[Music] [Applause] [Music] hello my dear curious and studio students of surgery myself dr mahesh chodri i am welcoming you in my surgery lecture series this surgery lecture series contains entire surgery with anesthesia with radiology with orthopedic so stay tuned with us let's start our surgery lecture series welcome dear students in my surgery lecture number 33 that is the decision of the rectum and disease of the anal canal in this lecture we will learn the rectum and the anal canal anatomy police of the rectum theist operation excision of the prolapse mucosa complete prolapse valence sponge that is the wrap operation rectopaxy operation rectal sling operation perennial approach that is the delaware's operation laghannan's operation resection operation that is the anterior resection of the rectum perineal rectosigmoid ectomy operation on the pelvic floor and perineum all this point will cover in this lecture now start with the rectum and anal canal anatomy first we will see the anatomy of the rectum it is continuous above with the sigmoid colon and below with the anal canal peritoneum is reflected from the anterior wall of the rectum to the bladder forming rector cycle pouch of the peritoneum in the male and rectory retain pouch in the female and arterial supply of the rectum are from arteries of like superior middle and inferior rectal arteries and middle sacral arteries dilatation and tortuosity of superior rectal vein are called internal hemorrhoids this possibility occurs due to absence of walls in the vein internal pressure from fecal impaction external pressure from a loaded pelvic column gravity uterus hybrid etc straining at stool especially during constipation as the vein passes through the rectal muscles and develop the hemorrhoids here is a good picture of rectum and anal canal anatomy you can watch this is the second picture clearly shown all the structures like sigmoid colon dented line surgical anal canal anal verge the internal sphincter the external sphincter all these are structures are clearly seen in this image now the nerve supply derived from the sympathetic and parasympatic systems now the anatomy of the anal canal it is about 1.5 inches long in adult in infinite relation with the perineal body laterally historical forcing behind anocox is a ligament which separates it from the tip of the coccyx and whole length surrounded by the sphincter muscles which in turn keeps it close each column contains the terminal radical of the superior electric artery and veins the left lateral that is the three o'clock and the right antenna that is the same o clock and the right posterior that is the eleven o'clock positions are the most common sides for the primary internal humerus that is the piles the imaginary line along which is the anal walls are situated is popularly known as the pectinate line that that is also called as a dented line the important landmarks for the surgeons the epithelium above this line is supplied by sensory fibers from autonomic nervous system and therefore in sensitive to painful stimuli such as the cutting and cauterization of epithelium below this line is innervated by spinal nose and has somatic sensation anal canal musculature compound by the internal sphincter the longitudinal muscles and the sphincter any externals no supply of the anal cannular upper part developed from the hinger supplied sympathetic and parasympathetic nerve supply lower part develop from protruder inferior rectal nerve and somatic nerve the spaces on the lateral side of the canal anal canal and the rectum are there are three species one is the the perineal spin contains external hemorrhoids plexus and the etherical space sites of the abscess formation and formation of the horseshoe fistula development perfectly perrectal space that is resulting in a high fistula now the next point of this lecture is prolapse of the rectum this can be differentiated into one partial prolapse and second is the complete prolapse first we will see the partial prolapse when only the mucosa and submucosa of the rectum come out through the anus it is called partial prolapse the length of such prolapse is never more than 3.75 centimeter if this prolapse mass is palpated with the fingers inside the anus and the thumb on the outside of the mass means outside of the anus it will be evident that it is a compose of two layers of the mucous membrane and submucosa in between now here is a animated picture on your screen there is a partial thickness of the mucosal prolapse and full thickness of the prolapse you can clearly see here the partial prolapse and complete prolapse is seen this is the diagram of normal rectum and prolapse rectum is seen in the lateral view of this image etf aciditis of the partial prolapse are this condition occurs children below the three years and elderly people in children faulty boil habits straining such as attack of diarrhea or whooping cough loss of weight and diminishing of pararectal fat in adults some loss of tone of anal sphincter third degree hemorrhoids in female torn perineum excessive straining due to irritable obstruction