Prepared & presented by my friend, Shahirah Aliya

1. SHAHIRAH ALIYA BINTI ABD
KAMAL
63

2. INTRODUCTION
• The length of the anal canal is about 4 cm (range, 3-5 cm),
• 2/3rd of this being above the dentate line
• 1/3rd below the dentate line.

3. ANATOMY
• SURGICAL anal canal : Begins where the rectum passes through
pelvic diaphragm and ends at the anal verge
• ANATOMICAL anal canal : At the junction of the puborectalis
portion of the levator ani muscle and the external anal sphincter,
and extends distally to the anal verge.
• ANORECTAL RING :
-Junction between rectum and anal canal
-Upper border of puborectalis and external spinchter complex
-Formed by:
Deep external sphincter + Conjoined longitudinal muscle + internal
spinchter (highest part)

4. TERMS
• Anal verge : Junction between perianal skin and anal canal
• Dentate line/pectinate line : Junction btw proctodeum below and
post allantoic gut above
• Anal columns of Mortgagni
• Anal valves
• Anal sinuses and crypts
• Anal glands

6. • MUSCLES of anal canal:
-External sphincter
-Puborectalis muscle
-Internal sphincter
-Longitudinal Muscle
• EXTERNAL SPINCTER
-Subdivided into subcutaneous
superficial and deep
-Attached anteriorly to perineal
muscle and posteriorly to
coccyx
-voluntary muscle (skeletal
muscle) and innervated
by pudendal nerve

7. INTERNAL SPHINCTER
• Thickened distal continuation of circular muscle coat of the
rectum and ends 0.5cm below dentate line
• Always in tonic state of contraction
• Involuntary (smooth muscle) and 2.5cm long.
• F(x):Maintain the anorectal angle, form the anorectal bundle,
and maintain continence.
• Innervated by ANS and intrinsic NANC (non-adrenergic non-
cholinergic) fibres → release of NO→ sphincter relaxation

8. • Parts of Levator Ani muscle
• Innervated by sacral somatic
nerves
• F(x):
-Maintain position and length
of anal canal
-Angle of anorectal junction
-Continence mechanism
• Space btw external
sphincter and longitudinal
muscle
• Contains intersphicteric anal
glands
• Route of spread of pus
• Can be opened for sphincter
surgery
PUBORECTALIS
MUSCLE
INTERSPHICTERIC
PLANE

9. • Continuation of smooth muscle
of the outer muscle coat of
rectum
• Caudally it splits into multiple
septum:
-inferiorly:surround S.C portion of
external sphicter→skin
-medially:across the internal
sphincter→submucosal space
-laterally:external sphincter +
ischiorectal space→fascia of pelvic
side wall
F(x) Widens the
lumen
Flatten anal
cushion
Shorten anal
canal
Everts anal
margin
LONGITUDINAL MUSCLE

10. EPITHELIAL AND SUBEPITHELIAL
True anal skin
Pigmented + hair + sebaceous gland
Anal canal skin/Anoderm
Thin and shiny white squamous epithelium without appendages
Below valves(dentate line)
Transit to stratifiedsquamous epithelium
Above the anal valves
Red then Plum cuboidal epithelium
Rectum mucosa and anorectal ring
Pink columnar epithelium

11. • ANAL CUSHION:
-Uneven mucosal and submucosal folds above dentate line
-Painless , it has 3 common position
(Left Lateral , Right Anterior , and Right Posterior)
-Submucosa lies btw epithelial layer and internal
Sphincter
-Contain vascular , muscular and connective tissue

12. BLOOD SUPPLY
• Supplied by superior, middle and inferior rectal arteries
VENOUS DRAINAGE
• Upper ½ of anal canal :
1. Superior rectal veins  tributaries of the inferior
mesenteric vein Portomesenteric venous system
2. Middle rectal veins internal iliac veins
• Lower ½ of the anal canal:
Inferior rectal veins + Subcutaneous perianal plexus of veins
eventually join the internal iliac vein on each side

13. • Upper ½ of anal canal drains
↑ into postrectal lymph nodes
inferior mesenteric chain 
para aortic nodes
• Lower ½ of anal canal 
drains each side into
superficial inguinal group 
deep inguinal group of lymph
node
• Found in submucosa and
intersphincteric space
• Drain into anal sinuses at the
level of dentate line
• Their function is unknown;
secretes mucin which lubricates
the anal canal ease
defaecation
• Intersphicteric anal gland
potential source of anal sepsis
-acute:perianal sepsis,ischiorectal
sepsis,pelvic sepsis
-chronic:cryptoglandular anal
fistula
Lymphatic drainage Anal glandpara

14. EXAMINATION OF ANUS
• Inform the patient
• Ask for consent
• Call for attendant
• Proper exposure and position
-Left lateral (Sims position)
-prone Jack-Knife position
-Lithotomy position
• Per rectal examination:
 Inspection
 Digital examination
 Proctoscopy/sigmoidoscopy

