ANATOMY

Rectum
o It is the distal portion of the large gut, placed between the
sigmoid colon above and anal canal below; in front of last
three pieces of sacrum and coccyx (From S3).
o The three cardinal features of large intestine (saccu lation,
appendices epiploicae and taeniae) are absent.
o The upper third of rectum is covered by peritoneum on
front and sides, mid third only on the front, lower third is
infraperitoneal.
o The rectum is pulled forward by the puborectalis muscle
forming the anorectal sling which is primarily responsible
for rectal continence.
o It has got three lateral exions left, right and left from below
upwards (Valves of Houston).
Rectosigmoid Junction
o Implies a segment of bowel comprising the last seven centimetre of sigmoid colon and upper ve centimetre of rectum.
o On sigmoidoscopic examination it is taken as a point 15
cm from the anal verge.
Supports of Rectum
o Pelvic oor.
o Fascia of Waldeyer: It is the condensation of pelvic
fascia behind rectum, contains superior rectal vessels and
lymphatics.
o Lateral ligaments of rectum: It is the condensation of pelvic
fascia, attaches rectum to the posterolateral wall of lesser
pelvis.
o Denonvilliers fascia: It is the fascial condensation which
separates rectum from prostate in males and vagina in
females.
Rectum is supplied by rich network of vessels that

originates from superior and middle rectal arteries and

median sacral artery.
Lymphatic drainage from upper half of rectum is to
inferior mesenteric nodes; from lower half to internal
iliac nodes.
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Fig. 25.1: Interior of the anal canal.
Fig. 25.2: Sphincters of anal canal.
It is innervated by autonomic nervous system; sympathetic
(L1, L2) is motor to sphincter and inhibitory to musculature;
parasympathetic (S234) is motor to musculature and inhibitory

to sphincter. Sensation of distension is carried through parasympathetic; pain sensation is carried by both.
Anal Canal
o It is 4 cm long, extends from levator ani muscle to anal
verge.
o The dentate line represents the former site of the embryonic
anal membrane.
o The lining of the canal above this line is columnar epithelium and below is skin.
o The mucosa above this line has an autonomic nerve supply,
below is by pudendal nerve.
o The venous drainage above this line is by inferior mesenteric and portal circulation, whereas below to systemic
venous circulation.
o Internal haemorrhoids develop above this line.
Sphincters of Anal Canal
Internal sphincter: Downward extension of circular muscle of
rectum, under control of autonomic nervous system.
External sphincter: Surrounds the internal and continuous with
the levator muscle.
Blood supply is from inferior rectal artery.
Venous drainage: Internal rectal venous plexus lies in the
submucosa of the anal canal. It drains mainly into the superior
rectal vein but communicates freely with external plexus. It is
an important site of portasystemic communication. They are
situated in anal column at 3,7,11 oclock. Their saccular dilatation forms primary internal piles.
Fig. 25.3: Blood supply of rectum.
PER-RECTAL EXAMINATION
(Digital Examination of the Rectum)
We had almost come to the conclusion that the case (of vasovesiculitis) was one of acute appendicitis, but decided to make a rectal

examination for the sake of completeness.

Ulysses Grant Dailey, WS Grant, 1924
No abdominal examination is complete without a per rectal
examination.
a. It is done to palpate.
1. Carcinoma r ectum.
2. Stricture r ectum.
3. Polyps.
4. Thrombosed piles.
5. BPH and carcinoma prostate.
6. Secondaries in the rectovesical pouch (Blumer shelf).
7. Sphincter t one.
8. Pelvic abscess (is felt as boggy swelling).
b. To feel the internal opening of anal stulas.
c. In bimanual palpation of the bladder or pelvic tumours.
d. In acute abdominal conditionsit reveals dilated empty
rectum with tenderness.
Positions for Per-rectal Examination
o Right lateral position.
o Left lateral position.
in the case of acute abdomen, it is more important to insert the nger into the
lower end than to put the thermometer
into the upper end of the alimentary tract. sir zachary cope
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o Dorsal position in ill-patients.
o Lithotomy position.
o Knee-elbow position.
o Picker position: Patient in standing position leans forward
by grasping a chair or stool. This method is used to palpate
seminal vesicles which is involved by tuberculous seminal
vesiculitis (as craggy feeling) or in trichomonas vaginalis
infestation of seminal vesicle.
Per-rectal examination is contraindicated in acute ssurein-ano.
PROCTOSCOPY (KELLYS)
Indications
a. Diagnosticpiles, ssure in ano, polyps, stricture, etc.
b. Therapeuticinjection therapy for partial prolapse or piles,
cryotherapy for piles, polypectomy, biopsy for carcinoma
rectum or anorectum.
Figs 25.4A and B: Types of proctoscopes:

(A) Non-illuminating, (B) Illuminating.