from enlarged prostate and excessive coughing complicate operations for fistula nano fischeri nano if excessive stretching of anal sphincter now the treatment first conservative treatment digital repositioning the mother is taught how to replace the protruded bowel avoiding straining of stools control of diarrhea and second line of treatment in conservative treatment of the partial prolapse of the rectum is sub mucus injection five percent phenol in almond oil under ga should be injected this is tried in children only after digital reproducing fails for six weeks trial this sub mucous injection treatment may also be tried in adults 10 ml of such solution may be injected in one setting will lead to fibrosis and the mucous membrane becomes fixed to the muscular cord and is drawn in now operative treatment for the partial problems of the rectum are first is the thiest operation and second is the excision of the prolapsed neurogram first is the theor's operation this operation means the stitch is taken around the anus in the external sphincters with silver or stainless steel wire wires should be removed after three months and second is the excision of the prolapsed mucosa the base of the prolapse is allocated by the good salsa ligature transmission twice and the ligature is then tightened dear student here is a image you can see that is the image of the theater operation the 20 gauge needle is used and the stitch is taken around the anus and fix there this is the step by step of theaters operation is showing on this image and last image is showing the complete of the theos operation this is the image of the excision of the prolapse mikoza you can see step by step this is the another image animated image of submucous excision of the partial progress of the rectum now the complete prolapse that is called as a presidential in this condition the rectum comes out through the anus and the protrusion consists of all the layers of the rectal wall it is descending sliding hernia it is always more than 3.75 centimeter in the length and usually about 10 centimeter in length if palpated between the finger and the thumb double thickness of the entire wall of the wall of the rectum can be palpated it must be remembered that a complete prolapse usually contains a pouch of peritoneum entirely between its wall when the prolapse is very large one this peritoneal cavity contains even coils of the small intestine so always remember this main and women's ratio are one s to five means remains are more affected for this procedure complete prolapse of the rectum than mean etiology factors bowel habit associated with a long history of difficulty with deprecation laxity of the anal sphincters most obvious abnormality found apart from the prolapse itself splintering response to voluntary contraction is also poor now here is a good image of the complete precedential this is the prolapse of the rectum complete prolapse procedure now the next etiology factor are sliding hernia may be periodontal pouch on the anterior aspect of the prolapse lag of the rectal fixation muscles of the pelvic floor are weak the rectum is more mobile it is also not fixed posteriorly to the sacrum rectal intersusception the rectum folds on itself and passes through the pelvic diaphragm and ultimately comes out the awareness the cause of such intersession is not known disorder functions of the pelvic floor muscles may have marked laxity of the whole pelvic floor and anal splinters mechanism a few patients even after rectopaxy shows persistence of the incontinence now the treatment there are various operations designed by various surgeons for complete prolapse of rectum the more commonly practice operations are mentioned below first is the fixation operation that is the eval sponge rap operation by wales wells described this operation in 1959 through the abdominal approach the rectum is fully mobilized to the pelvic floor a rectangular sheet of the avalanche polyvinyl alcohol is then sutured to the pre-sacral fascia and the peritoneum of the sacrum periosteum of the sacrum the mobilized rectum is done up to the up up to make it taut the valence sheet is wrapped over it and sutured on the peritoneum of the sacrum the anterior surface of the rectum is left uncovered to prevent constrictions of the lumen eval and sponge will initiate fibrosis and fix the rectum in the place dear student this is the text picture on your screen shows a valence phone's wrap over the rectum a sheet of the avalanche sponge is sutured to the pre-sacral fascia of the sacrum and then wrapped over the rectum and switcher the anterior part of the rectum is not covered evidence of the narrowing of the lumen this is the avalanche sponge now the second operation is the rectopaxy that is the lockhart memory operation the incision and preliminary steps are similar to the previous operation a current incision about two inches in length is made midway between the anus and tip of the coccyx external sphincter muscles and the anacostial ligaments are cut fascia and wall there is transversely in size the rectum is stripped off from the