16. Inspection
• Any skin lesions (e.g:psoriasis,lichen planus)
• Genital exm:warts,candidiasis
• Anal tags,sentinel piles,fistula in ano, pilonidal sinus, and carcinoma can
be diagnosed
Digital examination
• Lubricated index finger
• Palpate perianal region (e.g:induration,tenderness)
• Within the lumen :tone ,length
• In the wall
• Outside the wall ( anterior, right lateral , left lateral and posterior)
-Bimanual examination
-Abdominal examination
-Lymph nodes
• On withdrawal: stool colour,mucus,blood or pus

17. Proctoscopy
•Detail inspection can be done
• Perform minor procedure (e.g:treatment of hemorrhoid by
injection/band)
•Biopsy can be taken
Specific investigation
•Sigmoidoscopy
•Colonoscopy
•X-ray: Straight X-ray of the abdomen , Chest X-ray
•Barium enema X-ray
•CT scan and Ultrasonography

18. CONGENITAL ANOMALIES
EMBROLOGY
• Cloaca becomes two parts: 1) dorsal (rectum) 2) ventral
(urogenital)
• Cloaca is separated from surface ectoderm of the embryo by the
cloacal membrane
• Dorsal part (anal membrane) composed of outer layer of
ectoderm + inner layer of endoderm
• Resorption of this anal membrane by 8th week anal canal
• Anal canal is developed from fusion of postallantoic gut with
proctodeum.
• The junction of these is the dentate line or pectinate line. Anal
valves of Ball are remnants of proctodeal membrane .

19. Imperforated
Anus
• Atresia/Agenesis
•Divided into two main group – high and low
•Depends on termination of the rectum in
relation to pelvic floor
•Low defect:
•M=F : rectoperitoneal fistula
•M : Rectrobulbar fistula
•F : Rectovestibular fistula
•easy to correct; prone to constipation
•High defect:
•Fistula into bladder neck
•difficult to correct ; prone to faecal
incontinence
•Persistant cloaca:one opening in perineum

20. Management
• Investigation :clinical examination
Lateral prone radiography (after 24 hours)
• Treatment :
-First 24 hours : IV fluid correction and antibiotics
+ evaluate asst. abnormality
-Surgery:
 Anioplasty (low and perineal fistula)
 Early colostomy + Posterior Sagittal Anorectoplasty PSARP
+/- transabdominal mobilisation of left colon +
division of any relation with urinary tract (complex)
 PSARP + Vaginal and urinary reconstruction (cloaca)
 Anal dilatation programme

21. POST–ANAL DERMOID
• Soft cystic swelling occupying the space in front of the lower
part of the sacrum and coccyx (Hollow)
• Asymptomatic until adult life
• Difficulty to defecate due to its size
• Unlikely to be discovered unless a sinus communicating with
the exterior is present / develops as an inflammation
• Cyst easy to palpate per rectum

22. Dd(x)
• anterior sacral
meningiocele
(enlarges when the
child cries and is
associated with
paralysis of lower
limbs
+incontinence
• Pilonoidal sinus
• Anal fistula
Confirm ?
• Press over
sacrococcyngeal
region in rectum→
sebaceous discharge
• Contrast
media+radiography
→ bottle neck cyst
Treatment
• Excision
• Remove cocyx-if
large/child with
presacral dermoid

23. POST-ANAL DIMPLE
• Fovea coccygea is a dimple in the skin beneath the tip of the coccyx
• No consequences found
PILONIDAL SINUS
• Location:in the natal cleft overlying the coccyx
• One or more non-infected midline openings which communicate
with a fibrous track lined by granulation tissue and containing
hair lying loosely within the lumen
• ‘Jeep disease ‘
• Age 20-29 years
• Etiology:
-Congenital
-Acquired; Interdigital pilonidal sinus (hairdresser)

24. Buttock
friction+shearing
force
Broken hair drill
through the skin
Track/sinus
formation
Secondary track
spread laterally
Discharging
opening to skin
(lined granulation
tissues)
 Dark-haired
After puberty till 40 years
Intermittent pain,swelling
and discharge at the base of
the spine
H/o repeated abscess that
have burst
spontaneously/have been
incised AWAY from midline
PATHOGENESIS CLINICAL FEATURES
Infected hair
follicle +
buttock movt.
Sucked into
S.C layer
Midline track

26. MANAGEMENT
• If symptom is minor:
 Clean the tracks
 Remove all hair
 Regular shaving that area
 Strict hygiene
ACUTE EXACERBATION
(ABSCESS)
 Rest,bath,local antiseptic, broad
spectrum antibiotic
 Drained through small
longitudinal incision made over
abscess and off the midline +
curettage of granulation tissue
and hair
• Excision:
-Laying open +/- marsupilisation
-With/without 1⁰ closure
-Closure by other means:Z-plasty,
Karydakis procedure
• Bascom’s procedure involves:
1.Incision lateral to the midline to
gain access to the sinus cavity(
get rid of hair and granulation
tissue)
2.Excision and closure of the
midline
3. The lateral wound is left open
CONSERVATIVE
CHRONIC (SURGERY)