Types
a. Illuminating.
b. Nonilluminating.
Parts (10 cm)
Proctoscope is conical shape, with proximal diameter more
than the distal, so as to illuminate the light at the required site
properly. Obturator is the inner part which allows the easy
insertion of the proctoscope.
Positions for Proctoscopy
o Left lateral position (common).
o Right lateral.
o Lithotomy.
o Knee-elbow position.
Technique of Proctoscopy
After doing digital examination, proctoscope with the obturator
is introduced inside, through the anal canal in the direction
towards the umbilicus.The obturator is removed. Proctoscope is
withdrawn and during the course of withdrawal, any pathology
has to be looked for.
Acute anal ssure is contraindication for proctoscopy.
SIGMOIDOSCOPY
Annual sigmoidoscopy for all, after their fortieth birthday: something to look forward to.
Henry George Miller, 1968
Fig. 25.5: Rigid sigmoidoscope with ination
balloon and biopsy forceps.
o It is used to visualize rectum and sigmoid colon, take biopsies from suspected lesions and do therapeutic procedures
(polypectomy, control of bleeding, etc).
o There are two types:
1. Rigid25 cm long, with illumination.

2. Flexible60 cm long.
o In lateral position as in P/R examination or proctoscopy,
sigmoidoscope with obturator is passed into the rectum
and obturator is removed. Rectosigmoid is in ated with air
and scope is negotiated into the sigmoid through Alpha ()
manoeu vre. Looked for any disease, biopsies are taken and
also any required procedure is done.
Precaution: Care should be taken in acutely in amed sigmoid
colon, because chance of perforation is high.
COLONOSCOPY
o It is 160 cm long, exible.
o Technique is same as sigmoidoscopy, but is passed up to
the caecum.
Technique
It is often done under GA using propofol or with laryngeal mask
airway (LMA). It can be also done under high sedation. But
patient nds dif cult to tolerate pain and distension. Passage
by elongation; looping with a manoeuvre; dither-torquing
(clockwise-anticlockwise rotations) methods are used. Dif culty is encountered while passing through sigmoid colon,
AB
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splenic exure, and hepatic exures. Continuous air in ation
is important. It is better to visualise the lumen and then pass the
colonoscope. Often it can also be negotiated into the terminal
ileum. Changing position, abdominal pressure is required for
better negotiation of the colonoscope. Technique differs in
patients after haemicolectomy or through colostomy.
Indication
o Bleeding per rectum, resistant anaemia.
o To take biopsies from different parts of the bowel.
o To identify synchronous growths, ulcerative colitis.
o To remove polyps.
o When barium enema shows irregularity.
o For therapycolonoscopic polypectomy, dilatation of
stricture colon, fulgaration.
Contraindication
Acute ulcerative colitis.
Advantage
It helps to visualise full length of the colon. GA is not used,
except in children.
Disadvantage
Takes a long time and requires expertise to do the same.

Hazards
o Perforation of bowel, splenic exure is the commonest site.
o Trauma to anorectum.
o Sepsis.
o Haemorrhage.
o Problems of incomplete therapeutic procedures.
CARCINOMA RECTUM
Bubo is an apostem breeding within the anus in the rectum with
great hardness but little aching. This I say, before it ulcerates, is
nothing else than a hidden cancer. Out of bubo (cancer) goes
hard excretions and sometime they may not pass, because of the
constriction caused by the bubo, and they are retained rmly within
the rectum. I never saw nor heard of any man that was cured
but I have known many that died of the foresaid sickness.
John of Arderne, 1414
o It is common in females.
o Usually originates from a pre-existing adenoma or papilloma (tubular polyp).
o In 3% of cases, it occurs in multiple sites (syn chronous).
Aetiology
o Red meat and saturated fatty acids increase the risk.
o High bre diet reduces the risk.
o Alcohol and smoking increases the risk.
o FAP and adenomas are more prone to carcinomas.
Fig. 25.6: Polyps of colon. It is important
premalignant condition for colorectal cancers.
Fig. 25.7: Large rectal polyp which has come out
of the anal canal. It is potentially malignant.
Fig. 25.8: Pathological specimens of anal canal, rectum and sigmoid
colon after abdominoperineal resection for low rectal carcinoma and
midrectal carcinoma.
Never insult the vagina by examining the rectum rst An old axiom

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o Villous adenoma has 40% chance of turning malignancy,
size more than 2 cm is at high-risk.
o Ulcerative colitis; Crohns disease; HNPCC carries higher
incidence of carcinoma of rectum.
o Family history of rectal cancerany rst degree relative of
a person with rectal cancer will show two times increased
risk of carcinoma rectum.
o Risk of developing other cancers like of endometrium

(40%); stomach (20%); biliary tree (20%); ovary (10%) in

the same patient also increases.
o Adenomacarcinoma sequence like in carcinoma of
colon is known common method of occurrence.
Gross: It can be:
o Ulcerative.
o Papilliferous.
o In ltrative.
o Annular: It is common in rectosigmoid junction.
o Diffuse type: Often observed in patients with ulcerative
colitis which carries poor prognosis.
Histologically: It is adenocarcinoma which may be:
o Well-differentiated10%
o Moderately differentiated65%
o Undifferentiated25%
Spread
o Local spread: Initially, it spreads, locally circumferen tially
(takes 12-18 months to complete the circum ference of the
bowel). Later spreads out to the muscular coat and perirectal tissue. Then to prostate, bladder, seminal vesicles in
males, and uterus and vagina in females. Posteriorly into
the sacrum and sacral plexus, laterally into the ureters.
Haggitts invasion of malignant polyp
(Similar to carcinoma colon)
In pedunculated polyp
Level 0noninvasive carcinoma over the summit
Level 1invasion to head of pedunculated polyp
Level 2invasion to neck of the pedunculated polyp
Level 3invasion to stalk of the pedunculated polyp
Level 4invasion to base of pedunculated polyp
In sessile polypall lesions are level 4
Dukes staging of carcinoma rectum

