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General Surgery
Benign Disorders of the Anorectum (Pelvic Floor, Fissures, Hemorrhoids, and Fistulas)
Built from Maingot's Abdominal Operations
What’s inside
11 sections · 187 slides
Overview
- Scope of the topic
- Plan of the topic
Anatomy of the anorectum
The landmarks, muscles, nerves and vessels that every anorectal examination is read against
- The anorectum as a single unit
- Position and mobility of the rectum
- The puborectalis sling and the anorectal angle
- The anal canal and the two sphincters
- Autonomic nerve supply of the anorectum
- Somatic supply of the pelvic floor and external sphincter
- Course of the pudendal nerve
- Three anatomic points of reference
- Anoderm compared with perianal skin
- The dentate line and the limits of the anal canal
- Landmarks of the anorectum
- Muscle layers and glands of the anal canal
- Rectal columns, anal crypts and anal glands
- Sensation above and below the dentate line
- Arterial supply of the rectum and anal canal
- Venous drainage by two separate routes
- Vascular supply of the anus and rectum
Fecal incontinence
How continence is built, how it fails, and what can be measured and repaired
- Components of the normal continence mechanism
- Rectal capacitance and compliance
- Resting pressure and the internal sphincter
- The sampling reflex
- Voluntary control and pelvic floor tone
- Definition and impact of fecal incontinence
- Three mechanisms of fecal incontinence
- Mechanical incontinence
- Neurogenic incontinence
- Idiopathic incontinence
- Causes of fecal incontinence
- History and physical examination
- Anal manometry and normal values
- Rectal sensation and tolerable volume
- Pudendal nerve terminal motor latency
- Normal pudendal nerve conduction tracing
- Transrectal ultrasound of the anal sphincter
- Normal anal sphincter on transrectal ultrasound
- Anterior sphincter defect on transrectal ultrasound
- Interpreting a sphincter defect and the role of MRI
- Pathway for evaluating and managing anal incontinence
- Conservative treatment of fecal incontinence
- Biofeedback and sensory retraining
- Predicting benefit from biofeedback
- Anal sphincter reconstruction
- Exposing and mobilising the torn sphincter
- Overlapping and securing the sphincter repair
- Results of overlapping sphincter repair
- Sacral nerve stimulation
- Muscle transfer and the artificial bowel sphincter
- Stoma as a definitive option
Rectal prolapse and internal intussusception
The rectum telescoping into itself, and eventually turning inside out through the anus
- Mechanism of rectal prolapse
- The three contributing components
- Consequences of rectal prolapse
- Defecographic appearance of prolapse
- Internal intussusception of the rectum
- Mucosal prolapse compared with full-thickness prolapse
- Radial folds of mucosal prolapse
- Concentric rings of full-thickness rectal prolapse
- Symptoms of rectal prolapse
- Examination and endoscopic findings
- Defecography in rectal prolapse
- Triple-contrast and newer imaging of the pelvic floor
- Defecography grading of intussusception
- Using the grading system to plan treatment
- Four families of operation for rectal prolapse
- Rectopexy
- Low anterior resection for prolapse
- Laparoscopic resection with a stapled colorectal join
- Functional trade-offs after low anterior resection
- Laparoscopic and ventral mesh rectopexy
- Perineal proctectomy
- Perineal removal of the prolapsed rectum with levator repair
- Results and limits of perineal proctectomy
- Anal encirclement procedures
- Conservative treatment of internal intussusception
- Operation for internal intussusception
- Preoperative tests before surgery for intussusception
- Stapled transanal rectal resection
Pelvic floor outlet obstruction and solitary rectal ulcer
A normal muscle used the wrong way: straining against a door that will not open
- Nature of pelvic floor outlet obstruction
- Vicious cycle of straining against a closed outlet
- Psychological associations
- Related presentations of outlet obstruction
- Solitary rectal ulcer syndrome
- Symptoms of pelvic floor outlet obstruction
- Digital examination and defecography
- Balloon expulsion test
- Surface electromyography and colonic transit study
