Surgery Lecture 33: Diseases of the Rectum and Anal Canal

Introduction

• Lecture by: Dr. Mahesh Chodri
• Lecture series on: Surgery
• Lecture topic: Diseases of the Rectum and Anal Canal
• Key Areas Covered: Rectum anatomy, anal canal anatomy, various surgical operations

Rectum and Anal Canal Anatomy

Rectum

• Continuous with: Sigmoid colon above and anal canal below
• Peritoneum: Forms rectovesical pouch in males and rectouterine pouch in females
• Arterial Supply: Superior, middle, inferior rectal arteries, and middle sacral artery
• Veins: Dilatation of the superior rectal vein leads to internal hemorrhoids
• Nerve Supply: Sympathetic and parasympathetic systems

Anal Canal

• Length: About 1.5 inches in adults
• Relationships: Perineal body, anococcygeal ligament
• Muscles: Surrounded by sphincter muscles
• Key Positions for Internal Hemorrhoids: 3, 7, and 11 o’clock positions
• Pectinate Line: Landmark for surgeons dividing areas with different nerve supplies
• Nerve Supply: Upper part from autonomic fibers, lower part by somatic nerves
• Spaces: Perineal (external hemorrhoids), ischiorectal (abscesses, fistulas), perirectal (high fistulas)

Prolapse of the Rectum

Partial Prolapse

• Types: Only mucosa and submucosa protrude
• Length: Usually less than 3.75 cm
• Common in: Children under 3 years, the elderly
• Causes: Faulty bowel habits, weight loss, sphincter tone loss
• Treatment:
  • Conservative: Digital repositioning, submucous injection (phenol in almond oil)
  • Operative: Thiersch’s operation, excision of the prolapsed mucosa

Complete Prolapse

• Types: Entire layers of rectal wall protrude
• Length: Usually about 10 cm
• More Common in: Women (5:1 ratio)
• Etiology Factors: Bowel habits, sphincter laxity, sliding hernia
• Treatment Options:
  • Fixation Operations: Wells' procedure using Ivalon sponge
  • Rectopexy: Lockhart-Mummery operation
  • Rectal Sling Operation: Introduction by Rehn
  • Perineal Approach: Delorme’s operation, Altemeier's procedure
  • Resection Operations: Anterior resection, perineal rectosigmoidectomy
  • Pelvic Floor and Perineum Operations: Golligher's modification

Surgical Techniques

Wells’ Procedure

• Approach: Abdominal
• Technique: Suturing Ivalon sponge to presacral fascia and wrapping around rectum
• Purpose: Induces fibrosis to fix rectum

Lockhart-Mummery Rectopexy

• Incision: Midway between anus and coccyx
• Technique: Stripping rectum from sacrum and packing cavity with polyvinyl alcohol sponge
• Purpose: Fibrous reaction to anchor rectum to sacrum

Rectal Sling Operation

• Introduced by: Rehn
• Approach: Abdominal
• Technique: Mobilizing rectum, placing Teflon band, suturing to presacral fascia

Delorme’s Operation (Perineal Approach)

• Technique: Pull rectum down, implicate underlying muscles, suture anal canal mucosa
• Purpose: Reduce prolapse, reinforce anal canal

Anterior Resection of Rectum

• Similar to: Carcinoma anterior resection
• Focus: Remove redundancy while preserving nerve fibers

Perineal Rectosigmoidectomy

• Technique: Excise redundant rectosigmoid colon through prolapse
• Incision: Circular around external layer of prolapse
• Suturing: Interrupted stitches

Golligher’s Modification (Pelvic Floor Operation)

• Technique: Mobilize rectum, approximate levator muscles, obliterate peritoneal pouches
• Purpose: Improve pelvic floor and sphincter functions

Conclusion

• Extensive coverage of anatomy, prolapse conditions, surgical treatments for rectum and anal canal
• Emphasis on anatomical understanding and various surgical techniques
• Encouraged to watch videos on YouTube for practical understanding of surgical procedures

End of the lecture.