A. Con ned to bowel wall, mucosa and submucosa

B. Extends across the bowel wall to the muscularis propria with
no lymph nodes involved
C. Lymph nodes are involved
Modi ed Dukes staging
A. Growth limited to rectal wall (15%)
B. Growth extending into extra rectal tissues but no lymph
node spread (35%)
B1: Invading muscularis mucosa
B2: Invading in to or through the serosa
C. Lymph node secondaries (50%)
D. Distant spread to liver, lungs, bone, brain
Note:
Astler-Coller's grading (Refer Page No. 967, Chapter 22).
Colloid carcinoma of the rectum
It is 12% common in young people
Types
Primary and secondary
Secondary colloid carcinoma is common type and is due to
mucoid degeneration of adenocarcinoma itself.
Primary is mucus within the cell with displaced nucleus (signet
ring)
Primary type has got poorer prognosis compared to secondary
TNM staging of rectal cancers
TxPrimary not assessed
T0No primary tumour
TisCarcinoma in situ
T1Invasion to submucosa
T2Invasion to muscularis propria
T3I nvasion of subserosa or non-peritonealized perirectal
tissues
T4I nvolvement of visceral peritoneum, other organs or struc-

tures
N0No nodal spread
N11-3 nodal spread
N24 or more nodal spread
M0No distant spread
M1Distant spread present
o Lymphatic spread: Above the peritoneal re ection, spread
occurs upwards along the colonic lymph nodes. In midrectum, into the para rectal and mid-rectal lymph nodes.
Downward spread is rare occurs when growth is close to the
anal canal into the inguinal lymph nodes. Obturator nodes
may be involved in 8% of lower rectal growths.
o Venous spread occurs to the liver 35%, lungs 20%, adrenals
10% and other areas.
o Perineural spread carries poor prognosis.
Clinical Features
o Bleeding per rectum/anum (may mimic haemor rhoids)
earliest symptom.
o Spurious diarrhoea: It occurs in early morning due to
overnight mucus accumulation in the rectum causing
urgency for defecation, but results in spurious diarrhoea
with incomplete evacuation.
o Tenesmus: It is painful incomplete defecation with bleeding.
o Bloody slime: Mucus with blood in stool.
o Sense of incomplete evacuation, constipation.
o Presenting as piles due to proximal venous congestion
by tumour or as stula in perianal region (which itself is
tumour extension into the anal canal).
o Anaemia, malnutrition, loss of appetite and weight.
o Altered bowel habits.
o Urinary symptoms are due to in ltration of bladder or prostate.
o Back pain, due to invasion of sacral plexus.

o Ascites, liver secondaries, urinary symptoms.

90% of rectal growths can be felt by per-rectal examination.
Depth of tumour penetration can be assessed through digital
examination as super cial tumours are mobile; deep penetrating
tumours are not mobile.
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Investigations
o Proctoscopy.
o Sigmoidoscopy.
Fig. 25.9: Air-contrast CT of colon and rectum showing signicant
narrowing in rectosigmoid junction.

Fig. 25.10: CT picture of carcinoma rectum. CT is useful in

evaluating the extent, nodal status and operability.
Fig. 25.11: CT scan showing carcinoma of rectum.
o Biopsy using Yeomans forceps.
o Barium enema in case of FAP and synchronous growths.
o Colonoscopy is ideal to rule out presence of any synchronous growths proximally (5%) or polyps.
o Even though colonoscopy is done rigid proctosigmoidoscopy is a must to identify the precise location of the tumour
and to measure the tumour distance from anal sphincter
accurately.
o U/S abdomento look for secondaries in liver, ascites.
o CT scan to see operability, local extension, size, nodal
status, ureteral involvement, presence of perforation or
stula. CT is very useful to assess nodal status. Local
extension is better assessed by TRUS. Any mesorectal
node detected in CT is considered as malignant spread.
Liver secondaries are well-identied in CT. Ureteral
involvement in CT scan signi es requirement of stenting
prior to surgery. Chest CT is essential to look for secondaries.
o Endorectal ultrasonographyvery useful to assess the
local extent of the tumour. Transrectal ultrasound (TRUS)/
endorectal ultrasound gives more accurate picture of
primary tumour, layers, perirectal tissues and nodes. TRUS
is superior in T staging of rectal cancers. Its accuracy is 95%
compared to MRI (85%); and CT (75%). Endorectal US
based T staging and N staging used now depends on layers
involved and presence of nodes. TRUS detects nodes more
or equal to 5 mm size.
o Endorectal coil MRI (EC MRI) is very useful as it gives
larger eld of view compared to TRUS; extent, adjacent