- Pathway for pelvic floor outlet obstruction
- Treatment of outlet obstruction
Rectocele, enterocele and complex pelvic floor abnormalities
When the problem crosses compartments and needs more than one specialty
- Rectocele
- Repair of rectocele
- Enterocele
- Multidisciplinary management of complex pelvic floor disorders
Hemorrhoids
Normal anal cushions that have slipped down, and what to do about them
- Anal cushions
- How hemorrhoids develop
- Grading of internal hemorrhoids
- Anal skin tags and internal hemorrhoids
- Usual positions of the anal cushions
- External and mixed hemorrhoids
- External, internal and mixed hemorrhoids compared
- Evaluation of internal hemorrhoids
- Diet and bowel habit as first treatment
- Elastic ligation technique
- Rubber band ligation of an internal hemorrhoid
- Precautions during elastic ligation
- Complications of elastic ligation
- Management of post-ligation sepsis
- Practical points and other office procedures
- Indications for excisional hemorrhoidectomy
- Circular stapled hemorrhoidectomy
- Complications of stapled hemorrhoidectomy
- Incarcerated internal hemorrhoids
- Outcome after acute thrombosis of internal hemorrhoids
- Excision technique for mixed hemorrhoids
- Excision of a mixed hemorrhoid
- Avoiding anal stricture after hemorrhoidectomy
- Thrombosed external hemorrhoids
- Treatment of a thrombosed external hemorrhoid
Anal fissure
A small split in the anal lining that will not heal because the muscle beneath it will not relax
- Definition of an anal fissure
- Anal fissure at the anal verge
- Location of anal fissures
- The ischaemia and spasm cycle
- Chronic anal ulcer
- Fissures in atypical locations
- Recognising a Crohn's-related fissure
- Symptoms, examination and confirmation of anal fissure
- Stepwise treatment of anal fissure
- Conservative treatment and topical therapy
- Botulinum toxin injection
- Indications for surgery in anal fissure
- Open and closed lateral internal sphincterotomy
- Closed lateral internal sphincterotomy
- Open lateral internal sphincterotomy
- Results and risks of sphincterotomy
- Diamond skin advancement flap
- Mucosal ulcer at the anal verge and its excision
- Marking out the advancement flap
- Mobilising and advancing the flap
Anorectal abscess and anal fistula
One disease in two phases: the acute abscess, and the chronic track it leaves behind
- Cryptoglandular origin of abscess and fistula
- Where anorectal sepsis starts
- Cryptoglandular origin of abscess and fistula
- Perianal and ischiorectal abscess
- Supralevator abscess
- Spread of an intersphincteric abscess and the fistulas it leaves
- Timing of drainage and use of antibiotics
- Technique of abscess drainage
- Outcome after incision and drainage
- Goodsall's rule
- Goodsall's rule and unroofing of low fistulas
- Horseshoe fistula and the Hanley procedure
- Drainage of a horseshoe fistula
- Fistulotomy and the transsphincteric fistula
- Anterior midline fistula
- Endorectal advancement flap repair
- Advancement flap repair of a complex anal fistula
- Sphincter-sparing alternatives
- Assessment before rectovaginal fistula repair
- Non-cryptoglandular causes of anorectal sepsis
Sexually transmitted anal disease
Infections of the anus and rectum that surgeons are asked to see and must recognise
- Scope of sexually transmitted anorectal infection
- Appearances of anal human papillomavirus infection
- Dysplasia in anal human papillomavirus lesions
- Human papillomavirus types and cancer risk
- Anal intraepithelial neoplasia
- Detection and treatment of anal intraepithelial neoplasia
- Chlamydial infection of the rectum
- Behaviour of chlamydial organisms
- Presentation of chlamydial proctitis
- Diagnosis and treatment of chlamydial infection
- Anorectal herpes simplex virus infection
- Course, diagnosis and treatment of anorectal herpes
- Suppression and precautions in herpes
- Anorectal gonorrhea
- Diagnosis and treatment of rectal gonorrhea
- Primary anal syphilis
- Diagnosis of syphilis
- Secondary syphilis and treatment
- Precautions in treated syphilis
Bringing it together
The few ideas that make the whole of benign anorectal disease make sense
- Central anatomical ideas
- Central clinical principles
- References
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition