Anatomy of Anal

Canal
Dr Gopalakrishna K H
Associate professor
Dept of general surgery
MIMS, Mandya
Anal canal may be affected by many conditions
that are not so rare, not necessarily serious
and endangering to life but on the contrary
very INCAPACITATING

Haemorrhoids

Anal fistula
Anal fissure

Perianal abscess
 Anal Canal

• Anal canal forms the lowest part of the gastroIntestI

nal tract
 Location & Extent of anal canal
• Situated below levator ani muscle
• It lies in the anal region/ triangle
• From – anorectal junction to anus
• Anorectal junction-
– 2-3 cm in front and little
below tip of coccyx
• Anus –
– Surface opening of canal
– Front & below tip of coccyx
 Direction & Dimensions
• Directed downwards &
backwards
• Length – 3.8- 4 cm
 Relations of anal canal

Anterior & posterior

Relations of anal canal in
males

Sagittal Sections of male & female

pelvis
Anterior & posterior
Relations of anal canal in
females
 Interior of Anal Canal
(Subdivisions)

Subdivided into 3 parts:

Upper part- 15mm

Middle part- 15 mm

Lower part – 8 mm
 Upper part
• 15 mm long
• Endodermal in origin- primitive anorectal
canal
• Lining – mucus membrane
• Epithelium – simple/ stratified columnar
• Colour - Plum red
• Special features –
– Anal columns
– Anal valves
– Pectinate / dentate line
– Anal papillae
 Special features of upper part
ANAL COLUMNS
• 6-10 vertical mucosal ridges
• Permanent mucosal folds
•Contain radicals of superior rectal
vein
ANAL VALVES
• Semilunar mucosal folds uniting
lower end of anal column
•Form – PECTINATE LINE
ANAL SINUS
• Depression above
anal valve
• Floor contains
 Importance of pectinate line
• Divides canal into 2 parts that are different:
– In development
– In arterial supply
– In venous drainage
– In lymphatic drainage
– In nerve supply
 Middle part/ Pecten
Length -15 mm
Ectodermal origin- proctodeum
Epithelium- stratified squamous
Bluish pink in appearance
– Due to presence of dense
venous plexus between
mucosa and muscle coat
No glands – sweat/ sebaceous
 Lower part
Length -8 mm
Ectodermal origin-
proctodeum
Epithelium- stratified squamous
keratinized (true skin)
Pigmented skin
Glands present – sweat/
sebaceous & hair
• Contrast between bluish pink
mucosa and black skin

• WHITE LINE OF HILTON

• At the level of lower end

of internal anal sphincter/
intersphincteric groove
 Musculature of Anal Canal

• Anal Sphincters

Circular layer &

• Conjoint Longitudnal layer
longitudnal coat

• What is the
Anorectal ring ?
 Anal Sphincters

External

Internal

Thickening of circular
muscle layer
 Anal Sphincters
Internal anal sphincter External anal sphincter
• Skeletal muscle
• Smooth muscle- Thickened
• Voluntary
circular muscle layer
• Surrounds whole length of
• Involuntary
canal
• Surrounds upper 3/4th of • 3 parts-
canal
• Ends at white line of Hilton – Deep
– Superficial
• Intersphincteric groove
between it and subcutaneous – Subcutaneous
part of external sphincter

Sphincters allow defecation & maintain continence

 External Anal
Sphincter

Encircles upper end of canal –

Has no bony attachment

Encircles middle of canal – attached

to perineal body & anococcygeal
ligament

Encircles lower end of canal –

Has no bony attachment

Single Intersphincteri
Functional & Anatomic c groove
entity
Anorectal ring

Damage of the ring

results in
Incontinence
Through inferior
hypogastric
plexus

Through inferior
rectal nerve
 Clinical & surgical anatomy

• Hemorrhoids
– Internal
– External
• Anal Fissure
• Anal Fistula
• Anal / Perianal
abscess
 Hemorrhoids
• Fold of mucous membrane and submucosa with
varicosed venous tributary

INTERNAL

EXTERNAL

caused by increased straining or intra-

abdominal pressure (e.g., due
to constipation, pregnancy or
extended periods of sitting).
P
a
t
i
e
 CAUSES
More common when intra-abdominal pressure is raised, e.g. in
obesity, constipation and pregnancy.

• Symptoms: bright-red, painless bleeding, mucus discharge

and prolapse

• Hemorrhoids cannot be palpated, best diagnosed by

proctoscopy.
 Internal Hemorrhoids

First
degree

Second
degree

• Tributaries of superior rectal vein, covered by mucosa

• Protrusion from anal columns in upper half of canal
• Commoner is certain specific locations
Third
• Sensitive only to stretch so may cause non specific aching pain/degree
painless
PRIMARY PILES
– Enlargement of 3 main radicles of superior rectal veins
in anal columns
– usually occur at 3(left lateral), 7 (right posterior) & 11 o
clock (right anterior) position
SECONDARY PILES- any other location
 External hemorrhoids

• Tributaries of inferior rectal vein

• At the anal margin
• Covered by skin
• Painful
• Not ligated, excision
 Anatomical basis of engorgement of anal
cushions
• Pressure over veins at sites where they pierce the muscular
coat, during muscle contraction
• Increased portal pressure is directly transmitted at
portosystemic communications due to absence of valves
• Loose connective tissue around veins forms a poor
support
• Excessive straining associated with chronic constipation
• Some may have congenital weakness in vein walls
 Treatment of hemorroids

Medical therapy Bleeding from 1st and 2nd degree hemorrhoids often
improve with the addition of dietary fibre,
stool softeners and other diet regulation.

Rubber band ligation Done for 1st,2nd and selected 3rd degree hemorrhoidsQ

infrared Done for 1st and 2nd degree hemorrhoids

Photocoagulation
Sclerotherapy • Done for 1st,2nd and selected 3rd degree hemorrhoidsQ
• Most commonly used sclerosant is 5% phenol in almond or
arachis oil.
Operative • 3rd and 4th degree hemorrhoidQ
hemorrhoidectomy • 2nd degree not cured by non-operative methodsQ
• Mixed (combine internal/external hemorrhoids)Q
• Fibrosed hemorrhoids
 RECTAL PROLAPSE
• Mucous membrane and submucosa of the rectum protrude
outside the anus for approximately 1–4 cm.

• It may be mucosal or full thickness (whole wall of the rectum is

included)
• Commences as a rectal intussusception

• In children, the prolapse is usually mucosal and should be treated

conservatively

• In the adult, the prolapse is often full thickness and is frequently

associated with incontinence

• Surgery is necessary for full-thickness rectal prolapse

 RECTAL PROLAPSE
Children :

• Mucosal prolapse often commences after an attack of diarrhea, or from loss of weight
and consequent
loss of fat in the ischiorectal fossae.
• It may also be associated with fibrocystic disease, neurological causes and
maldevelopment of the pelvis.

Adults:

• Often associated with third-degree hemorrhoids.

• In the female a torn perineum, and in the male straining from urethral obstruction,
predisposes to mucosal prolapse.
• In old age, both mucosal and full-thickness prolapse are associated with atony of the
sphincter mechanism.
 RECTAL PROLAPSE
Prolapsed mucous membrane is pink (prolapsed internal
hemorrhoids are plum colored, trifoliate and more pedunculated)

Diagnosis
• Before operative intervention, a careful history, physical
examination, and colonoscopy should be performed.
• Manometry should be done in cases associated with incontinence
RECTAL PROLAPSE
Treatment of Rectal Prolapse in Childhood

• Prolapse during childhood is best managed conservatively, the only exception is

persistence of prolapse despite effective treatment
of diarrhea, worm infestation and malabsorption. These cases are managed by
surgery.
 Anal Fissure

• Elongated ulcer in mucosa due to tearing of anal valves

• In people suffering from chronic constipation
• Extremely painful (lower part of canal)
• Mostly posterior midline, may occur in anterior midline
( superficial external sphincter does not encircle
anteriorly & posteriorly)
Etiology
• Trauma caused by the strained evacuation of a hard stool or from the repeated passage of
diarrhea.
• Anterior anal fissure: More common in women, arise following vaginal delivery.

Clinical features
• Acute fissure: Characterized by severe anal pain associated with defecation with passage
of fresh blood, normally noticed on the tissue after wiping.
• Chronic fissures: Characterized by a hypertrophied anal papilla + Sentinel tag + Deep
canoe shaped ulcer
• Mostly seen in young adults, men and women are affected equally.

Treatment
• Conservative initially, consisting of sitz bath (in a basin containing warm antiseptic
lotion), stool-bulking agents and softeners, nitrates and calcium channel blockers to relax
the anal sphincter and improve blood flow
• Surgery if above fails, consisting of lateral internal sphincterotomy or anal advancement
flapQ
Treatment of Anal Fissure

• Chemical sphincterotomy: Nitroglycerine (0.2%) or diltiazem (2%) for relaxation of

anal sphincter

• Lord’s procedure: Dilatation of sphincter under GA, not practiced due to high rate of
incontinence

• Notara’s lateral sphincterotomy: Surgical procedure of choice for anal fissure

• Anal advancement flap: An inverted house-shaped flap of perianal skin is carefully

mobilized on its blood supply and advanced without tension to cover the fissure, and then
sutured with interrupted absorbable sutures.
 Anal Abscess
• Due to fecal trauma to anal
mucosa
– Infection in submucosa
following
fissure
– Complication of fissure
– Infected anal mucosal
glands

• On the basis of location

– Submucosal abscess
– Subcutaneous
abscess
– Ischiorectal abscess
– Pelvirectal abscess
is a painful condition in which a collection of pus
develops near the anus.
This often appears as a painful boil-like swelling near
the anus. It may be red in color and warm to the
touch.
Anal abscesses located in deeper tissue are less
common and may be less visible.
Clinical Features
• Usually produces a painful, throbbing swelling in the anal region with swinging pyrexia
• Patients with infection in the larger fatty-filled ischiorectal space, in which tissue tension
is much lower, usually present later, with less well localized symptoms but more
constitutional upset and fever.
• Increased incidence of infection in ischiorectal fossa is due to poor blood supply.

Treatment
• Drainage of pus + Antibiotics
• Always look for a potential underlying problem
• For perianal and ischiorectal sepsis (with an incidence of 60% and 30% respectively),
drainage is through the perineal skin, usually through a cruciate incision over the most
fluctuant point, with excision of the skin edges to de-roof the abscess
 Anal Fistula
Usually results from anorectal abscess
(cryptoglandular abscess)
• Other causes: Crohn’s disease,
tuberculosis, lymphogranuloma venereum,
actinomycosis, rectal duplication, foreign
body and
Malignancy

• Types: High or Low (according to

whether internal opening is below or
above the anorectal ring)

An anal fistula is a small tunnel that develops

between the end of the bowel and the skin near
the anus
Clinical Presentation

• Non-specific anal fistulae are more common in men than

women.
• Most commonly affect patients in 3rd-5th decade
• Patients usually complain of intermittent purulent discharge
and pain (which increases until temporary relief occurs when the
pus discharges).

• There is a previous episode of acute anorectal sepsis that settled

(incompletely) spontaneously or with antibiotics, or which was
surgically drained.
 Key Points to Determine

• Site of the internal opening

• Site of the external opening
• Course of the primary track
• Presence of secondary extensions
• Presence of other conditions complicating the fistula

MRI is the ‘gold standard’ for fistula imaging

• Usually reserved for difficult recurrent cases
• Advantage of MRI: Its ability to demonstrate secondary extensions,
which may be missed at surgery and which are the cause of persistence.
Setons
• A seton is a ligature of silk, nylon, silastic or linen.
• Used for marking, draining, cutting or staging.
• A high fistula may be converted into a low fistula by setons.

Setons are useful in the management of

• Complex anorectal fistulas with risk of incontinence or poor healing

• Patients with Crohn’s disease
• Immunocompromised (HIV) and incontinent patients
• Patients with chronic diarrheal states
• Anterior fistula in women

Treatment
• Treatment options: Fistulotomy, fistulectomy, setons, advancement flaps and glues
• Laying open is the surest method of eradication, but sphincter division may result in
incontinence
THANK YOU