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![MX OF HAEMORRHOIDS
• FIRST DEGREE: Conservative[Medical]
• SECOND DEGREE: BARRON’S BANDING
• 3RD & 4TH DEGREE: OPEN
HAEMORRHOIDECTOMY
OR
STAPLED HAEMORRHOIDECTOMY](https://image.slidesharecdn.com/anorectaldiseases-141216020340-conversion-gate02/75/Anorectal-diseases-20-2048.jpg)
![STAPLED
HAEMORRHOIDECTOMY
• Introduced by Longo in 1998
• Utilises a purpose designed stapling
gun[PPH]
• Excises a strip of mucosa & submucosa
circumferentially
• Above Dentate Line](https://image.slidesharecdn.com/anorectaldiseases-141216020340-conversion-gate02/75/Anorectal-diseases-22-2048.jpg)
Uploaded byDHARMENDRA KR
Anorectal diseases
The document presents an overview of common anal problems, including surgical anatomy, hemorrhoids, anal fissures, and anal fistulas. It details causes, symptoms, management strategies, and surgical techniques for each condition. Key surgical landmarks and classifications, such as Park's classification for anal fistulas and treatment options like stapled hemorrhoidopexy, are also discussed.
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- 1. COMMON ANAL PROBLEMS DR.K.R.DHARMENDRA, MS.,DNB., GENERAL & LAPAROSCOPIC SURGEON, AL HAYAT INTERNATIONAL HOSPITAL, MUSCAT.
- 2. OUTLINE • RELEVANTSURGICAL ANATOMY • HAEMORRHOIDS • FISSURE IN ANO • FISTULA IN ANO
- 3. SURGICAL ANATOMY OF ANAL CANAL • THE ANORECTAL RING • PUBORECTALIS MUSCLE • EXTERNAL ANAL SPHINCTER • THE INTERNAL ANAL SPHINCTER • DENTATE LINE • ANAL CUSHIONS
- 4. ANORECTAL RING Marksthe junction between rectum & anal canal Formed by joining of Puborectalis muscle Deep External Sphincter Conjoined Longitudinal muscle Highest part of internal sphincter
- 5. PUBORECTALIS MUSCLE •Funnel shaped muscle • Maintains angle between anal canal & rectum • Important for continence mechanism • Innervated by Sacral somatic nerves
- 7.
- 8. EXTERNAL ANAL SPHINCTER • Single, somatic, voluntary muscle • Divided by lateral extensions from longitudinal muscle into 3 portions • Deep • Superficial • Subcutaneous • Innervated by Pudental Nerve
- 9. INTERNAL SPHINCTER •Involuntary muscle • Thickened distal continuation of circular coat of rectum • In a tonic state of contraction • Receives intrincic non-adrenergic and non-cholinergic fibres, stimulation of which causes release of NO which induces IS relaxation
- 10. DENTATE LINE •Important surgical landmark • Represents the site of fusion of proctodaeum and post-allantoic gut. • Site of crypts of Morgagni through which anal ducts that communicate with anal glands open into anal lumen.
- 11. DENTATE LINE Above Pink Mucosa Columnar epithelium Superior Rectal Artery Portal circulation Autonomic Nervous system Painless Below Parchment coloured mucosa Stratified Squamous epithelium Inferior Rectal Artery Systemic circulation Somatic innervation Painful
- 12. ANAL CUSHIONS •Uneven folds of mucosa & submucosa just above the dentate line • Left lateral • Right posterior • Right anterior • Contains sub epithelial meshwork of supporting tissues • Site of dense arterio venous plexus
- 14. HAEMORRHOIDS • Greek: haima = blood Rhoos = flowing • Latin: pila = a ball • Definition: Symptomatic anal cushions
- 15. Piles characteristically liein 3, 7& 11 o’ clock positions These are the locations of the terminal branches of superior rectal artery
- 16. CAUSES OF HAEMORRHOIDS • Constipation • Fiber deficient diet • Straining to pass stool Shearing forces acting on the anus lead to caudal displacement of anal cushions. Fragmentation of supporting structures leads to loss of elasticity of cushions such that they no longer retract following defecation.
