anorectal diseases

COMMON ANAL PROBLEMS

DR.K.R.DHARMENDRA, MS.,DNB.,

GENERAL & LAPAROSCOPIC SURGEON,

AL HAYAT INTERNATIONAL HOSPITAL, MUSCAT.

OUTLINE

• RELEVANT SURGICAL ANATOMY

• HAEMORRHOIDS

• FISSURE IN ANO

• FISTULA IN ANO

SURGICAL ANATOMY OF ANAL CANAL

• THE ANORECTAL RING• PUBORECTALIS MUSCLE• EXTERNAL ANAL SPHINCTER• THE INTERNAL ANAL SPHINCTER• DENTATE LINE• ANAL CUSHIONS

ANORECTAL RING

Marks the junction between rectum & anal canal

Formed by joining of

Puborectalis muscle

Deep External Sphincter

Conjoined Longitudinal muscle

Highest part of internal sphincter

PUBORECTALIS MUSCLE

• Funnel shaped muscle

• Maintains angle between anal canal &

rectum

• Important for continence mechanism

• Innervated by Sacral somatic nerves

West becomes East !!!

EXTERNAL ANAL SPHINCTER

• Single, somatic, voluntary muscle

• Divided by lateral extensions from

longitudinal muscle into 3 portions

• Deep

• Superficial

• Subcutaneous

• Innervated by Pudental Nerve

INTERNAL SPHINCTER• Involuntary muscle

• Thickened distal continuation

of circular coat of rectum

• In a tonic state of contraction

• Receives intrincic non-

adrenergic and non-

cholinergic fibres, stimulation

of which causes release of NO

which induces IS relaxation

DENTATE LINE

• Important surgical landmark

• Represents the site of fusion of

proctodaeum and post-allantoic gut.

• Site of crypts of Morgagni through which

anal ducts that communicate with anal

glands open into anal lumen.

DENTATE LINE Above Pink Mucosa Columnar epithelium Superior Rectal Artery Portal circulation Autonomic Nervous system Painless

Below Parchment coloured mucosa Stratified Squamous epithelium Inferior Rectal Artery Systemic circulation Somatic innervation Painful

ANAL CUSHIONS• Uneven folds of mucosa &

submucosa just above the dentate line

• Left lateral• Right posterior• Right anterior• Contains sub epithelial

meshwork of supporting tissues

• Site of dense arterio venous plexus

HAEMORRHOIDS

• Greek:

haima = blood

Rhoos = flowing

• Latin: pila = a ball

• Definition:

Symptomatic

anal cushions

Piles characteristically lie in 3, 7& 11 o’ clock positions

These are the locations of the terminal branches of superior rectal artery

CAUSES OF HAEMORRHOIDS• Constipation

• Fiber deficient diet

• Straining to pass stool

Shearing forces acting on the anus lead to

caudal displacement of anal cushions.

Fragmentation of supporting structures leads to

loss of elasticity of cushions such that they no

longer retract following defecation.

SYMPTOMS OF HAEMORRHOIDS

• Bright –red , painless bleeding

• Mucus discharge

• Prolapsed mass

• Pain only when prolapsed

BEWARE OF GI SYMPTOMS!!

• Change of bowel habits

• Mucus discharge

• Tenesmus

• Back pain

• Anorexia/ Weight loss

• Abdominal pain

DEGREES OF HAEMORRHOIDS

MX OF HAEMORRHOIDS

• FIRST DEGREE: Conservative[Medical]

• SECOND DEGREE: BARRON’S BANDING

• 3RD & 4TH DEGREE: OPEN

HAEMORRHOIDECTOMY

OR

STAPLED HAEMORRHOIDECTOMY

BARRON’S BANDING

STAPLED HAEMORRHOIDECTOMY

• Introduced by Longo in 1998

• Utilises a purpose designed stapling

gun[PPH]

• Excises a strip of mucosa & submucosa

circumferentially

• Above Dentate Line

STAPLED HAEMORRHOIDECTOMY

EXTERNAL HAEMORRHOIDS

• Arising from superficial

haemorrhoidal plexus

• 5-Day, Painful, Self curing lesion

• Termed as Perianal Haematoma

• Within 48 hours: Evacuate under LA

EXTERNAL HAEMORRHOIDS

FISSURE IN ANO

• A longitudinal split

in the anoderm

of distal anal canal

• Not beyond Dentate line

Aetiology of Anal Fissure

• Strained evacuation of hard stool

• Anal Hypertonicity

• Vascular insufficiency

Clinical Features of Anal Fissure

• Severe anal pain on defecation

• Bright red bleeding

• Sentinel tag

• Discharge, itching

Ectopic site suggests a more sinister cause!!!

• Crohn’s Disease• TB• HIV• Syphilis

• Chlamydia• Chancroid• Lymphogranuloma Venereum• HSV• Cytomegalovirus• Kaposi’s Sarcoma• B cell Lymphoma• Squamous cell carcinoma

Management of Anal Fissure

• Conservative MX:

Stool bulking agents

Stool Softeners

• Local Anaesthetic cream

• 0.2 % Glyceryl Trinitrate

• 2% Diltiazem cream

Operative measures for Anal Fissure

• Lateral Anal Sphincterotomy

• Anal Advancement Flap

FISTULA IN ANO

It is a chronic abnormal

communication lined by granulation

tissue, which runs outwards from the

anorectal lumen to an external

opening on the skin of perineum or

buttock.

Presentation of Anal Fistula

• Intermittent perianal

purulent discharge

• Pain

• Previous episode

of anorectal sepsis

Park’s Classification

“Based on the centrality of intersphincteric anal

gland sepsis, which results in a primary track

whose relation to the External sphincter”

• Intersphincteric

• Trans-sphincteric

• Supra sphincteric

• Extra sphincteric

Goodsall’s Rule

Anterior: Drain straight

Posterior: Drain curved to anorectal midline

Surgical Management

• Fistulotomy

• LIFT Procedure

• Fistula Plug

• Advancement flap

• Setons

FIAT TRIAL

LIFT

• Identify the internal opening

• Incision at intersphincteric groove

• Dissection through intersphincteric plane to find intersphincteric

fistula tract

• Secure suture ligation of intersphincteric fistula tract

• Remove the fistula tract

• Curette fistula tract from external opening

• Suture closure of external sphincter muscle defect

• Closure of intersphincteric wound

Cutting Setons

• Latin: seta = bristle

• High Fistula eradication without functional

impairment

• The enclosed muscle is gradually severed

• Divided muscles do not spring apart

• Fistulous tract is replaced by fibrosis

Synthetic, bioabsorbable scaffold of polyglycolic acid and trimethylene carbonate copolymer

Practice Pearls Squatting is the only natural defecation posture

Proctoscopy is the guide to plan the treatment of piles

Currently Stapled Haemorrhoidopexy is the choice

Proctoscopy is abandoned in acute anal fissure

Pain is the differentiating feature between fissure & piles

Only complicated piles presents with pain

Beware of GI symptoms associated with piles

Hence never hesitate to go for colonoscopy

Majority of external piles don’t need any intervention

Ectopic Fissure smells danger

Rule out Crohn’s Disease in recurrent anal fistula

MRI is essential to locate internal opening

LIFT & Fistula Plug procedures preserves continence

ADHARMENDRAPRESENTATION