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Dr. Mehul Tandel
Objectives
• Rectum
– Introduction
– Course
– Measurements
– Curvatures
– Relations
– Structure
– Blood supply
– Nerve sup...
Rectum
• Rectum = ?
• Straight in quadrupeds
• Not straight in man
• But curved in A-P & Side
to side.
• Misnomer
Straight
Rectum
• Lower dilated part of large
gut lies in pelvis
• B/w Sigmoid colon and Anal
canal
• Devoid of taenia coli,
saccul...
Ano-rectal Junction
Rectum – Extent & Course
Begins as continuation of
sigmoid colon
Opposite S3
Ends at a point: 2-3cm in...
Rectum - Measurements
• Length = 12cm
• Breadth = 4cm
• Lower dilated part –
Ampulla
• When empty – Transverse
slit
Rectum - Curvatures
• 2 types :- Antero-posterior & Lateral
Antero-posterior Curves
Convex backward
Convex Forward
Rectum - Curvatures
Lateral Curves
Upper
Convex on right
Middle
Convex on Left
S3 – S4
Sacro-coccygeal
Junction
Lower
Conv...
Relations Peritoneal Relations
Non-
peritoneal
Posterior
Anterior
Upper 2/3rd -
peritoneal
Reflection
Differ in Male & Female
Recto-vesical pouch
In Males
7.5 cm above anus
On each Side
Para-rectal
Fossa
In Females
Recto-uterine pouch
of Douglas
Utero-vesical pouch
5.5 cm above anus
Relations Peritoneal Relations
On each Side
Para-rectal
Fossa
Relations General Relations - Male
Recto-vesical fascia
of Denonviller
In Front
Relations General Relations - Female
Recto-vaginal fascia
In Front
Relations General Relations - Posterior
Relations General Relations
On each Side
Para-rectal
Fossa
Pelvi-rectal
Space &
Levator ani
Ischio-rectal
Fossa
Interior of Rectum
• Mucosal folds
• 2 types
• Temporary
• Permanent
• Temporary:
• Longitudinal
• In Lower part
• Disappe...
Permanent Mucous folds
• Horizontal
• Semilunar
• Along Concavity of
lateral curves
Houston’s Valves
Reduplication of muco...
Permanent Mucous folds
• 1 & 3rd are constant
• 2nd & 4th are inconstant
Total 4 Valves
1st Valve
Recto-Sigmoid Jn
S3
Right / Left wall
12 – 14 cm above
Anus
3rd Valve
Most important &
constant
Anterior & Right wall
Along concavity of
middle lateral curve
Nelaton’s Sphincter
S5, ...
Upper Chamber
Pre-allantoic hind gut
May contain faeces
without reflex act of
defaecation
Lower Chamber
Endodermal Cloaca
...
2nd Valve
2.5cm above 3rd
Left wall
Along concavity of
upper lateral curve
4th Valve
2.5cm below 3rd
valve
Left wall
Along concavity of
lower lateral curve
• Support weight of faeces
• Prevent passage of
instrument
• Rectal washing should be
done in left lateral
position
• To p...
Arterial Supply
Five rectal arteries
Arterial Supply Superior rectal artery
Posterior View
Continuation of IMA
Principal artery of
rectum
Entire mucosa and
upp...
Arterial Supply Middle rectal artery
Posterior View
Branch of Anterior
division of Internal
Iliac Artery
Supply lower part
Arterial Supply Inferior rectal artery
Posterior View
Branch of Internal
Pudendal Artery
Supply peri-anal skin
& Sphincter...
Arterial Supply Median Sacral artery
Posterior View
Branch of Aorta
Supply posterior wall
of Ano-rectal
Junction
Venous Drainage
Arranged in plexus Annulus Haemorrhoidalis
2 sets
Internal rectal
venous plexus
External rectal
venous ple...
Venous Drainage
Superior Rectal Vein
Internal rectal
venous plexus
External rectal
venous plexus
Inferior Mesenteric Vein
...
Lymphatic Drainage
From Upper PartFrom Middle Part
From Lower Part
Nerve Supply
Sympathetic:
•Sup Hypogastric plexus (L1 & L2)
•Vasomotor
•Stimulate Sphincter & Inhibit musculature
Parasymp...
• Pelvic floor by Levator ani muscles
• Fascia of Waldeyer
• Lateral ligaments of the Rectum
• Rectovesical fascia of Deno...
Anal Canal
Downwards & Backwards
Anal Canal – Extent & Course
Begins at ano-rectal jn
At a point 2-3cm in front &
little below tip of...
Anal Canal – Pecularities
• Ant wall shorter
• Surrounded by Sphincter
Ani
• Tone of it close the anal
canal
• Opens only ...
