3. resection resection
4
Anal/rectal prolapsAnal/rectal prolaps
TherapyTherapy–– Treatment of primary Treatment of primary
diseasedisease
–– 1. reposition 1. reposition purse purse string suturestring suture
–– 2. reposition 2. reposition colopexycolopexy
–– 3. 3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
TherapyTherapy–– Treatment of primary diseaseTreatment of primary disease–– 1. reposition 1. reposition purse string suturepurse string suture
–– 2 reposition 2 reposition colopexycolopexy
–– 3. 3. resection („’pull through”)resection („’pull through”)
Rectal resectionRectal resection„„PullPull--through”through”
Rectal resectionRectal resection„„PullPull--through”through”
IndicationIndication–– Partial rectal resection between pubic bone and Partial rectal resection between pubic bone and
anorectal lineanorectal line–– necrosis, tumour, stricture, injurynecrosis, tumour, stricture, injury
SurgerySurgery–– preparation preparation (see general considerations)(see general considerations)
–– prolapsing of rectumprolapsing of rectum–– circumferential transectioncircumferential transection–– rectal resectionrectal resection–– interrupted monofilament absorbable stitchesinterrupted monofilament absorbable stitches
IndicationIndication–– Partial rectal resection between pubic bone and Partial rectal resection between pubic bone and
anorectal lineanorectal line–– necrosis, tumour, stricture, injurynecrosis, tumour, stricture, injury
SurgerySurgery–– preparation preparation (see general considerations)(see general considerations)
–– prolapsing of rectumprolapsing of rectum–– circumferential transectioncircumferential transection–– rectal resectionrectal resection–– interrupted monofilament absorbable stitchesinterrupted monofilament absorbable stitches
Rectal resectionRectal resection„„PullPull--through”through”
Rectal resectionRectal resection„„PullPull--through”through”
Rectal resectionRectal resection„„PullPull--through”through”
Rectal resectionRectal resection„„PullPull--through”through”
Rectal resectionRectal resection„„PullPull--through”through”
Rectal resectionRectal resection„„PullPull--through”through”
5
Rectal resectionRectal resection„„PullPull--through”through”
Rectal resectionRectal resection„„PullPull--through”through”
Rectal resectionRectal resection„„PullPull--through”through”
Rectal resectionRectal resection„„PullPull--through”through”
A vastagbél sebészeteA vastagbél sebészete„„PullPull--through”through”
A vastagbél sebészeteA vastagbél sebészete„„PullPull--through”through”
VIDEOVIDEOVIDEOVIDEO
Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
IncidenceIncidence–– mainly in dogsmainly in dogs
–– primary or secondaryprimary or secondary
–– combined with allergodermatitiscombined with allergodermatitis
Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
DiagnosisDiagnosis–– Local signsLocal signs
Increased amount of Increased amount of contentcontent
Local irritationLocal irritation
abscess / phlegmone / abscess / phlegmone / cystcyst
–– Systemic signsSystemic signs prurituspruritus septic signsseptic signs
allergic reactionsallergic reactions
Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
TherapyTherapy–– conservativeconservative–– surgicalsurgical
6
Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
Conservative therapyConservative therapy–– precise evacuation of the sac (rectally!!!)precise evacuation of the sac (rectally!!!)–– parenteral antibioticsparenteral antibiotics
–– analgesia/NSAIDsanalgesia/NSAIDs
AnalAnal sacculitissacculitis / / ParaproctitisParaproctitis SurgerySurgery ((analanal sacculectomysacculectomy))
„closed”„open”
AnalAnal sacculitissacculitis / / ParaproctitisParaproctitis
Surgery (anal sac removal)Surgery (anal sac removal)
Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
Surgery (anal sac removal)Surgery (anal sac removal)
PerianalPerianal fistulafistula / / furunculosisfurunculosis IncidenceIncidence / / AetiologyAetiology
–– inin GermanGerman shepherdshepherd and and itsits mongrelsmongrels
–– IrishIrish settersetter, Labrador, , Labrador, CollieCollie
–– uncertainuncertain aetiologyaetiology:: immuneimmune--mediatedmediated ((autoimmuneautoimmune)) DecreasedDecreased activityactivity of of mucosalmucosal and and circulatingcirculating IgAIgA hyperaktívhyperaktív local local immuniyimmuniy ((IgAIgA, , IgGIgG, , BB--andand TT--lymphocyteslymphocytes, ,
CD3+, CD3+, macrophagesmacrophages, , plasmaplasma cellscells, IL, IL--2, INF2, INF--))
–– concurrentconcurrent chronicchronic colitiscolitis
–– AnalogyAnalogy withwith human human Crohn’sCrohn’s--diseasedisease (?)(?)
Perianal fistula / furunculosisPerianal fistula / furunculosis
DiagnosisDiagnosis–– breedbreed–– typical chronic, nontypical chronic, non--
healing, recurring healing, recurring analis fistulous tractanalis fistulous tract
–– concurrent colitisconcurrent colitis
7
Perianal fistula / furunculosisPerianal fistula / furunculosis
DiagnosisDiagnosis–– breedbreed–– typical chronic, nontypical chronic, non--
healing, recurring healing, recurring analis fistulous tractanalis fistulous tract
–– concurrent colitisconcurrent colitis
Perianal fistula / furunculosisPerianal fistula / furunculosis
TherapyTherapy–– Currently no effective causative treatment !!!Currently no effective causative treatment !!!