organ spread are better assessed by MRI. Recurrent tumour

is better assessed by MRI.
Figs 25.12A and B: MRI showing carcinoma of rectum and adjacent
structures. MRI is good method to evaluate the spread and staging.
o Fluorine18 uorodeoxy ucose PET scan is useful to
detect recurrent local tumours; metastatic disease; to detect
pathologic response in preoperative chemoradiation. PET
is not accurate for nodal spread.
o Blood tests like haematocrit; CEA; blood urea and serum
creatinine; serum electrolytes and proteins for management
purpose. CEA estimationit is raised in metastatic disease.
It is important during follow-up after treatment.
AB
Diseases of the soul are more dangerous than those of the body.
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Differential diagnosis
In ammatory stricture
Amoebic granuloma
Tuberculosis
Carcinoid
Solitary ulcer syndrome
Treatment
Surgery
Principles
o Surgery is the main method of treatment. Preoperative
chemoradiotherapy is often used if growth is invading
into adjacent tissues (T4). Adjuvant chemotherapy and
radiotherapy is a must.
o Genetic, morphologic, biologic features of rectal cancers
are similar to colonic cancers.
o But anatomical factors make it more complex than colonic
cancers, like its location deep in the pelvis, relation to
important structures like ureters, bladder, genital, autonomic nerves and anal sphincters. So surgical approach is
very dif cult.
o Avascular endoplelvic fascial plane is important during
dissection to avoid injury laterally to autonomic nerves
(will cause impotence in men and bladder dysfunction in
both sexes); more medial dissection leads into incomplete
clearance and high local recurrence.
o Abdomino perineal resection (APR) is the gold standard.

But if tumour is well-differentiated and if there is adequate

margin above the anal canal, a sphincter saving anterior
resection (AR) can be done. Low anterior resection (LAR)
is possible if EEA stapler is used for anastomosis. But
anterior resection should not be done by compromising the
adequacy of tumour clearance. Tumour clearance is still the
priority in rectal cancer as it decides the eventual outcome.
o Total mesorectal excision (TME) should be the goal in all
procedures as mesorectum contains nodes and lymphatics,
clearance of which gives better result.
It is a sharp dissection (not blunt) in avascular areolar
plane between fascia of rectum which encroach the
mesorectum and parietal pelvic wall fascia.
Mesorectum should not be breached.
Absolute haemostasis, preservation of autonomic nerves
and dissection under vision are the essential principles.
Both layers of membranous anterior Denonvilliers facia
should be dissected off the prostate and seminal vesicles
in male to have proper clearance.
In TME for middle and lower rectum, entire mesorectum
should be removed.
For upper rectal tumors, TME is done 5-6 cm below the
lower margin of the tumour.
TME improves the quality of life in relation to impotence, retrograde ejaculation and urinary incontinence.
These complications are around 50% or more in APR
whereas in TME it is less than 20%.
o Recommended distal rectal margin clearance is 5 cm,
however 2 cm distal margin is an acceptable clearance.
o Circumferential resected marginCRM (radial margin,
> 2 mm) is more important than proximal and distal margin.
A 5 cm clearance of mesorectum from the primary tumour

is essential as tumour implants can occur only for up to 4

cm from primary tumour margin.
o Principles to be followedadequate lymphatic and vascular
clearance; en bloc resection of primary tumour; no / less
touch technique; avoiding spillage; adequate radical
surgery.
o Ultra low anterior resection or intersphincteric resection
can be considered in low rectal tumours.
o After resection (on table) irrigation of rectal bed with
cetrimide or hypertonic solution like distilled water is often
practiced as they are tumoricidal.
o Selection of the procedure AR or APR is decided by proper
staging using TRUS and MRI.
o Neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is often used in T3 lesions which also may avoid
APR; and AR may be suf cient.
o Local wide excision approaches are often used when
tumour is < 4 cm; < 40% circumference involved; T1 N0/
T2 N0 tumour:
Transanal approach is used in small tumours that is
3-5 cm above the dentate line but within 10 cm from
the anal verge:
Transcoccygeal Kraskes approach for posterior wall
rectal tumours (dangerous posterior faecal stula can
occur);
Transanal endoscopic microsurgery (Buess) using
operating microscope and videoscope can also be done.
This endosurgical device is 4 cm in diameter, specialized
sealed proctoscope with ports for CO2 insuf ation, water
irrigation, and suction and for monitoring intrarectal
pressure. CO2 insuf ation distends the rectum and local
excision is done with proper positioning of the device.

