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 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
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 .

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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.

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 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

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 Superior rectal valve

Middle rectal valve

Inferior rectal valve

Three submucosal
folds ( the valves of
Houston )

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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.
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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
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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.
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 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.
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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
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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.

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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
 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

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 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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Definition

Etiology or risk factors

Types & Classification

Clinical picture & DDX

Diagnosis& treatment

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 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
 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
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Bleeding-fresh bright red

mucous discharge

prolapse

pruritus

Anal pain ?  complicated

SARA AL-GHANEM 33
1.Bleeding
2.Strangulation
3.Thrombosis
4.Ulceration
5.Gangrene
6.Fibrosis
7.Suppuration
8.Pylephlebitis 34
 Physical visualize
Clinical Examination with
history
( PR ) anoscope.

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Medical Therapy

minimally invasive
techniques

SURGICAL
THERAPY

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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
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 Rubber band ligation Cryosurgery

Bipolar, infrared, and laser

Laser hemorrhoidectomy
coagulation

Doppler-guided
Sclerotherapy hemorrhoidal artery
ligation
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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.
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Sitz bath
Analgesics
Antibiotics
Laxative
Dressing
P/R after 3 weeks
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Early Late
Secondary
Pain
hemorrhage

Acute
retention of Anal fissure
urine

Reactionary Anal
hemorrhage stricture

Incontinence

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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

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SARA AL-GHANEM 43