complete slides on benign anorectal disease part 1

1. BENIGN
ANORECTAL
DISEASE-1
Moderator: Dr. P. Arya
Presentor: Dr. Azhar

2. Anatomy
• Anorectum : It includes perianal skin, anal canal,
anal sphincter and distal rectum.
• The skin around the anus is supplied by the inferior
rectal (hemorroidal) nerve. The lymph vessels of
the skin drain into the medial group of the
superficial inguinal nodes.

4. Anal canal Anatomy:

8. Anal canal Anatomy:
• Length= 3.8 to 4.0 cm.

9. Anorectal Bundle or Ring:
• Demarcating Line B/W the Rectum & Anal
Canal.
• Can be felt Posteriorly- Thickened Ridge
• Formed by- Puborectalis, Deep Ext Sphincter,
Conjoined long Muscle & Internal Sphincter

10. Puborectalis Muscle:
• Maintain the angle b/w
rectum & anal canal
• Gives off fiber to the
longitudinal muscle layer.
• It passes around the
junction of the rectum and
anal canal.

11. 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.

12. Image of Anal Sphincter

13. • During valsalva maneuver the junction of
rectosigmoid descends down to 2-3 cm.
• The sympathetic innervation of the internal
sphincter is motor , while the parasympathetic
innervation is inhibitory. Injury to the pelvic
autonomic nerve during pelvic surgery may result
in bladder dysfunction.

14. Ischiorectal fossa
• Wedge shaped space on each side of the anal
canal,
• Contents: Pudendal nerve (S2, S3, S4 ) and
internal pudendal vessels.

15. Blood Supply of Anal Canal
• Superior Rectal
Artery:
Right & Left Branch
• Middle Rectal Artery
• Inferior Rectal Artery

17. 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

18. Examination of Anal Canal
• Relaxed Patient
• Informed Consent
• Private environment
• Good Light
• Position – Left Lateral Position/ Sims’s Position-
most commonly used.

19. Image for different position:
Knee elbow position
Lithotomy
Sim’s position

20. 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.

21. 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.

22. Proctoscope

23. Proctoscopy
• Position: Left lateral position
• Inspection of the distal rectum and anal canal
• Injection in Hemorrhoids
• Banding of Piles mass
• Biopsy of mass

24. Hemorrhoids
• Hemorrhoid occurs due to sliding down of anal
cushions (anal columns) which are aggregation of
blood vessels (arterioles , venules, arteriolar-
venular communication), smooth muscle and
elastic connective tissue in the submucosa.
• Anal cushion: left lateral , right posterior, and right
anterior cushions leads to hemorrhoids at 3, 7, 11
o’clock respectively.

25. Etiology
• Portal HTN & varicose veins.
• Infection of the anal lining.
• Diet and stool consistency (constipation).
• Anal hypertonia.
• Aging , Obesity & pregnancy (increased intra-
abdominal pressure).

26. Classification
• External hemorrhoids are dilated inferior
hemorrhoidal plexus located below the dentate line
and are covered by squamous epithelium.
• Thrombosed external hemorrhoids: Segmental
thrombus is confined to the anoderm and perianal
skin and doesn’t extend above the dentate line.

27. • External hemorrhoids usually recognized due to
painful acute thrombosis.
• Anal skin tags may be the end result of
resolved thrombosed external hemorrhoid &
may be due to inflammatory bowel disease.

28. Internal Hemorrhoids
• Due to dilatation of superior hemorrhoidal plexus,
reside above the dentate line and are covered by
transitional and columnar epithelium.
• Primary hemorrhoids: Located at 3, 7, 11 o’clock
positions.
• Secondary hemorrhoids: One which occurs
between the primary sites.

29. Internal Hemorrhoids
• First degree: Painless bleeding with
defecation.
• Second degree: Prolapse during defecation,
but returns back spontaneously.
• Third degree: Prolapsed during defecation,
requiring manual reduction.
• Fourth degree: Permanently prolapsed.

30. • Internal hemorrhoids are most common
cause of rectal bleed , can't be detected by
DRE so proctoscope is necessary.

33. Complications
• Strangulation & thrombosis.
• Ulceration .
• Gangrene .
• Portal pyaemia.
• Fibrosis .

34. Treatment

35. • Regulation of diet (increase fiber diet 25-35gm),
stool softner & avoidance of prolonged straining
at the time of defecation.
• 1st or 2nd degree piles not improving with
conservative management then injection
sclerotherapy (fibrosing agent) mubmucosal
may be advised.

36. • For bulky piles band ligation therapy can be
used.
• As with sclerotherapy 3 piles can be treated at
once & can be repeated after 8 weeks.
• Usually one hemorrhoid is ligated once and
after 2-4 weeks procedure can be repeated if
required.
• Patients with bleeding diathesis or portal HTN
are not good candidates for ligation therapy.

37. Indications of Surgery
• 2nd degree piles, not cured by conservative
management.
• 3rd & 4th degree hemorrhoids.
• Fibrosed hemorrhoids.
• Intero-external hemorrhoids.
• Doughtful diagnosis go for EUA.
• Bleeding leads to anemia.

38. Techniques of Surgery
• Stool softener should be given day before sx &
a pre-operative enema to empty the rectum.
• Under GA/Regional Anesthesia in Lithotomy or
prone jack knife position.
• Open and Closed Techniques.

39. Open Technique
• Milligan Morgan Operation:- ligation & excision
of the hemorrhoids and anal mucosa & skin are
left open to heal by secondary intension.

41. Closed (Ferguson) Technique

42. Post-Op Complication
• Urinary retention MC (30%).
• Fecal incontenance (2%).
• Delayed hemorrhage (1%).
• Stricture .