o In females, partial vaginectomy with or without hysterectomy and bilateral oophorectomy may be needed in T4
lesions to achieve surgical resection. Removal of uterus
and ovaries prevents patient from developing possible
associated cancers of these organs. Carcinoma rectum also
spreads to ovaries commonly which can be prevented by
oophorectomy.
o Often resection of liver secondaries can be undertaken
in selected patients when one lobe is involved or solitary
secondaries are present.
o Laparoscopic APR/AR is becoming popular.
Features are:
Dissection will be more meticulous.
Less blood loss, less postoperative pain.
Early bowel function.
Clearance is same as open method in relation to primary
tumour and nodes.
Short hospital stay, mortality and morbidity are similar
to open method.
Port site recurrence chances are 0.5-2% (Earlier it was
higher; now it has reduced due to proper technique,
careful handling of the specimen, specimen isolation
prior to extraction, trocar site irrigation with cytotoxic
agents and povidone iodine).
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o For carcinoma rectum presenting with obstruction, an initial
proximal colostomy is done. Neoadjuvant chemoradiation
is given. Patient is reassessed for operability. Then APR is
done with permanent colostomy.
o Incidence of local recurrent rectal cancer is 30%.
80% of local recurrence occurs within 2 years of surgery.
Common site of recurrence is in the pelvic wall. It also
can occur at distal anastomotic margin.
Intractable pelvic pain, urinary symptoms, sepsis,
bleeding, perineal sinus, swelling and induration, bowel
disturbances are the features.
It is evaluated by CEA, biopsy, CT abdomen, MRI of
pelvis and PET scan.
It is often dif cult to manage.
Incidence of recurrence will come down to 5% in proper
TME.
Palliative chemoradiation, end colostomy, ureteral
stenting are the palliation. RT controls pain and bleeding.

 Extensive radical surgery like removal of tumour with

pelvic structures can be undertaken with diversions but
with a high mortality rate and failure rate.
o Proper preoperative bowel preparation is a must in all
rectal cancers which reduces the postoperative problems
like sepsis, leak and increases the early chance of recovery.
Bowel preparation by polyethylene glycol; electrolytes
orally; bowel wash per anally; bowel antiseptics like
neomycin 1 gm tid previous day/erythromycin 1 gm tid/
metronidazole tid orally.
o Systemic antibiotics like cefazolin, metronidazole, gentamycin.
o Prophylactic heparin or low molecular weight heparin.
o Foleys catheterisation and nasogastric tube should be
passed.
o Preoperative adequate hydration using IV uids.
o Blood grouping and crossmatching and required bottles
of blood should be reserved if needed to transfuse during
the procedure.
Different surgeries for carcinoma rectum are:
1. Abdominoperineal resection (A-P resection) (APR)
wherein sigmoid, descending colon and upper rectum is
mobilised per abdominally. Anal canal with perianal and
perirectal tissues are dissected per anally. Retained colon
is brought out as end colostomy in left iliac fossa.
APRtypes
Milesabdomen rst, perineum later
Gabrielperineum rst, abdomen later
Lioyd-Davissynchronised (together), (combined)
o APR is done through lower midline incision in lithotomy
position. Left-sided colon and entire rectum is mobilised
from above. Rectum is mobilised posteriorly in avascular

plane in front of nerve plane (hypogastric nerve) between

mesorectum and sacrum. Inferior mesenteric artery is
ligated high proximal (as lymphovascular ligation) at its
origin or just beyond its rst branch. Colon is transected and
proximal cut end is fashioned for end colostomy in left iliac
fossa. Through perineum, a purse string suture is placed
around anal margin. Circumferential incision is placed
around the anus. Dissection is deepened using scissor and
cautery into the perineal body, coccyx, ischial tuberosity,
ischiorectal fossa. First posterior and lateral dissections are
undertaken until it reaches above. Lastly, anterior dissection
is done to reach above and specimen is removed through
perineal wound. Perineal wound is closed in layers often
with a drain. Abdomen drain is placed. Colostomy is created
by suturing skin to mucosa using silk.
Fig. 25.13: Laparoscopic view of mobilised rectum in APR.
Figs 25.14A and B: Colostomy done in left
iliac fossa after APR. Colostomy care is important.
o Complications of APR are:
Bleeding.
Infection of perineal wound.
Complications of colostomy like prolapse, stenosis,
and infection.
Injury to urinary system, ureter, impotence, urinary
incontinence.
Operative mortality is less than 2%.
APR is the treatment of choice when mesorectum is involved
or when it is poorly differentiated tumour or when nodes are
involved. It gives adequate clearance.
AB
Knowledge is proud that she knows so much, wisdom is humble that she
knows no more.

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o Sphincter saving APR with coloanal anastomosis: It is
done in operable distal rectal tumour in young individual
wherein within oncological principle anal sphincter need
not be sacri ced but adequate oncological tumour clearance
can be achieved. Here a permanent colostomy stoma is
avoided. Approach is both abdominal and perineal. Initial
dissection of rectal mobilisation is done from above; dissection of rectal mucosa from the anal sphincter at the level