anterior surface of the sacrum up to the third sacral vertebra the resulting cavity is packed with long strips of gaze of the polyvinyl alcohol sponge and suture the effect of this sponge is to provoke vigorous fibrous reaction which will anchor the rectum again the sacrum this is the good picture we showing the rectum is sutured with the pre-saxon area of the sacrum this is the image of the rectopaxy showing before and after the operation the posterior part of the rectum is sutured with the pre-sacral area and coccyx in dotted now the third operation for the rectal prolapse is the rectal sling operation introduced by the refstrain in 1965 by abdominal approach rectum mobilized down to the tip of the coccyx the lateral peritoneum folds are open and the rectum is free from the sacrum the rectum is pulled up thought a five centimeter band of teflon is placed around the rectum and suture and pre-sacral facial and period periosteum of below the sacrum five centimeter below the promontory of the sacrum then then the next operation is the perineal approach that is the the deluxe operation the collapse rectum is pulled down is pulled down as far as possible a series of the chronic chromic cat guard sutures are used to implicate the underlying muscles when these are tied the rectal muscles is pulled up towards the anal canal the anal canal mucous membrane is now sutured to the rectal mucosa which remains at the tip of the prolapse so the prolapse is reduced and the ring of the muscle surrounds the anal canal which narrows its orifice this prevents occurrence then the hands operation whole of the rectum and lower sigmoid colon are mobilized this is now held up and stitched with the rectus sheath here is the sling operation image of the sling operation you can see then the second type of the operation in the directional pull ups are the resection operation first is the anterior decision of the erecture technique the technique is essentially similar to the anteriorization of the rectum for carcinoma only difference is that the dissection should be close to the rectum to prevent injury to the nerve supply of the bladder and to prevent importance in the meals the proximal line of rejection should be at the convenient point at the reactor sigmoid junction or in the sigmoid colon so that the river redundancy is removed the anastomosis must be done without intention and the second resection operation is the perennial recto sigmoidectomy this is a technique in which the redundancy electrosegment colon is excited through the prolapse itself the patient is placed in treadline position or prone jack knife operation a circular incision is made through the outer layer of the prolapse two centimeter prolapse to the dented line up to the two center proximal to the dented line the pelvic colon should be pulled down as far as possible until it becomes stout from above the sigmoid colon is completely divided below the anus in such a way that there is a greater length posteriorly the two cut ends of the bowel the anal cut externally and pelvic collar internally are now sutured by a series of interrupted switches the suture stump is now pushed into the anal canal and a rubber tube is inserted this is the perennial retrosigmoidactomy picture of the very electro sigmoidectomy you can see here is a symmetric tummy seen on your screen now the third resection operation in the rectal prolapse are operation on the pelvic floor and perineum this operation is gollinger's modification of rose graham operation with this operation the rectum is mobilized and pulled up the levator and muscles are approximated anterior to the sacrum the peritoneal pouches are obliterated also used avalon rectopaxy as the primary treatment and posterior anal repair to the improved pelvic floor and sprinter functions these are mainly varying degrees of the incontinence due to the anal sphincter dysfunction the simplest method of for trying to improve sprinter function is by exercising the pelvic floor muscles and by applying the thyroidic stimulation here is a anodical picture of for the resection operations on the pelvic floor and the perineum peritoneum there is the levator and muscles the glutenous muscles maximus the coccyx the anus all are seen anatomically this is the lateral view of the pelvic floor where the operation is to be done recession operation for the rectal prolapse dear students this is the theoretically i explain you but there are very good videos on the youtube you can refer it for the fixation operation like the avalanche sponge wrap operation that is also called wheels explained by the wheels retropixy lockhard memory operations and rectal sealing operations perennial approach developments operational lands operation resection operations operation like anterior resection of the rectum perineal electrosigmoid tectomy and operation of the pelvic floor all these videos are available on the youtube you can refer it to clear your concepts and here is the end of our surgery lecture number 33 that is the disease of the rectum and the disease of the anal canal thank you students [Music] you