43. Other Techniques
• Application of Ultrasonic (harmonic scalpel) or
electrical energy (ligasure, bloomfield, CT). Post-
op pain is less here.
• Stapled hemorroidopexy:- excision of a
circumferential portion of the lower rectum & upper
anal canal mucosa and submucosa with a stapling
device. A purse string suture is placed 3-4 cm
above the dentate line.

44. Anal Fissures
• Linear tear usually found in midline , distal to
the dentate line.
• MC posterior(90%) > anterior > lateral.
• These lesions are easily seen by visual
inspection of the anal verge with gentle
spreading of the buttocks.
• Sentinel tag at the distal portion of the fissure
and a hypertrophied anal papilla proximal to
the fissure.

49. Etiology
• Passage of large & hard stool (constipation).
• Low fiber diet.
• Previous anal surgery.
• Trauma .
• Infection.
• Frequent stools (diarrhea).
• Anal sex.
• Can affect any age (M=F).

50. Presentation
• MC- Excruciating anal pain with defecation &
bleeding.
• Episodes of constipation.
• Digital & anoscopic examination may result in
severe pain & not necessary if fissures are
visualized.
• Passage of fresh blood.

51. Chronic Fissures
• Hypertrophied anal papilla internally & a sentinal
tag externally b/w which lies the slightly indurated
anal ulcer overlying the fibers of the internal
sphincter.
• Itching secondary to irritation from sentinal tag ,
discharge from the ulcer.

52. Treatment
• Most fissures are superficial & heal rapidly with
no specific treatment.
• Dietry changes with bulking agents to promote
soft stool, sitz bath may provide comfort &
adequate fluid intake(6-8 glasses).
• Topical ointments of nitrates (nitroglycerin) >
CCB (nifedipine or dilteziam).

53. • Injection of 20-25 units of Botulinum-A into
both edges of an anal ulcer & internal
sphincter (chemodenervation)

54. Operative procedure
• 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

55. 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

56. 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

57. Complications of LAS:
• Hemorrhage
• Hematoma
• Bruising
• Perianal Abscess
• Fistula
• Incontinence.

58. ANORECTAL ABSCESS
• Infected cavity filled with pus found near the
anus or rectum.
• Usually produces a painful, throbbing swelling
in the anal region
• Patient often has swinging pyrexia

59. • MCC of anorectal suppuration is nonspecific
cryptoglandular infection. Other causes include
Crohn’s disease and hidradenitis suppurativa.
• Abscess represents the acute manifestation
and the fistula the chronic sequela.
• Subdivided according to anatomical site into
perianal, ischiorectal, intersphincteric, and
supralevator

60. • A complex horseshoe abscess may result if the
infectious process spreads circumferentially
from one side to the other of the intersphincteric
space, supralevator space, or ischiorectal
fossa.`

64. • Acute sepsis in the region of the anus is
common
• Underlying conditionts include
–Fistula-in-ano (most common)
–Crohn’s disease
–Infected hematoma
–Foreign body/trauma
–Diabetes
–Immunosuppression
• Treatmentdrainage of pus + antibiotics

65. Fistula In Ano
• A fistula-in-ano, or anal fistula, is a chronic
abnormal communication, usually lined to some
degree by granulation tissue, which runs outwards
from the anorectal lumen (the internal opening) to
an external opening on the skin of the perineum or
buttock (or rarely, in women, to the vagina).

68. Praks classification

69. • 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

70. Etiology
• Primary
– Obstruction of anal gland which leads to stasis and infection
with absces and fistula formation (most common cause).
• Secondary
– Iatrogenic (hemorrhoideal surgery)
– Inflammatory bowel diseases (Crohn's disease more
common than colitis ulcerosa)
– Infections (viral, fungal or TB)
– Malignancy

72. Presentation
• Skin maceration, pus/serous fluid or feces
discharge.
• Itching.
• Depending on presence and severity of
infection: pain, swelling, tenderness, fever,
unpleasant odor.

73. Diagnosis
• Mainly clinical.
• Radiological:-
1. Fistulography
2. Ultrasound
3. MRI (IOC).

74. Differential diagnosis
• Pilonidal sinus disease
• Perianal abscess

75. Management
• Fistulotomy
• Fistulectomy
• Setons- Loose & Tight Setons
• Biological Agent- Fibrin Glue & porcine derived fistula plug.
• Advancement Flap- To preserve both anatomy & Function .
• VAAFT: Video Assisted Anal Fistula Treatment.
• LIFT: Ligation of Intersphincteric Fistula Tract.

76. Fistulotomy
• Laid open the track.
• Indication : Intersphincteric & Transsphincteric
Fistula.
• Steps:
1. - Position - Lithotomy
2. - Anesthesia - G/A.
3. -Identified the internal opening

77. Fistulotomy
4. Pass the probe through
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

78. Fistulotomy

79. FISTULECTOMY: Excision of
whole Fistulous tract

80. Setons: Bristle material
• Thread
• Wire
• Proline
• Infant feeding tube
• Ksharsutra: kshar- corrosive & Sutra- Thread

81. Loose Setons
Purpose:
- Eradicate the acute sepsis & Secondary
extension
- To simplify the fistula
- Allow fibrosis

82. 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. Biological Agent to fill the fistula.

84. Insertion of Fibrin Glue

85. 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

86. LIFT: Ligation of Intersphincteric
Fistula Tract
• A dissection in the intersphincteric plane to the
level of the fistula with double-suture ligation
and partial excision of the intersphincteric
portion of the tract will result in healing of
approximately 50% of fistulas.

87. Thank You
For
Guidance