of dentate line and complete dissection of distal rectum is

done through anal canal. Entire rectosigmoid is removed
retaining only the anal sphincter. Colonic J pouch or coloplasty reservoir is created in the mobilised descending
colon; coloanal anastomosis is done per anally using hand
sutures under direct visualisation.
o APR with neo sphincter reconstruction is also occasionally sought; but technically dif cult with complications.
Perineal colostomy is done with gracilis muscle wrap which
is made to produce sphincter like muscle twitch using an
implanted pacemaker.
2. Anterior resection (Abdominal radical restorative operation) is done in growths located in the mid and upper part
of the rectum, which is well-differentiated, small-sized and
with a clear adequate length for anastomosis after resection.
o Anterior resection is also called as anterior proctosigmoidectomy through abdominal approach wherein rectum
above the peritoneal re ection is resected with colorectal
anastomosis.
o Low anterior resection (LAR) is resection of rectum below
the peritoneal re ection along with the sigmoid colon
(as sigmoid should be removed due its precarious blood
supply after dissection), with total mesorectal excision
(TME) through abdominal approach (laparotomy) and
colorectal anastomosis using circular stapler device (EEA
stapler). Stoma should be inspected using proctoscope
for integrity and when in doubt a covering temporary
proximal colostomy should be done. LAR often leads into
frequent small bowel movements causing more frequent
stools called as low anterior resection syndrome (LAR
syndrome)/clustering. It can be avoided by creating reservoir either by doing colonic J pouch or by doing coloplasty

6 cm from proximal divided end of colon (longitudinal

colostomy between taeniae of 10 cm which is sutured
horizontally).
Criteria for anterior resection(Low anterior resection, LAR)
Upper and middle third rectal growth
Above peritoneal re ection
Well-differentiated tumour
< 4 cm size tumour
In females, growth 7 cm above the anal verge
T1 N0/T2 N0 tumour
Tumour without lymphatic or venous spread
Advantages:
Avoids permanent colostomy.
Sphincter is retained.
Patients acceptance.
Fig. 25.15: Anterior resection for carcinoma
upper rectum using stapler device.
Disadvantages:
Uncertainity of clearance which is very important in
cancer surgeries and so chances of local recurrence
is high.
Anastomotic leak, infection; stenosis.
3. Hartmanns operation is an excellent palliative proceduredone in elderly people who are not t for major
surgery like AP resection and also in locally advanced
tumours. Here rectal growth is resected and upper end of
the rectum is closed completely. Proximal colon is brought
out as end colostomy.
4. Pelvic evisceration (Brunschwigs operation): It is
removal of rectum with the tumour, all the lymph nodes,
urinary bladder, fat, fascia, uterus, vagina, with colostomy and urinary diversion. It is neither favourable nor

popular.
Figs 25.16A to C: Surgeries for Ca rectum (A) A-P resection,
(B) Anterior resection, (C) Hartmanns resection.
5. Palliative colostomy is done in advanced unr esectable
growth which presents with intestinal obstruction.
A
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C
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Radiotherapy
It is bene cial in carcinoma rectum showing increased

survival rate. It is useful when growth is below the level

of peritoneal re ection.
Radiotherapy in carcinoma rectum
Only rectal adenocarcinoma in GIT responds well for RT
Preoperative RT can be given to down stage the tumour
so as to make it amenable for APR or make it for anterior
resection
Postoperative RT is commonly used
In small well-differentiated growths papillon's intracavitary
curative RT can be tried with proper follow-up
Palliative RT
IORT (Intraoperative RT) is used in pelvic wall disease. It can
cause peripheral neuropathy and ureteral stenosis
As a component of chemoradiation
Short course 25 Gy in 5 fractions in 5 days
Long course 5040 Gy in 28 fractions in 6 weeks
RT sterilises eld; causes down staging of tumour; preserves
sphincter
Chemotherapy
It has been tried using endoxan, 5 FU, semustine also with
leucoverin (Folinic acid) or levamisole.
Capecitabine, oxaliplatin are newer drugs used (refer
chapter large intestine for detail). Indications are positive nodes; T2 stage; blood spread; for chemoradiation;
recurrent tumour; advanced/ metastatic disease.
Biologic agents.
Bevacizumab VEGF receptor antagonist.
Cetuximab EGFR antagonist.
Other Methods
Electrocoagulation and decoring of the tumour, as a
palliative procedure; stenting.
Laser photocoagulation, cryotherapy.

 Portal vein infusion; hepatic artery infusion for metastases.

Tumour vaccines: Tumour antigen does not elicit
immune response in situ; but vaccines are injected
to evoke immune response. (1) BCG with irradiated
tumour cells (2) Monoclonal antibodies 17-1A [Murine
Ig G2A] (3) CEA vaccines.
Chemoradiation in Carcinoma Rectum
o It is very useful adjuvant therapy.
o To prevent recurrence after anterior resection.
o Neoadjuvant (preoperative) chemoradiation can be used
in tumour like T3 to downstage the disease and make it
possible for AR.
o Postoperative chemoradiation.
o Palliative chemoradiation in locally advanced disease or
metastatic disease also.
o Recurrent local carcinoma of rectum.
o In carcinoma of rectum presenting with obstruction, chemoradiation is given after loop colostomy.
Prognosis in carcinoma rectum
5-year survival is Prognostic
factors are
Follow-up
Stage I 90%
Stage II 75%
Stage III 40%
Stage IV 5%
Size of the
tumour
Differentiation
Mesorectal
involvement

 Stage of the
disease
Nodal status,
perineural
spread
Distant spread
Circumferential
resected
margin
Adjuvant
therapy used
Regular
colonoscopy
CEA
assessment
PET scan
CT/MRI
C olostomy
care in APR
SOLITARY ULCER SYNDROME
o It is mainly thickening and disorganisation of muscularis
mucosa with super cial ulceration.
o It is usually 4-12 cm from the anal verge in the anterior
wall of the rectum. But often can occur in sigmoid colon.
o Attempt to defaecate in the closed pelvic oor causes
funneling of the rectum and descent of the anterior rectal
wall. Raised intrarectal pressure and hidden intussusception is the cause. It is often seen in sexual abused
individuals. Often typical crater like ulcer is seen/felt on
the anterior rectum. Chronic ischaemia at that point may
be the cause.
o In 30% cases, there are multiple ulcers.

o Often there will be in ammation and induration of the area

without an ulcer.
o Presentations arecommon in young females, constipation, bleeding, mucosal prolapse, chronic pain in the anal
canal, incontinence. But sphincter tone on rectal examination is usually normal.
o Investigations: Defaecography shows nonrelaxing persistent puborectalis impression waves. EMG shows decreased
electrical activity. Colonoscopy should be done to rule out
other conditions like neoplasm, ulcerative colitis. Colonic
transit time shows rapid lling of the rectum but delayed
clearance of 7 days from the rectum.
o Condition is commonly associated with rectal prolapse.
o Differential diagnosis are carcinoma, tuberculosis, ulcerative colitis.
o Treatment:
High bre diet.
Treatment for rectal prolapse.
Avoid surgical excision in solitary ulcer syndrome as
much as possible.
The place to improve this world is rst in ones own heart, head and hands.
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RECTAL PROLAPSE
o It is circumferential descent of recetum (bowel) through
the anal canal.
o It is commonly seen in infants, children and elderly individual.
o It is common in females (6 : 1).
o Faecal incontinence is very common feature; urinary
incontinence occurs in 35% of patients; 15% of patients
are associated with vaginal vault prolapse.
o Rectal prolapse can be:
Partial.
Complete.
Hidden/concealedit is internal intussusception of the
sigmoid into the rectum or part of the rectum distally;
they do not come out of the anal ori ce. Here only
mucosa and submucosa separates from muscularis layer
and descends.
Fig. 25.17: Rectal prolapse.
Aetiology
o Alexis Moschowitz put his theory of rectal prolapse is due

to sliding herniation of the pouch of Douglas through pelvic

oor fascia into the anterior aspect of the rectum.
o Broden and Snellman proposed that procidentia is a full
thickness rectal intussusception starting approximately 7.5
cm above the dentate line which is extending beyond the
anal verge.
o Decreased sacral curvature and decreased anal canal tone
are the probable causes in infants.
o Chronic constipation with straining is the common cause.
o Diarrhoea, cough, malnutrition are the additional factors
in children.
o It may be due to reduced ischiorectal fossa fat, neurological
causes, brocystic disease of pancreas or poorly developed
pelvis.
o There is diastasis of the levator ani, abnormally deep cul
de sac, redundant sigmoid colon, patulous sphincter, loss
of rectal sacral support, lax and atonic pelvic oor musculature.
o Pudendal nerve damage is said to be the cause for pelvic
oor and anal sphincter weakness. It may be due to obstetric
injury, diabetes, sacral nerve damage.
o In adults, it is common in females, common in multipara
repeated birth injuries to perineum results in damage to the
perineal nerve supply.
o Additional factors are due to increased intra-abdominal
pressure due to any cause like chronic cough, stricture
urethra.
Types
Partial Rectal Prolapse
Here only mucosa and submucosa of the rectum descends, not
more than 3.75 cm. There is no descent of the muscular layer.
It is the commonest type of rectal prolapse.

Fig. 25.18: Partial rectal prolapse is less than

3.75 cm and only mucosal.
Clinical Features of Partial Rectal Prolapse
o History of mass per anum, which can be observed when
child is allowed to strain in squatting position.
o It is pink in colour and circumferential.
o It differs from piles (differential diagnosis), the piles are
not circumferential and are plum or blue coloured (not
pink).
Treatment for Partial Prolapse
1. The nutrition of the child is improved and digital repositioning is tried. Correction of constipation is important.
2. Submucosal injections of 10 ml of 5% phenol in almond oil
or ethanolamine oleate is given into the apex of the prolapse
under. G/A so as to create an aseptic in ammation leading
to tethering of mucosa to the underlying muscular coat.
Injection can also be given at the base or both at the apex
and base.
Alternatively 30 ml of tetracycline or oxytetra cycline
or hypertonic saline injection can also be used. Initial
injection is supported by Thiersch wiring using (temporary) chromic catgut until adhesion occurs between the
mucosa and muscular layer (in 3 weeks).
In adults, injection therapy is tried for partial prolapse,
results are not as good as in children.
3. Thiersch wiring alone is tried with good success rate in
children.
4. Goodsalls operation is excision of the prolapsed mucosa
at its base, usually in three positions.
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5. Stapled transanal rectal resection surgery (STARR) is also
often used.
Fig. 25.19: Goodsalls ligature for partial prolapse. Prolapsed mucosa
is ligated at different positions using nonabsorbable suture material
often with double needled. Usually, it is done for one side in three
portions.
Complete Rectal Prolapse
o Also called as procidentia, is less common than partial
prolapse.
o It is common in females (6 : 1 :: female : male).
o It is due to weakened levator ani and supporting pelvic
tissues.
o The descent is always more than 3.75 cm, contains all