Perianal fistula / furunculosisPerianal fistula / furunculosis
TherapyTherapy–– conservativeconservative (!!!)(!!!)–– surgicalsurgical (!?)(!?)
PerianalPerianal fistulafistula / / furunculosisfurunculosis ConservativeConservative therapytherapy (!!!)(!!!)
–– ProtocolProtocol #1 (Michigan #1 (Michigan StateState University)University) dietdiet PrednisolonePrednisolone AzathioprineAzathioprine
–– ProtocolProtocol #2 (Ontario #2 (Ontario VeterinaryVeterinary College)College) dietdiet CyclosporineCyclosporine
–– ProtocolProtocol #3#3 #1 #1 oror #2 + #2 + TacrolimusTacrolimus ointmentointment topicallytopically
PerianalPerianal fistulafistula / / furunculosisfurunculosis
Surgery• Previous failed techniques
cryo-surgery (UK)soft lasertail amputation (USA)castration (???)
• Current surgical recommendation „Anoplasty”
fistulectomyparaproctectomycryptectomy (zona columnaris)
Anal / Rectal tumoursAnal / Rectal tumours
IncidenceIncidence–– hepatoid circumanal gland tumours hepatoid circumanal gland tumours
(hyperplasia, adenoma, anapl. carcinoma)(hyperplasia, adenoma, anapl. carcinoma) in male dogsin male dogs
–– anal sac tumours (adenocarcinoma) anal sac tumours (adenocarcinoma) in female dogsin female dogs
–– rectal adenoma / adenocarcinomarectal adenoma / adenocarcinoma
8
Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
DiagnosisDiagnosis–– inin malemale dogsdogs–– testosteronetestosterone
dependencydependency–– multilocalmultilocal perianalperianal
lumpslumps ((anusanus, , basebase of of tailtail))
–– commoncommon ulcerationulceration–– RDPRDP–– finefine needleneedle aspiratesaspirates / /
cytologycytology
Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
DiagnosisDiagnosis–– in male dogsin male dogs–– testosterone testosterone
dependencydependency–– multilocal perianal multilocal perianal
lumps lumps (anus, (anus, base of base of tail)tail)
–– common ulcerationcommon ulceration–– RDPRDP–– fine needle aspirates / fine needle aspirates /
cytologycytology
Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
DiagnosisDiagnosis–– in male dogsin male dogs–– testosterone testosterone
dependencydependency–– multilocal perianal multilocal perianal
lumps lumps (anus, (anus, base of base of tail)tail)
–– common ulcerationcommon ulceration–– RDPRDP–– fine needle aspirates / fine needle aspirates /
cytologycytology
Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
TherapyTherapy–– castration (!)castration (!)–– (oestrogen inj.)(oestrogen inj.)–– excision of tumourexcision of tumour–– histopath (!)histopath (!)–– postop. antibioticspostop. antibiotics–– local cleansinglocal cleansing
Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
TherapyTherapy–– castration (!)castration (!)–– (oestrogen inj.)(oestrogen inj.)–– excision of tumourexcision of tumour–– histopath (!)histopath (!)–– postop. antibioticspostop. antibiotics–– local cleansinglocal cleansing
Anal /Rectal tumoursAnal /Rectal tumoursRectalRectal tumourstumours
DiagnosisDiagnosis–– bloody fecesbloody feces–– tenesmustenesmus–– RDP RDP (pelvic lymphonodes)(pelvic lymphonodes)
–– rectoscopyrectoscopy–– (US)(US)–– cytologycytology
9
Anal /Rectal tumoursAnal /Rectal tumoursRectal tumoursRectal tumours
TherapyTherapy–– „pull„pull--open”open”–– excision of excision of
tumour tumour (electrocautery)(electrocautery)
–– histopath.histopath.–– antibioticsantibiotics–– dietdiet
„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture „„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture „„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
10
„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture „„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture „„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
RectalRectal tumourstumours
TherapyTherapy–– DorsallyDorsally positionedpositioned
intrapelvicintrapelvic localisationlocalisation::–– „„dorsaldorsal rectalrectal
approachapproach””
RectalRectal tumourstumours
TherapyTherapy–– LaterallyLaterally positionedpositioned
intrapelvicintrapelvic localisationlocalisation::–– „„laterallateral rectalrectal
approachapproach””
11
RectalRectal tumourstumours
TherapyTherapy–– CaudalCaudal intrapelvicintrapelvic
localisationlocalisation::–– „„pullpull--throughthrough””rectumrectum resectionresection
RectalRectal tumourstumours
TherapyTherapy–– CranialCranial intrapelvicintrapelvic
localisationlocalisation::–– „„ventralventral rectalrectal
approachapproach withwith pubicpubicosteotomyosteotomy””