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Done BY : Sara Al-Ghanem | 208009915
Supervised BY: Dr. M. Yasser


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To understand surgical anatomy of anus and rectum in relation
to surgical disease and treatment
To understand the pathol...

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A 60 year old man known to have hemorrhoids
complains of anal itching & discomfort , particularly
toward the end of the d...

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Anorectal diseases

  1. 1. Done BY : Sara Al-Ghanem | 208009915 Supervised BY: Dr. M. Yasser 1
  2. 2. To understand surgical anatomy of anus and rectum in relation to surgical disease and treatment To understand the pathology, CF, investigations, D/Ds and treatment To appreciate that ano-rectal disease is common and conservative treatment may be appropriate before surgery To understand that too aggressive or inappropriate surgery may be dangerous Benign diseases overview: Anal Fissure, Haemorrhoid, Pilonidal Sinus Anorectal suppurations: Absesses & Fistulas. Rectal prolapse Per Rectal Examination 2
  3. 3. A 60 year old man known to have hemorrhoids complains of anal itching & discomfort , particularly toward the end of the day . He has mild perianal pain when sitting down & finds him self sitting away to avoid the discomfort . 3
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  5. 5. 12-16 cm in length, starting at about the sacral promontory extending to dentate line of anal canal Anterior aspect of the upper 4- 6 cm is intraperitoneal with serosal surface. Lower (majority of) rectum lies within extraperitoneal pelvis, with no serosa. 5
  6. 6.  No taenia coli. Taeniae coli spread out at rectosigmoid junction to form a continuous, external longitudinal muscle layer  No Sacculations.  No appendices apiploicae  transverse folds 6
  7. 7. Superior rectal valve Middle rectal valve Inferior rectal valve Three submucosal folds ( the valves of Houston ) 7
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  9. 9. The superior rectal the terminal branch of the inferior artery mesenteric artery (superior hemorrhoidal artery) The middle rectal artery The internal Iliac artery (middle hemorrhoidal artery) from the internal pudendal artery, The inferior rectal artery which is a branch of the internal (inferior hemorrhoidal artery) iliac artery. 9
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  11. 11. The superior into the portal system via the inferior rectal vein mesenteric The middle into the internal iliac vein rectal vein The inferior into the internal pudendal vein, and rectal vein subsequently into the internal iliac 11
  12. 12. I- inferior mesenteric nodes Lymph from the upper and middle rectum flows in channels that parallel the arterial supply and is filtered by the inferior mesenteric nodes. II- the internal iliac lymph nodes Lymph from the distal rectum flows into channels adjacent to the middle and inferior rectal arteries. These channels drain to iliac nodes. 12
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  16. 16.  It is the terminal part of the large intestine.  It lies below the pelvic diaphragm level, in the ANAL TRIANGLE OF PERINEUM, between the ischiorectal fossae.  The anatomical anal canal extends from the perineal skin to the linea dentata.  The surgical anal canal measures 4 to 5cm in length and It begins at the anorectal junction ( anorectal ring ) and terminates at the anal verge.  The anorectal ring This is the circular upper border of the puborectal muscle which is digitally palpable upon rectal ex. It lies approximately 1-1.5 cm above the linea dentata. 16
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  18. 18. The dentate or pectinate line: marks the transition point between columnar rectal mucosa and squamous anoderm. The anal transition zone: The 1 to 2 cm of mucosa just proximal to the dentate line shares histologic characteristics of columnar, cuboidal, and squamous epithelium. The columns of Morgagni: The dentate line is surrounded by longitudinal mucosal folds, known as the columns of Morgagni, into which the anal crypts empty. These crypts are the source of cryptoglandular abscesses 18
  19. 19. Canal includes dentate line, anal glands, internal and external sphincter muscles, and hemorrhoidal vessels . The anal canal is lined by anoderm, a specialized epithelium that is devoid of hair follicles, sebaceous glands, or sweat glands but has a rich nerve supply. The junction between the anoderm and perianal skin is the anal verge. 19
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  21. 21. The anal sphincter is comprised of three layers: Internal sphincter: continuance of the circular smooth muscle of the rectum, involuntary and contracted during rest, relaxes at defecation. Intersphincteric space. Small anal glands are located between the internal and external sphincters and communicate with the anal crypts via anal ducts. External sphincter: voluntary striated muscle, divided in three layers that function as one unit. These three layers are continuous cranially with the puborectal muscle and levator ani. 21
  22. 22. Above The dentate line Below The dentate line Arterial blood supply Superior rectal artery Middle rectal artery inferior rectal artery Venous drainage Superior rectal vein middle & inferior rectal (Portal) veins (systemic ) Lymphatic drainage upper part of anal canal: Lower part of anal canal  Internal iliac nodes into Superficial inguinal nodes. Innervations Autonomic Somatic 22
  23. 23.  Internal & external venous plexus.  Internal or hemorroideal venous plexus lies in submucosa,  external lies outside the muscle coat of canal. Both communicates with each other so it is a site of portocaval anastomoses. Superior rectal (Portal) anastomoses freely with middle & inferior rectal veins (systemic ) •23
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  26. 26. Definition Etiology or risk factors Types & Classification Clinical picture & DDX Diagnosis& treatment 26
  27. 27.  Hemorrhoids basically means "blood flow" [Greek 'haima' meaning "blood" + 'rhoia' meaning "flow"].  Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement. 27
  28. 28.  Hemorrhoids: Hemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smooth muscle fiber. They are thought to play a role in maintaining continence.  They are located in the left lateral , right anterior and right posterior.  This normal tissue protects the sphincter during defecation and permits complete closure of the anus during rest.  Risk factors: Constipation, pregnancy, increased pelvic pressure (ascites,tumors), portal hypertension 28
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  33. 33. Bleeding-fresh bright red mucous discharge prolapse pruritus Anal pain ?  complicated SARA AL-GHANEM 33
  34. 34. 1.Bleeding 2.Strangulation 3.Thrombosis 4.Ulceration 5.Gangrene 6.Fibrosis 7.Suppuration 8.Pylephlebitis 34
  35. 35. Physical visualize Clinical Examination with history ( PR ) anoscope. 35
  36. 36. Medical Therapy minimally invasive techniques SURGICAL THERAPY 36
  37. 37. Bleeding from first- and second-degree hemorrhoids often improves with the addition of : dietary fiber  stool softeners Sitz bath  increased fluid intake avoidance of straining. Associated pruritus may often improve with improved hygiene 37
  38. 38. Rubber band ligation Cryosurgery Bipolar, infrared, and laser Laser hemorrhoidectomy coagulation Doppler-guided Sclerotherapy hemorrhoidal artery ligation 38
  39. 39. Failure of medical and nonoperative therapy Symptomatic third-degree, fourth-degree mixed internal and external hemorrhoids Fibrosed hemorrhoids External hemorrhoids Symptomatic hemorrhoids in the presence of a concomitant anorectal condition that requires surgery Patient preference after discussion of the treatment options with the referring physician and surgeon. 39
  40. 40. Sitz bath Analgesics Antibiotics Laxative Dressing P/R after 3 weeks 40
  41. 41. Early Late Secondary Pain hemorrhage Acute retention of Anal fissure urine Reactionary Anal hemorrhage stricture Incontinence 41
  42. 42. Anorectal diseases lecture ,Dr.M.Yasser Daoud Anatomy of rectum & anus , Dr. MOHD. IMTIYAZ Netter’s surgical anatomy review Schwartzs.Principles.of.Surgery.9Ed NMS Surgery First Aid Surgery Uptodate 42
  43. 43. SARA AL-GHANEM 43

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