By: Dr.

Allin Pradhan
• RECTUM
• Lower dilated part of the large
gut(devoid of taenia coli ,
sacculations , appendices
epiploicae and mysentry)

• Extent- rectosigmoid junction

to anorectal junction

• Begins as continuation of
sigmoid colon – in front of S3

• Passes downwards - sacro

coccygeal curve- about 2-3 cm
in front and below the tip of
the coccyx.
Measurements

12 cm long and 4 cm wide

Lower part - dilatation -

ampulla

Curvatures or flexures
Anteroposterior – sacral
curve and perineal curve
Lateral - upper, middle
and lower curves
Lateral curves
Upper curve – convex – right –at
the junction of 3rd and 4th sacral
vertebrae
Middle curve – most prominent -
convex –left –at the sacro –
coccygeal junction.
Lower curve – convex –right – at
the tip of the coccyx.

IMPORTANCES
Along the concavities of the curves
– horizontal rectal valves projects-
support the weight of the faeces.
Peritoneal relation
Upper 1/3rd-infront and
on sides

• Middle 1/3rd –in front

• Lower 1/3rd –devoid of

peritoneum
• Posterior surface –
entirely non peritoneal
Male-rectovesical pouch
Female-rectouterine pouch
Lateral- para rectal fossae
 Visceral relation
Anterior
• Male
– upper 2/3rd-rectovesical
pouch.7.5cm above the
anus. sigmoid colon
and small intestine
– Lower 1/3rd-base of
urinary bladder, seminal
vesicles, vas deferens
and prostate -recto
vesical fascia of
denonvillier – separate–
these structures from
rectum.
• Female
– upper 2/3rd–
rectouterine
pouch 5.5cm
above the anus
and 7.5 cm
above the
external orifice
of vagina.
– Lower 1/3rd-
posterior surface
of vagina
– Recto- vaginal
fascia- separate
posterior surface
of vagina from
rectal ampulla
 Posterior
In the middle line
• Lower 3 pieces of sacrum,
coccyx, anococcygeal raphe,
median sacral vessels, superior
rectal artery and fascia of
waldeyar(ano-rectal junction –
the coccyx )

On each side of the rectum

Piriformis, coccygeus, levator
ani
Sacral plexus and sympathetic
trunk
 Pelvic splanchnic nerves and
Lateral Sacral vessels
 Posterior

Laterally
Upper 1/3rd – para-rectal
fossae –sigmoid colon and S.I
Middle 1/3rd – pelvi –rectal
space and levator ani muscles.
Lower 1/3rd - ischio-rectal
fossae and their contents.
Interior of the rectum
Mucous fold
Longitudinal folds-temporary
Transverse folds(Houstonʼs valves)
 Houston’s valves
formed by reduplication of
mucous membrane containing
submucous tissue and circular
muscle of rectum.

1) First valve
close to recto-sigmoid
junction ,opposite S3 vertebra
12 to 14cm above the anus
arises from right or left side of
the gut
 Second valve –
 2.5 cm above the third valves,
along the concavity of the upper
lateral curve.

Third valve-
constant
arises from the anterior and right wall of the rectum,
along the concavity of the middle lateral curve.
Nelaton’s sphincter- sometimes valves encircles the
rectum
 opposite S5 about 5cm the anus .

Fourth valve
2.5 cm below the third valve ,arises from the left wall of
rectum along the concavity of lower lateral curve.
Third valve divides the interior of rectum into upper and
lower chambers .
Upper chamber – contain faeces without the reflex act of
defaecation
Lower chamber- defaecation starts spontaneously.

IMPORTANCE OF HOUSTON’S VALVES

Supports the weight of faeces
Prevent the passage of instrument from the anus
To avoid injury of the 3rd valve –cannula of rectal washing –
passed in left lateral position.
 Blood Supply
Superior rectal artery

Middle rectal
artery Superior rectal vein

Middle rectal
vein

Inferior rectal vein

Inferior rectal artery

Arterial supply
Superior artery –
continuation of inferior
mesenteric artery.
-principal artery of rectum
.
Middle rectal artery –
branch of internal iliac
artery
Inferior rectal artery-
branch of internal
pudendal artery.
Venous drainage
Superior rectal vein-
inferior mesenteric
vein-(portal system)
Middle rectal vein-
internal illiac
vein(systemic vein)
Inferior rectal vein-
internal pudendal
vein(systemic vein)
Importance of rectal veins
1. Rectal veins are important sites of
communications between portal and
systemic veins
The radicles of superior rectal veins-
devoid of valves- increased portal pressure
–veins – distended.
The trunk of superior rectal vein – pierces
– posterior wall of rectum- during prolong
straining at defecation – radicles of the
veins - distended
 Venous drainage

 Rectal veins are arranged –plexus.-

Annulus haemorrhoidalis Venous
plexus consist of internal and
external sets

 Internal VP - surrounds the

analcanal –above Hiltons line-bet –
mucous membrane n sphincter ani
internus muscles.
 it drains above into the superior
rectal vein.
 Communicates below freely with the
external plexus and thus with the
middle and inferior rectal veins.
 It is important site of
communication between portal and
systemic veins
.
External VP –
surrounds the anus – bet
– peri-anal skin n
subcutaneous part of
external sphincter
muscle.
 Anal veins are arranged
radially around the anal
margin. Excessive straining
during the defaecation may
rupture one of these veins,
forming a subcutaneous
perianal haematoma
known as external piles.
 Nerve supply
Sympathetic fibres –
derived from –superior
hypogastric plexus,(l1,l2)
stimulate the internal sphincter
and inhibit rest of the
musculature of rectum.

