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SURGERY ON THE ANAL CANAL

Principles & Practice

Dr.Shivananda Prabhu,

Professor of General Surgery,

KMC, Mangalore.

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Golden Rule

Save Continence at all cost

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Problems

Lack of Training

Bottom Case

Lack of Understanding of Pathology

of Procedure

Lack of Interest

Not one more Haemorrhoidectomy

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Pre-requisites

Before embarking on Anal surgeryunderstand

The parts

The pathology

The procedure

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Beware!!!

More sinister disease may underlie analproblems . eg. Ca Rectum, Crohns

Anal Disease may coexist

Evaluation may need E.U.A

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Anatomy

Note Arrangement of

sphincters Position of anal

glands

Layout of the

mucosa Vascular supply

Ischiorectal fossa

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Pathology

Piles

Fissure

Fistula

Abscess

Polyp

Mucosal Prolapse Pilonidal Sinus

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Haemorrhoids

Large section ofpopulation affected

Loss of support of

anorectal cushion

Is there varicosity ofveins?

Causes

Straining

Gravity

Internal Vs External pile

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Treatment

Conservative methods like banding,sclerotherapy etc are safe

Butare they effective enough?

Excision SurgeryFerguson Closed

Milligan Morgan Open

Do not damage the Internal Sphincter

Avoid blind ligation

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MIPH

Era of staplers Based on loss of anal cushion

support theory

Easier to learn

Advantages Less pain

Minor pile masses treated at thesame time

Less chance of anal stricture

Disadvantages ?Long term efficacy

Less effective when external pileis big

Expensive

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Fissure

Breach in the anal mucosa Acute

Chronic

Pathology

Orgin ill understood ?Trauma

Ischaemia leads topersistance

Spasm of the sphincter maynot be entirely due to pain

90 % occurs at 6 o clockposition

Off the midline fissure

Suspect

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Treatment

Trial of conservative treatment + Life stylemanagement

Lords Dilatation

Effective when done exactly right

Mostly underdilated

Fissurectomy no longer done

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Sphincterotomy

Better lateral

Internal sphincter is cut till dentate line

Dont do sphincterotomy if sphincter is already

lax

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Fistula

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Etiology

Cryptoglandular abscess

Can spread along many pathways

Delination may need Clinical examination ( Goodsalls rule)

Proctoscopy

USG

MRI

?Fistulogram

Probing mentioning to be condemned

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Procedure

Fistulotomy

Seton

Cutting Non Cutting

Endorectal advancement

?Colostomy Fibrin Glue

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Remember

Sphincter is the most at risk in surgery for

fistula

Even experts consider fistula as difficult

problem

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Perianal abscess

Usually infection from anal glands Submucous

Subcutaneous

Ischiorectal

Supralevator

Can be bilateral

C/f may be vague Treatment is I & D

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Postop problems after anal

surgery

Pain may be due to sphincter spasm

Bleeding Urinary retention

Incontinence Beware !!!

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Conclusion

Good anal surgery means improved

quality of life for large pool of patients

Popular surgeon

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Thank You