4. Anal Canal
Length= 3.8 to 4.0 cm
Zona Columnaris: Upper ½- lined by Simple columnar
Zona Hemorrhagica: Upper part of lower half ( above the
Hilton’s white line) – Stratified squamous non-keratinizing
epithelium
Zona Cutanea: Lower part of lower half( below the
Hilton’s white line)- Stratified squamous keratinizing
epithelium
5.
6. Anorectal Bundle or Ring:
Demarcating Line B/W the
Rectum & Anal Canal.
Can be felt Posteriorly-
Thickened Ridge
Formed by- Puborectalis, Deep
Ext Sphicter,Conjoined long
Muscle & Internal Sphincter
7. Puborectalis Muscle:
Maintain the angle b/w
rectum & anal canal
Gives off fiber to the
longitudinal muscle layer.
Position, Length as well as
angle of the anorectal Junction
- integrity & strength of the
Puborectalis muscle sling.
8. Development of Anal Canal:
Fusion of Post-allantoic gut ( upper) with the
Proctodeum( lower part)
Pectinate or Dentate line is the junction of these two.
Anal valves of Ball - Remnants of the proctodeal
membrane
Column of Morgagni- Mucosa at dentate line folded in
longitudinal column.
10. Image of Anal Sphincter:
Deep External
Sphincter.
Sub cutaneous
External Sphincter
Superficial External
Sphincter
Circular
muscles of
Rectum
Longitudinal
muscle of
Rectum
Internal anal S
Conjoined
longitudinal
muscle
11. External & Internal Sphincter:
External Sphincter Internal Sphincter
Muscle Single muscle k/as Goligher
Muscle
Continue of the Circular muscular
coat of the rectum
Color Red Pearly white
Nerve Pudendal Nerve Autonomic nervous system-
Intrinsic non-adrenergic & non-
cholinergic fiber
Types of
Muscle
Somatic Voluntary Muscle Non-striated Involuntary Muscle
Parts/fts Deep, Superficial and
Subcutaneous portion
Always lie in the tonic state of
contraction
12. Blood Supply of Anal Canal
Superior Rectal Artery Right & Left Branch
Middle Rectal Artery
Inferior Rectal Artery
Superior R.A
Middle R.A
Inferior. R.A
13. Venous Drainage:
Upper Half- Superior Rectal Vein IMV Porto
mesenteric venous system
- Middle rectal vein Internal Iliac Vein
Lower Half- Inferior rectal vein & Subcutaneous peri -
anal plexus of veins Internal Iliac Vein
Lymphatic Drainage:
Upper Half- Post Rectal LN Para aortic nodes
Lower Half- Superficial Deep Inguinal LN
14. Venous system of Anal Canal:
SUPERIOR RECTAL
VEIN
MIDDLE RECTAL
VEIN
INFERIOR
RECTAL VEIN
15. Anal Canal
Above the dentate line Below the dentate line
Development Post-allantoic gut Proctodeum
Epithelium Cuboidal/Columnar Squamous without sweat & hair
gland
Name Surgical anal canal Anatomical anal canal
Color Pink Skin Colour
Nerve Parasympathetic: painless Spinal nerves: very painful
Venous
Drainage
Portal System Systemic-Ext iliac vein
Lymphatic
Drainage
Para-aortic Superficial & Deep inguinal LN
16. Examination of Anal Canal:
Relaxed Patient
Informed Consent
Private environment
Good Light
Position – Left Lateral Position/ Sims’s Position- most
commonly used.
17. Image for different position:
Lithotomy
Sim’s PositionSim’s position
Knee elbow position
18. P/R Examination:Inspection
Skin Lesion- Psoriasis
-Lichen planus
- Warts
-Candidiasis&Herpes simplex
Whether anus is closed
or patulous
Position of the anus/perineum
Evidence of piles/
sentinel tag
( Anal fissure or SCC) Psoriasis
19. P/R:Gloves,jelly etc………
Sling of puborectalis- Posteriorly at the apex
Posterior surface of the prostate gland with median
sulcus( Male) & Uterine cervix( in female)-Anteriorly.
Intrarectal, Intraanal or extraluminal mass.
Sphincter length
Resting tone
Voluntary squeeze
Examining finger – Mucus, Blood, Pus
Stool Color.
21. Proctoscopy:
Position: Left lateral position
Inspection of the distal rectum and anal canal
Injection in Hemorrhoids
Banding of Piles mass
Biopsy of mass
22. Sigmoidoscopy:
Mainly used for Rectal
examination
But Also recommended
in Fissure &
Hemorrhoids
Cos Colitis & Rectal
Carcinoma is frequently
A/W Fissure &
Hemorrhoids.