Anal Canal- Measurements
• Length = 3.8cm
• Breadth
• When empty – laterall
wall approximated
Antero-posterior slit
Relations
• Anteriorly: Perineal body
Males: membranous urethra
bulb of penis
Females: lower end of vagina
• Posteriorly: ...
Relations - Male
PosteriorAnterior
Relations - Female
Relations
On each Side
Interior of Anal Canal
Divided in to 3 parts
Pectinate Line
Hilton’s White Line
Upper area
Intermediate area / Pecten
Lowe...
Upper Muscular
part
• 15 mm
• Endodermal origin
• Lined by semitransparent
mucous membrane
– Simple columnar /
Stratified ...
Upper Muscular
part - Features
Anal Columns /
Columns of Morgagni
Permanent longitudinal
mucosal folds
Contains Radicals o...
Upper Muscular
part - Features
Anal Valves / Valves of Ball
Crescentic mucosal folds
Connect lower ends of
anal columns
Pe...
Importance of Pectinate Line
Divide canal in to Upper &
Lower Areas
Development
Arterial Supply
Pectinate Line / Dentate L...
Upper Muscular
part - Features
Anal Papillae
Epithelial processes
Remnant of anal
membrane
Upper Muscular
part - Features
Anal Sinuses
Recesses above valves
between anal columns
Foreign body
Upper Muscular
part - Features
Anal Glands
Open in floor of sinuses
Infection - Fistula
Intermediate area /
Area of Pectane
• 15 mm
• Ectodermal origin
• Anal column: Absent
• Bluish pink appearance
of mucosa
•...
Lower area / Anal Verge
• 8 mm
• Ectodermal origin
• True skin with
pigmentation
• Corrugation due to
corrugator cutis ani...
Intermediate area /
Area of Pectane
• Color contrast between
Bluish pink mucosa above
& black skin below
• Lies at lower e...
Musculature of Rectum & Anal Canal
Musculature of Rectum
Outer longitudinal
Anterior Thick Band
Posterior Thick Band
Musculature of Rectum
Longitudinal Muscle
Pubo-rectalis / Levator Ani
Conjoint Fibro-elastic
sheath
Internal Anal Sphincte...
Musculature of Rectum
Conjoint Fibro-elastic
sheath
Splits into
number of septa
Corrugator Cutis
Ani
Anal Intermuscular
Se...
Musculature of Rectum
Conjoint Fibro-elastic
sheath
Laterally
Medially
Recto-urethral
muscle of Roux
Recto-coccygeal
muscle
Musculature Anal Canal
• Anal Sphincters:
• Internal:
– Thickened lower
circular muscle of
rectum
– Involuntary
• External...
Sphincters
Subcutaneous
Internal
Superficial
Deep
External Anal Sphincter
Subcutaneous
Superficial
Deep
Inf Rectal nerve
Perineal Br of S4
Clinical Anatomy
• Digital Per Rectal Examination
• Proctoscopy/Sigmoidoscopy
• Prolapse of Rectum
• Neurological disturba...
DPRE
Incomplete/Mucosal
Complete/Procidentia
Internal hemorrhoids:
• Tributary of sup rectal
• Above white line
• Generally painless
External hemorrhoids:
• Tributary ...
11 o’clock
7 o’clock
3 o’clock
Anal Fissure
Rupture of
anal valves
Painful
Anal Fissure
Drainage of Perianal
abscess
Fistula in Ano
A fistula-in-ano is a hollow tract lined with granulation tissue
connecting a primary opening inside the an...
Rectum & anal canal
Rectum & anal canal
Rectum & anal canal
Rectum & anal canal
Rectum & anal canal
Rectum & anal canal
Rectum & anal canal
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Rectum & anal canal

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Detailed anatomy of rectum and anal canal along with applied aspects.
very useful for students.

