A crisp & advanced update on Haemorrhoids, Anal Fissure & Fistula in Ano. Very useful for young aspirants. Authentic. Cohesive..

1. COMMON ANAL
PROBLEMS
DR.K.R.DHARMENDRA, MS.,DNB.,
GENERAL & LAPAROSCOPIC SURGEON,
AL HAYAT INTERNATIONAL HOSPITAL, MUSCAT.

2. OUTLINE
• RELEVANT SURGICAL ANATOMY
• HAEMORRHOIDS
• FISSURE IN ANO
• FISTULA IN ANO

3. SURGICAL ANATOMY OF
ANAL CANAL
• THE ANORECTAL RING
• PUBORECTALIS MUSCLE
• EXTERNAL ANAL SPHINCTER
• THE INTERNAL ANAL SPHINCTER
• DENTATE LINE
• ANAL CUSHIONS

4. 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

5. PUBORECTALIS MUSCLE
• Funnel shaped muscle
• Maintains angle between anal canal &
rectum
• Important for continence mechanism
• Innervated by Sacral somatic nerves

7. West becomes East !!!

8. EXTERNAL ANAL SPHINCTER
• Single, somatic, voluntary muscle
• Divided by lateral extensions from
longitudinal muscle into 3 portions
• Deep
• Superficial
• Subcutaneous
• Innervated by Pudental Nerve

9. 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

10. 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.

11. 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

12. 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

14. HAEMORRHOIDS
• Greek:
haima = blood
Rhoos = flowing
• Latin: pila = a ball
• Definition:
Symptomatic
anal cushions

15. Piles characteristically lie in 3, 7& 11 o’ clock
positions
These are the locations of the terminal branches of
superior rectal artery

16. 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.

17. SYMPTOMS OF HAEMORRHOIDS
• Bright –red , painless bleeding
• Mucus discharge
• Prolapsed mass
• Pain only when prolapsed

18. BEWARE OF GI SYMPTOMS!!
• Change of bowel habits
• Mucus discharge
• Tenesmus
• Back pain
• Anorexia/ Weight loss
• Abdominal pain

19. DEGREES OF HAEMORRHOIDS

20. MX OF HAEMORRHOIDS
• FIRST DEGREE: Conservative[Medical]
• SECOND DEGREE: BARRON’S BANDING
• 3RD & 4TH DEGREE: OPEN
HAEMORRHOIDECTOMY
OR
STAPLED HAEMORRHOIDECTOMY

21. BARRON’S BANDING

22. STAPLED
HAEMORRHOIDECTOMY
• Introduced by Longo in 1998
• Utilises a purpose designed stapling
gun[PPH]
• Excises a strip of mucosa & submucosa
circumferentially
• Above Dentate Line

23. STAPLED
HAEMORRHOIDECTOMY

24. EXTERNAL HAEMORRHOIDS
• Arising from superficial
haemorrhoidal plexus
• 5-Day, Painful, Self curing lesion
• Termed as Perianal Haematoma
• Within 48 hours: Evacuate under LA

25. EXTERNAL HAEMORRHOIDS

28. FISSURE IN ANO
• A longitudinal split
in the anoderm
of distal anal canal
• Not beyond Dentate line

29. Aetiology of Anal Fissure
• Strained evacuation of hard stool
• Anal Hypertonicity
• Vascular insufficiency

32. Clinical Features of Anal Fissure
• Severe anal pain on defecation
• Bright red bleeding
• Sentinel tag
• Discharge, itching

33. 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

34. Management of Anal Fissure
• Conservative MX:
Stool bulking agents
Stool Softeners
• Local Anaesthetic cream
• 0.2 % Glyceryl Trinitrate
• 2% Diltiazem cream

35. Operative measures for Anal
Fissure
• Lateral Anal Sphincterotomy
• Anal Advancement Flap

36. 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.

37. Presentation of Anal Fistula
• Intermittent perianal
purulent discharge
• Pain
• Previous episode
of anorectal sepsis

40. 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

42. Goodsall’s Rule
Anterior: Drain straight
Posterior: Drain curved to anorectal midline

43. Surgical Management
• Fistulotomy
• LIFT Procedure
• Fistula Plug
• Advancement flap
• Setons

44. FIAT TRIAL

45. 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

47. 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

48. Synthetic, bioabsorbable scaffold of polyglycolic
acid and trimethylene carbonate copolymer

50. 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

52. A
DHARMENDRA
PRESENTATION