23. Physiology of Anal canal:
Cerebral
Autonomic nervous system
Gastrointestinal system( Especially Rectum)
Pelvic floor
Anal sphincter mechanism
24. Physiology
Structural Integrity of the sphincter- Endoluminal USG
Neuromuscular Function –(a) Assessment of conduction
velocity along with the Pudendal nerve or
-(b) Needle Electromyogram(EMG)-Slightly Painful.
Evacuation Proctography or Dynamic Proctography:
- In Rectal Sensorimotor dysfunction( Overflow of
rectal content)
25. Dynamic Proctography:
Radio-opaque pseudo-stool is inserted into the rectum
Rest, Squeeze and than bear down to evacuate the
rectal contents under real-time imaging.
Can be combined with EMG & Pressure studies
27. Anal Fissure:
Longitudinal tear in the anal canal
Site: Posterior midline (90%) and Anterior midline in
10% case especially in female.
28. Etiology & Predisposing factors of
Anal Fissure:
Age: Young adult & middle aged man
Gender : Male > Female
Posterior midline is the commonest site because-
-Maximum stretching on this site
- Less tissue here
-Minimal tissue perfusion
29. Etiology of Anal Fissure
Main cause-Trauma–Strained evacuation of Hard stool
or
Less commonly - Repeated passage of stool ( diarrhea)
Anterior anal fissure in 10% cases – Mostly in Women
that occurs following vaginal delivery
30. Predisposing Factors: FISSURE
Faces – Hard
Ischemia
Surgical procedure- Haemorrhoidectomy
Sphincter hypertonia
Underlying disease – Crohn’s , TB, L.V, Syphilis etc
Repeated Childbirth
Enthusiastic usage of ointments and abuse of luxatives.
31. C/F of Anal Fissure:
Severe anal pain during the defecation
Blood streak outside the stool
Bleeding P/R- Bright
Mucous Discharge
Constipation
Itching
33. D/D –Especially if ectopic site i.e
other than Posterior –midline:
Crohn’s Diseases Kaposi’s Sarcoma
Tuberculosis B-Cell Lymphoma
Lymphogranuloma Venereum CMV
Syphilis Chlamydia
HIV Chancroid
HSV SCC
34. Confirmation of Diagnosis:
Adequate clinical examination under G/A
Proctoscopy
Sigmoidoscopy
Take Biopsy
Do Culture
35. Treatment: Conservative & Surgical
Conservative treatment helpful in most of cases
Main objective to treat Constipation.
-Add the fiber to the diet
-Encourage water intake
-Laxative to make the stool soft
Application of local anesthetic- Lignocaine jelly
Antibiotics- Ofloxacine + Orinidazole
37. Conservative Treatment:
Drugs that release the Nitric oxide donor- Glyceryl
Trinitrate( GTN) 0.2 % & Diltiazam 2%.
GTN 0.2% - QID at Anal Margin
- S/E- Headache and Recurrence
Diltiazam 2%- BD at anal margin
- M/A- Produces NO – Relaxation of the internal
Sphincter- reduces the spasm, pain & Increase the vascular
perfusion to promotes healing
38. Conservative Treatment
Botulinum toxin injection
Site of Inj- Internal Sphincter
M/A- Inhibits presynaptic release of Ach from
cholinergic nerve endings- Paresis of Striated muscle
and release the spasm .
Other use- Achalasia cardia, Sphincter of Oddi
dysfunction, Frey Syndrome
39. Operative procedure for FIA.
Anal Dilatation
Posterior division of the exposed fibers of the internal
sphincter in the base of the fissure.
Lateral Anal Sphincterotomy of Notaras
Anal advancement Flap
40. Anal Dilatation: Lord’s Anal
Dilatation
Position- Lithotomy
Under G/A
Manual 4 to 8 finger sphincter dilatation
Useful in Young men with very high sphincter tone
Risk: Incontinence.
41. Posterior division of the exposed
fibers of the internal sphincter in
the base of the fissure
Indication – if fissure is associated with
INTERSPHINCTERIC FISTULA
Disadvantage- Prolonged healing
- Passive anal leakage because of
resulting ‘ Keyhole gutter deformity’.
42. Lateral Anal Sphincterotomy:
Position- Lithotomy
Anesthesia- Regional or G.A
Palpate the distal internal sphincter with the help of
bivalved speculum at the intersphincteric groove.
Give a small longitudinal incision in right or left lateral
position
43. Lateral Anal Sphincterotomy
Cut the Mucosa
Get the sub- mucosal & Intersphincteric planes
Allow the Exposure of Internal sphincter
Cut the Internal sphincter up to the apex of the fissure
Closed the wound with the absorbable suture
45. Anal Advancement Flap:
Very useful in women and those with Normal or Low
Resting Anal Pressures (persistent, chronic, non healing
fissure)
Excised the edge as well as base of the fissure.