Published in: Health & Medicine
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Rectum & anal canal

  1. 1. Dr. Mehul Tandel
  2. 2. Objectives • Rectum – Introduction – Course – Measurements – Curvatures – Relations – Structure – Blood supply – Nerve supply – Applied
  3. 3. Rectum • Rectum = ? • Straight in quadrupeds • Not straight in man • But curved in A-P & Side to side. • Misnomer Straight
  4. 4. Rectum • Lower dilated part of large gut lies in pelvis • B/w Sigmoid colon and Anal canal • Devoid of taenia coli, sacculations, appendices epiploicae and mesentery
  5. 5. Ano-rectal Junction Rectum – Extent & Course Begins as continuation of sigmoid colon Opposite S3 Ends at a point: 2-3cm in front & little below tip of coccyx Lies at level of apex of prostate
  6. 6. Rectum - Measurements • Length = 12cm • Breadth = 4cm • Lower dilated part – Ampulla • When empty – Transverse slit
  7. 7. Rectum - Curvatures • 2 types :- Antero-posterior & Lateral Antero-posterior Curves Convex backward Convex Forward
  8. 8. Rectum - Curvatures Lateral Curves Upper Convex on right Middle Convex on Left S3 – S4 Sacro-coccygeal Junction Lower Convex on right Tip of Coccyx
  9. 9. Relations Peritoneal Relations Non- peritoneal Posterior Anterior Upper 2/3rd - peritoneal
  10. 10. Reflection Differ in Male & Female
  11. 11. Recto-vesical pouch In Males 7.5 cm above anus
  12. 12. On each Side Para-rectal Fossa
  13. 13. In Females Recto-uterine pouch of Douglas Utero-vesical pouch 5.5 cm above anus
  14. 14. Relations Peritoneal Relations On each Side Para-rectal Fossa
  15. 15. Relations General Relations - Male Recto-vesical fascia of Denonviller In Front
  16. 16. Relations General Relations - Female Recto-vaginal fascia In Front
  17. 17. Relations General Relations - Posterior
  18. 18. Relations General Relations On each Side Para-rectal Fossa Pelvi-rectal Space & Levator ani Ischio-rectal Fossa
  19. 19. Interior of Rectum • Mucosal folds • 2 types • Temporary • Permanent • Temporary: • Longitudinal • In Lower part • Disappear on distension
  20. 20. Permanent Mucous folds • Horizontal • Semilunar • Along Concavity of lateral curves Houston’s Valves Reduplication of mucous membrane containing submucosa & thickening of circular muscle
  21. 21. Permanent Mucous folds • 1 & 3rd are constant • 2nd & 4th are inconstant Total 4 Valves
  22. 22. 1st Valve Recto-Sigmoid Jn S3 Right / Left wall 12 – 14 cm above Anus
  23. 23. 3rd Valve Most important & constant Anterior & Right wall Along concavity of middle lateral curve Nelaton’s Sphincter S5, 5cm above Anus Divide rectum in to upper & lower part
  24. 24. Upper Chamber Pre-allantoic hind gut May contain faeces without reflex act of defaecation Lower Chamber Endodermal Cloaca Entry of faeces – Start defaecation
  25. 25. 2nd Valve 2.5cm above 3rd Left wall Along concavity of upper lateral curve
  26. 26. 4th Valve 2.5cm below 3rd valve Left wall Along concavity of lower lateral curve
  27. 27. • Support weight of faeces • Prevent passage of instrument • Rectal washing should be done in left lateral position • To prevent injury to 3rd valve Importance of Valves
  28. 28. Arterial Supply Five rectal arteries
  29. 29. Arterial Supply Superior rectal artery Posterior View Continuation of IMA Principal artery of rectum Entire mucosa and upper musculature Straight vessels arise from plexus – anastomose with inferior rectal artery
  30. 30. Arterial Supply Middle rectal artery Posterior View Branch of Anterior division of Internal Iliac Artery Supply lower part
  31. 31. Arterial Supply Inferior rectal artery Posterior View Branch of Internal Pudendal Artery Supply peri-anal skin & Sphincter ani
  32. 32. Arterial Supply Median Sacral artery Posterior View Branch of Aorta Supply posterior wall of Ano-rectal Junction
  33. 33. Venous Drainage Arranged in plexus Annulus Haemorrhoidalis 2 sets Internal rectal venous plexus External rectal venous plexus
  34. 34. Venous Drainage Superior Rectal Vein Internal rectal venous plexus External rectal venous plexus Inferior Mesenteric Vein Middle Rectal Vein Internal iliac Vein Inferior Rectal Vein Internal Pudendal Vein Six Radical Veins Porto-Caval Anastomosis
  35. 35. Lymphatic Drainage From Upper PartFrom Middle Part From Lower Part
  36. 36. Nerve Supply Sympathetic: •Sup Hypogastric plexus (L1 & L2) •Vasomotor •Stimulate Sphincter & Inhibit musculature Parasympathetic: •Pelvic splanchnic nerves (S2, S3 & S4) •Secreto-motor •Stimulate peristalsis & Inhibit sphincter
  37. 37. • Pelvic floor by Levator ani muscles • Fascia of Waldeyer • Lateral ligaments of the Rectum • Rectovesical fascia of Denonvillers • Pelvic peritoneum • Perineal body with its muscles • Pelvi-rectal & Ischio-rectal fat Support of Rectum
  38. 38. Anal Canal
  39. 39. Downwards & Backwards Anal Canal – Extent & Course Begins at ano-rectal jn At a point 2-3cm in front & little below tip of coccyx Opens at anal orifice – 4cm below & in front of tip of coccyx Terminal part of Large Intestine
  40. 40. Anal Canal – Pecularities • Ant wall shorter • Surrounded by Sphincter Ani • Tone of it close the anal canal • Opens only during defaecation
  41. 41. Anal Canal- Measurements • Length = 3.8cm • Breadth • When empty – laterall wall approximated Antero-posterior slit
  42. 42. Relations • Anteriorly: Perineal body Males: membranous urethra bulb of penis Females: lower end of vagina • Posteriorly: Anococcygeal ligament Tip of coccyx • Laterally: Ischiorectal fossae • All round: Sphincteric muscles, tone of which keeps the anal closed...