- 17. SYMPTOMS OF HAEMORRHOIDS • Bright –red , painless bleeding • Mucus discharge • Prolapsed mass • Pain only when prolapsed
- 18. BEWARE OF GISYMPTOMS!! • Change of bowel habits • Mucus discharge • Tenesmus • Back pain • Anorexia/ Weight loss • Abdominal pain
- 19.
- 20. MX OF HAEMORRHOIDS • FIRST DEGREE: Conservative[Medical] • SECOND DEGREE: BARRON’S BANDING • 3RD & 4TH DEGREE: OPEN HAEMORRHOIDECTOMY OR STAPLED HAEMORRHOIDECTOMY
- 21.
- 22. STAPLED HAEMORRHOIDECTOMY •Introduced by Longo in 1998 • Utilises a purpose designed stapling gun[PPH] • Excises a strip of mucosa & submucosa circumferentially • Above Dentate Line
- 23.
- 24. EXTERNAL HAEMORRHOIDS •Arising from superficial haemorrhoidal plexus • 5-Day, Painful, Self curing lesion • Termed as Perianal Haematoma • Within 48 hours: Evacuate under LA
- 25.
- 28. FISSURE IN ANO • A longitudinal split in the anoderm of distal anal canal • Not beyond Dentate line
- 29. Aetiology of AnalFissure • Strained evacuation of hard stool • Anal Hypertonicity • Vascular insufficiency
- 32. Clinical Features ofAnal Fissure • Severe anal pain on defecation • Bright red bleeding • Sentinel tag • Discharge, itching
- 33. Ectopic site suggestsa more sinister cause!!! • Crohn’s Disease • TB • HIV • Syphilis • Chlamydia • Chancroid • Lymphogranuloma Venereum • HSV • Cytomegalovirus • Kaposi’s Sarcoma • B cell Lymphoma • Squamous cell carcinoma
- 34. Management of AnalFissure • Conservative MX: Stool bulking agents Stool Softeners • Local Anaesthetic cream • 0.2 % Glyceryl Trinitrate • 2% Diltiazem cream
- 35. Operative measures forAnal Fissure • Lateral Anal Sphincterotomy • Anal Advancement Flap
- 36. FISTULA IN ANO It is a chronic abnormal communication lined by granulation tissue, which runs outwards from the anorectal lumen to an external opening on the skin of perineum or buttock.
- 37. Presentation of AnalFistula • Intermittent perianal purulent discharge • Pain • Previous episode of anorectal sepsis
- 40. Park’s Classification “Basedon the centrality of intersphincteric anal gland sepsis, which results in a primary track whose relation to the External sphincter” • Intersphincteric • Trans-sphincteric • Supra sphincteric • Extra sphincteric
- 42. Goodsall’s Rule Anterior:Drain straight Posterior: Drain curved to anorectal midline
- 43. Surgical Management •Fistulotomy • LIFT Procedure • Fistula Plug • Advancement flap • Setons
- 44.
- 45. LIFT • Identifythe internal opening • Incision at intersphincteric groove • Dissection through intersphincteric plane to find intersphincteric fistula tract • Secure suture ligation of intersphincteric fistula tract • Remove the fistula tract • Curette fistula tract from external opening • Suture closure of external sphincter muscle defect • Closure of intersphincteric wound
- 47. Cutting Setons •Latin: seta = bristle • High Fistula eradication without functional impairment • The enclosed muscle is gradually severed • Divided muscles do not spring apart • Fistulous tract is replaced by fibrosis
- 48. Synthetic, bioabsorbable scaffoldof polyglycolic acid and trimethylene carbonate copolymer
- 50. Practice Pearls Squatting is the only natural defecation posture Proctoscopy is the guide to plan the treatment of piles Currently Stapled Haemorrhoidopexy is the choice Proctoscopy is abandoned in acute anal fissure Pain is the differentiating feature between fissure & piles Only complicated piles presents with pain Beware of GI symptoms associated with piles Hence never hesitate to go for colonoscopy Majority of external piles don’t need any intervention Ectopic Fissure smells danger Rule out Crohn’s Disease in recurrent anal fistula MRI is essential to locate internal opening LIFT & Fistula Plug procedures preserves continence
- 52.