Parasympathetic
pelvic splanchnic nerves(S1,S2,S3)
secretomotor to the
glands ,stimulates peristalsis and
relax the sphincters.
Supports of rectum

Pubo-rectal sling of levator ani

Reflexion of pelvic fasica

Fascial sheet of waldeyer and

pair of lateral ligaments of
rectum.

Pelvi-rectal and ischio-rectal

fasia fat.
Applied Anatomy
• Colonoscopy
• Prolapse of rectum
• Cancer
 CLINICAL ANATOMY OF RECTUM
1. Digital Per Rectum (PR) Examination:
The finger enters anal canal before reaching lower end of
rectum.help in the palpation of following abnormalities.
a. Within the lumen, faecal impaction & foreign bodies.
b. In the rectal wall: rectal growths & strictures, & thrombosed
piles
c. Outside the rectal wall: distended bladder, lower ureteric
stones

2. Proctoscopy & Sigmoidoscopy: Proctoscopy shows internal piles &

growths in lower part of rectum. Sigmoidoscopy helps in
revealing the ulcers, growths & diverticula, & taking a rectal
biopsy.

3. Carcinoma of Rectum: Situated at the rectosigmoid junction

(constricting type) or in the ampulla (proliferating type).
Applied Anatomy
Rectal examination
(cont..)
 Anal Canal
 Terminal part of large
intestine
 L- 3.8cm
 Extent- anorectal junction –
anal orifice.
Interior of anal canal
• 3 parts by pectinate line
n Hilton’s line.
1. Upper mucous part-
15mm
2. Middle mucous
part/pecten-15mm
3. Lower cutaneous part-
8mm
 Hiltons line
Color contrast between bluish pink
area above and black skin below

Represented by the anal inter

sphincteric groove at the lower end
of the internal sphincter muscle

Importance of Hilton’s line

Lower end of the internal sphincter
HILTONS LINE
muscle
Anal fascia and the lunate fascia
extend up to this line.
 Upper mucous part
• Lined by simple columnar
• Shows 6-10 vertical folds(anal
columns)

• Lower ends-united by anal valves

• Above each anal valve-
depression (anal sinus).

• Anal glands- sinus receives the

duct of anal gland.

• Anal valves-position of the valve

–indicated-(pectinate line)-
Pectinate line – correspond with anal
valve.muco-cutaneous junction
Development
1)
 Upper-endodermal
 Lower-ectoderm (proctodeum)

2) Blood supply
 Upper- superior rectal artery and vein
 Lower-inferior rectal artery and vein

3)Lymphatic drainage
 Upper- internal iliac LN
 Lower- superficial inguinal LN

4) Nerve supply
 Upper- autonomic N
 Lower- somatic spinal N
 Middle mucous part
Lined by NKSSE

Between pectinate line and

Hilton’s line

Surrounded by internal rectal

venous plexus

Richly supplied by vessels n

somatic spinal nerves.
 Lower cutaneous part

• Lined by true skin

• At anus-dry and hairy skin

MUSCULATURE OF THE ANAL CANAL

ANAL SPHINCTERS
Internal anal
sphincter –
- involuntary in
nature.
- surrounds the
upper 3/4th i.e. 30
mm of the anal
canal extending
from the upper end
of the canal to the
white line of Hilton.
 MUSCULATURE OF THE ANAL CANAL
External anal sphincter
-voluntary control.
- made of a striated
muscle & is supplied by
the inferior rectal nerve
& the perineal branch
of the 4th sacral nerve .
- surround the whole
length of the anal canal
& has 3 parts,
subcutaneous,
superficial & deep
Subcutaneous part: lies
below the level of the
internal sphincter &
surrounds the lower part of
the anal canal.
Superficial part: arises of
the coccyx & the
anococcygeal ligament or
raphe. Fibres surround the
lower part of the internal
sphincter & are inserted into
the perineal body.
Deep part: surrounds the
upper part of the internal
sphincter & is fused with the
puborectalis.
 Nerve Supply
1. Above the pectinate line - supplied by the autonomic
nerves, both sympathetic (inferior hypogastric plexus; L1,
L2) & parasympathetic (pelvic splanchnic; S2, S3, S4).
These upper area is insensitive to modalities of cutaneous
sensation.(insensitive to pain)

2. Below the pectinate line, it is supplied by somatic (inferior

rectal; S2, S3, S4) nerves. These area possesses all
modalities of cutaneous sensation.(sensitive to pain)

3. Sphincters: Internal sphincter is caused to contract by

sympathetic nerves & is relaxed by parasympathetic
nerves. External sphincter is supplied by the inferior rectal
nerve & by the perineal branch of the S4.
 Applied anatomy

Anal fissure- damage

to the valve – painful
condition.
Anal fistula-fibrous
tract –
communacating with
2 surfaces- ano rectal
mucosa n skin.

Hemorrhoids
Internal
external
Internal haemorrhoids

Distended and varicose

vein above the pectinate
line.
Bright red blood.
These upper area is
insensitive to
modalities of cutaneous
sensation.
Splanchnic innervation
–insensitive to pain
External haemorrhoids
Distended and varicose
vein below the pectinate
line.
External haemorrhoids
are covered by skin and
may be extremely painful
due to thrombosis or
rupture of the small
peri-anal veins.
 These area possesses all
modalities of cutaneous
sensation.
Somatic innervation via
inferior rectal nerve.
Classification of haemorrhoids
In portal obstruction
distension of the superior
rectal vein passing
through the anal canal
can cause the internal
haemorrahage .sites 3
oclock ,7 o clock and 11
oclock position.
These are the 3 sites of
primary internal plies.