  43. 43. Relations - Male PosteriorAnterior
  44. 44. Relations - Female
  45. 45. Relations On each Side
  46. 46. Interior of Anal Canal Divided in to 3 parts Pectinate Line Hilton’s White Line Upper area Intermediate area / Pecten Lower area / Anal Verge
  47. 47. Upper Muscular part • 15 mm • Endodermal origin • Lined by semitransparent mucous membrane – Simple columnar / Stratified columnar or squamous • Plum red due to?
  48. 48. Upper Muscular part - Features Anal Columns / Columns of Morgagni Permanent longitudinal mucosal folds Contains Radicals of Sup rectal veins Reduplication of mucous membrane
  49. 49. Upper Muscular part - Features Anal Valves / Valves of Ball Crescentic mucosal folds Connect lower ends of anal columns Pectinate Line / Dentate Line Upper surface Lower surface Injury – Anal Fissure
  50. 50. Importance of Pectinate Line Divide canal in to Upper & Lower Areas Development Arterial Supply Pectinate Line / Dentate Line Venous Drainage Lymphatic Drainage Nerve Supply 85% diseases starts here
  51. 51. Upper Muscular part - Features Anal Papillae Epithelial processes Remnant of anal membrane
  52. 52. Upper Muscular part - Features Anal Sinuses Recesses above valves between anal columns Foreign body
  53. 53. Upper Muscular part - Features Anal Glands Open in floor of sinuses Infection - Fistula
  54. 54. Intermediate area / Area of Pectane • 15 mm • Ectodermal origin • Anal column: Absent • Bluish pink appearance of mucosa • St sq epithelium • No sweat / Sebaceous gland
  55. 55. Lower area / Anal Verge • 8 mm • Ectodermal origin • True skin with pigmentation • Corrugation due to corrugator cutis ani • Course hairs
  56. 56. Intermediate area / Area of Pectane • Color contrast between Bluish pink mucosa above & black skin below • Lies at lower end of internal anal sphincter White line of Hilton
  57. 57. Musculature of Rectum & Anal Canal
  58. 58. Musculature of Rectum Outer longitudinal Anterior Thick Band Posterior Thick Band
  59. 59. Musculature of Rectum Longitudinal Muscle Pubo-rectalis / Levator Ani Conjoint Fibro-elastic sheath Internal Anal Sphincter External Anal Sphincter
  60. 60. Musculature of Rectum Conjoint Fibro-elastic sheath Splits into number of septa Corrugator Cutis Ani Anal Intermuscular Septum
  61. 61. Musculature of Rectum Conjoint Fibro-elastic sheath Laterally Medially Recto-urethral muscle of Roux Recto-coccygeal muscle
  62. 62. Musculature Anal Canal • Anal Sphincters: • Internal: – Thickened lower circular muscle of rectum – Involuntary • External: – Striated muscles – Voluntary, – 3 parts: 1) Subcutaneous 2) Superficial 3) Deep
  63. 63. Sphincters Subcutaneous Internal Superficial Deep
  64. 64. External Anal Sphincter Subcutaneous Superficial Deep Inf Rectal nerve Perineal Br of S4
  65. 65. Clinical Anatomy • Digital Per Rectal Examination • Proctoscopy/Sigmoidoscopy • Prolapse of Rectum • Neurological disturbances of Rectum • Rectal incontinence • Carcinoma of Rectum • Piles/Haemorrhoids • Anal Fissure/Fissure in ano • Fistula in ano
  66. 66. DPRE
  67. 67. Incomplete/Mucosal Complete/Procidentia
  68. 68. Internal hemorrhoids: • Tributary of sup rectal • Above white line • Generally painless External hemorrhoids: • Tributary of inf rectal • Below white line • Generally painful Hemorrhoids / Piles
  69. 69. 11 o’clock 7 o’clock 3 o’clock
  70. 70. Anal Fissure Rupture of anal valves Painful
  71. 71. Anal Fissure
  72. 72. Drainage of Perianal abscess
  73. 73. Fistula in Ano A fistula-in-ano is a hollow tract lined with granulation tissue connecting a primary opening inside the anal canal to a secondary opening in the perianal skin. Secondary tracts may be multiple and from the same primary opening.

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