28. ANAL INCONTINENCE
ETIOLOGY
Congenital/childhood
• Anorectal anomalies
• Spina bifida
• Hirschsprung’s disease
• Behavioural
Acquired/adulthood
• Diabetes Mellitus
• CVA
• Parkinson’s disease
• Multiple sclerosis
• Spinal cord injury
• GI infection
• Irritable Bowel Syndrome
• Metabolic bowel syndrome
• IBD
• Anal trauma/abdominal
surgery/pelvic
• Pelvic malignancy
• Rectal prolapse
• Rectal evacuation disorder
• Anal surgery
• Obstetric event
General
• Ageing
• Dependance on nursing care
• Psychobehavioral factors
• Intellectual incapability
• Drugs:
• primary constipating and
laxative

29. Spincteric
cause
neuropathic
structural
Anal
surgery
trauma
Obstetric
damage

30. MANAGEMENT
CONSERVATIVE
-stool bulking/constipating agent
-nurse-led bowel retraining
-anal plugs
SURGICAL
• Operation to reunite divided
sphincter muscles
• Operation to reef the external
sphincter and puborectalis
muscle
• Operation to augment the anal
sphincter
-if the function cant be restored,we
can augment by transposition
(gluteus maximus and gracilis) /
artificial sphincter
Sacral nerve stimulation
PTNS

31. HEMORRHOID
Definition:
• It is a dilated plexus of haemorrhoidal veins in the anal cushion, in relation
to anal canal.
• CLASSIFICATION :-
• Primary/Idiopathic haemorrhoids-familial or genetic,upright position
• Secondary haemorrhoids – carcinoma of rectum, ascites,paraplegia,
pregnancy.
• Depending upon the location of haemorrhoids –internal, external,
interno-external
• LOCATION
(lithotomy
position)

32. Theories of development
• VENOUS OBSTRUCTION
-Portal hypertension and varicose veins
-Pregnancy,ascites,pelvic tumor
• INFECTION
-2⁰ to trauma during defecation→ weakening of venous wall
• DIET
-Fibre-deficient diet (western cuisine)
DEFECATION HABIT
-Straining
-Sitting for prolong periods on lavatory
• ANAL TONE
-hypertonia
• AGEING

33. CLINICAL FEATURES
• Bright red painless bleeding
-on wiping/Splash in pan
• Mucous discharge
• Prolapse
• Pain only on prolapse
GRADING
GRADES FEATURES SYMPTOMS
1 Never prolapse Bleeding per rectum
2 Prolapse on defecation
Spontaneous reduction
Something coming down and going
back
3 Prolapse on defecation require
manual reduction
Something coming down, bleeding,
mucus discharge, pruritis
4 Permanent prolapse Acute pain, throbbing discomfort

35. COMPLICATIONS OF HAEMORRHOIDS
• Chronic anemia
• Ulceration
• Thrombosis and strangulation
• Fibrosis
• Portal pyaemia
• Gangrene
INVESTIGATIONS
• Per rectal examination – thrombosed or fibrosed
• Proctoscopy or Sigmoidoscopy

36. MANAGEMENT
COMPLICATION
-Strangulation,thrombosis and
gangrene→ analgesic + bed rest
+frequent hot bath +compression
-Severe hemorrhage
→bleeding diathesis/on
anticoagulant
→Local compression (adrenaline
solution) +morphine inj. +blood
transfusion
TREATMENT
• Conservative
-medical
-Invasive therapy
*sclerosing inj.
*band ligation
*cryotherapy
*infrared photocoagulation
• Operative treatment
-hemorrhoidectomy

37. NON OPERATIVE
• Fibre supplementation
• Increased fluid intake
• Bulk purgative
• Suppositories
• Reading in toilet to be
discouraged (respond to call
and do not strain)
• Encourage to lose weight
INVASIVE THERAPY
• Injection of sclerosant –
 Subbmucosal injection of 5 ml of
5 % phenol in almond/arachis oil
 Using Gabriel syringe at apex of
pedicle
 reassessed after 8wks
Barron`s band application
-put a elastic band at the base of
pedicle
-ishemic→slough off + bleeding (after
10 days)

38. HEMORRHOIDECTOMY
Definition:
-Excision of the pile masses up to base.
• Indicated in Grade II and III
• It can be done by 3 methods :-
OPEN METHOD – Milligan Morgan ligature and excision
 CLOSED METHOD – Hill-Ferguson
STAPLER HAEMORRHOIDOPEXY – Non-excisional procedure
• Complications of haemorrhoidectomy
• Early = Pain, Acute retention of urine,
Reactionary haemorrhage
• Late = Secondary haemorrhage, Anal stricture, Anal fissure,
Incontinence

45. CLOSED OPERATION
• Same procedure like open but the difference is the defect will be
closed by continuous suture

47. STAPLED HEMORRHOIDEXTOMY

48. REFERENCE