Inverted house shaped flap of Perianal skin is mobilized
to cover the fissure.
Post-op instruction- Stool softeners, Bulking agent &
Topical sphincter relaxants.
46. Fistula-in-ano:
Chronic abnormal communication
Between the Internal opening (anorectal lumen) &
External opening on the skin of the perineum or
buttock
Lining is Granulation tissue.
Commonest cause – Non-specific, Idiopathic & Crypto
glandular & Inter-Sphincteric anal gland infection.
50. Types of Fistula in ano:Standard
Low type- Internal opening below the anorectal ring.
High Type-Internal opening above the anorectal ring.
Importance – Low type fistula- fistulotomy without
damage to sphincter
- High type fistula – Staged operation
51. Park’s Classification:
Based on relationship of fistulous tract to the anal
sphincters- 4 types.
Intersphincteric Fistula
In vast majority of Cases.
Trans sphincteric Fistula
Supra Sphincteric Fistula
Extra Sphincteric Fistula
54. Trans-sphincteric Fistula:
2nd Most common type
Incidence=40%
It’s track crosses both external & Internal sphincter
Passes through the Ischio-rectal fossa to reach the
skin of the buttock
56. Extra-sphincteric Fistula:
Run without specific
relation to the sphincter
Cause- Trauma or Pelvic
Disease.
Originates in the rectal
Wall
Tracks lateral to both
Sphincters
57. Clinical Assessment/Investigation:
A. Complete the General advise like
-Obstetric history
-Gastrointestinal history
-Surgical history
-Continence history
-Proctosigmoidoscopy examination
58. Clinical Assessment/Investigation
B.Important point about fistula
1. Site of the internal opening & External opening.
2. Course of the primary track
3. Presence of the secondary extension
4. Presence of other associated condition.
68. Management : Fistula in Ano:
Fistulotomy
Fistulectomy
Setons- Loose & Tight Setons
Biological Agent- Fibrin Glue
Advancement Flap- To preserve both anatomy & Function .
VAAFT: Video Assisted Anal Fistula Treatment.
69. Fistulotomy
Laid open the track( John of Arderne)
Indication : Intersphincteric & Transsphincteric
Fistula.
Steps:
1. - Position - Lithotomy
2. - Anesthesia - G/A.
3. -Identified the internal opening
70. Fistulotomy: Steps Continue
4. Pass the probe through
E.O to E.O to the I.O
5. The track is laid open over
the probe.
6. Curette the granulation
tissue and sent for HPE.
7.Wound edges are trimmed
E.O
I.O
Probe
Laid
open
75. Uses of Loose Setons:
1 .Crohn’s Diseases & Problematic fistulae- To prevent
the incontinence.
2.Prior steps of an “Advanced technique” like
Fistulectomy, Advanced flap & Cutting Seton
3. Staged fistulotomy
4. Therapeutic strategy to preserve the external
sphincter in trans-sphincteric fistula
76. Purpose to use of Loose Setons:
Purpose:
- Eradicate the acute sepsis & Secondary extension
- To simplify the fistula
- Allow fibrosis
77. Tight/Cutting Seton
Placed with intention to cut the enclosed muscles.
Also k/as “ Cheese Wiring through the ice”
Fistulous tract is replaced by a thin line of fibrosis.
Types- Elastic & Self cutting
- Non elastic & tightened
- Ksharsutra- most commonly used.
83. VAAFT:Video Assisted Anal Fistula
Treatment
Visualization of the F.tract with the Fistuloscope
Aim is to find the correct position of Internal Opening.
A stapler to close the Internal opening.
Fistuloscopy is done under irrigation & F.tract as well as all
granulation tissues are coagulated
Total closure of the Internal opening with inserting the
Cyanoacrylate
84. Home message:Fissure:
Post-midline is the commonest site for Fissure ( 90% )
Main cause is Constipation – hard stool i.e trauma
Pain during defecation is the commonest complaint.
Clinical examination is sufficient to diagnose it
GTN & Diltiazam 2% local application along with diet
modification have an excellent result as equivalent to LAS.
FISTULA IN ANO:
Persistent anal gland infection is the commonest cause of
Fistula in Ano
85. Home message:
Goodsall’s rule is very useful in determining the site of external &
internal opening as well as about the fistulous tract.
Intersphincteric type of fistula in Ano is the commonest type
( 45%)
MRI is the gold standard for fistula imaging in complicated fistula
Fistulotomy, Fistulectomy & Ksharsutra are common procedure to treat
it.
VAAFT is the recent advance in Fistula surgery