layers of the rectum (i.e. including muscular layer). Often

descends down up to 10-15 cm.
o It is often associated with the uterine descent (uterine
prolapse).
o It is also thought to be as an intussusception of the
rectum.
o Once complete prolapse is more than 5 cm, anteriorly it
drags peritoneum as pouch which often contains small
intestine. On digital pushing it reduces with gurgling.
o Patulous anal sphincter is typical with mucus discharge and
faecal incontinence.
Fig. 25.20: Complete rectal prolapse.
Figs 25.21A and B: Complete rectal prolapse. It should be conrmed
by observing the patient during straining in squatting position.
Fig. 25.22: Female patient presented with both complete uterine
and rectal prolapse (Procidentia).
o Mucosa of the chronic rectal prolapse is thickened, ulcerated,
bleeds, and often incarcerated below the level of anal verge.
Aetiological factors
Weak anus, external sphincter and pelvic muscle
Lax, mobile rectum
Obliterated ano-rectal angle
Abnormally mobile rectum with descent
Clinical Features of Complete Rectal Prolapse
o Complete descent of rectum as mass per anum circumferentially which is red in colour. Mass is usually reducible and
painless. Incarcerated or infected rectal prolapse is painful.
o Rectal prolapse may be associated with the uterine prolapse
(uterine procidentia) in females.
He who is angry is seldom at ease.
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o Faecal incontinence (75%) is very common. It is due
to disruption of the anal sphincter and prolapsed rectal
mucosal discharge.
o Bleeding can occur because of the congestion.
o Sepsis, discharge, fever, anaemia are other features.
o P/R examination shows lax sphincter. Anteriorly, peritoneal
sac comes down as a pouch which may contain small bowel.
Figs 25.23A to C: Complete rectal prolapse. It is more than 3.75 cm,

prolapse of mucosa with muscular layer.

Differential Diagnosis
Rectosigmoid intussusception, third degree piles, large rectal
polyp.
Folds in rectal prolapse are concentric and red in colour; in piles
there are radial nonconcentric invaginations of haemorrhoidal
cushions which are plum coloured with a cutaneous component.
Complications of rectal prolapse
Ulceration, bleeding, anaemia
Proctitis, sepsis
Irreducibility, gangrene
Rupture with evisceration
Investigations
o Defecography reveals increased mobility of the rectum
from sacral xation point with redundant mesorectum and
funnel formation. It is uoroscopic and spot lming in lateral
projection after instilling radio-opaque material into the
rectum done in sitting posture over a radiolucent commode.
Cinedefecography, triple contrast cinedefecography,
dynamic MRI defecography, colpocystodefecography
are helpful to delineate complex pelvic oor problems.
Defecography detected abnormalitiesmegarectum,
incontinence, nonrelaxing puborectalis, abnormal
perineal descent (2.5 cm), mucosal prolapse, solitary
ulcer rectocoele, enterocele.
Preprolapse (in defecography): Rectum is funnel
shaped, lack of xation to sacrum, excessive rectosigmoid mobility, ring pocket formation, intussusception.
Rectal prolapse (in defecography): Redundant sigmoid
colon, wide deep pouch of Douglas.
Defecographic grading of rectal prolapse
N normal rectal xation and sphincter relaxation and rectal

emptying
1nonrelaxed puborectalis
2mild intussusception
3moderate intussusception
4severe intussusception
5prolapse
Rrectocele
o Sigmoidoscopy: It is to detect the tumour in the intussuscepted prolapsed rectum which is an occasional cause.
o Anal manometry: Resting (40 mmHg of internal sphincter)
and squeeze (80 mmHg, exteranal sphincter) pressures at
various points in anal canal is measured by placing water
lled balloons attached to catheters and transducers placed
in the anal canal.
o Pudendal nerve latency study: Specialized transducer
attached to a glove like device is to be worn on the nger
through which digital rectal examination is done. Electrode
in the nger is directed over the right and left levator ani
complex to measure pudendal nerve terminal motor latency
(PNTML) which is normally 1.8-2.2 msec. It is prolonged
in pudendal nerve damage.
o Electromyography study of the puborectalis muscle tone
is also very useful.
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Treatment for Complete Prolapse
Aim of Treatment
o To control the prolapse; to restore continence; to prevent
constipation.
o In young males, abdominal repair should be avoided as
it injures pelvic nerves leading to sexual impotency. So
perineal approach is better.
o Rectopexy is xing the rectum to sacrum by sutures or mesh
after complete mobilisation of the rectum. Laparoscopic
rectopexy using polypropylene mesh and sutures gives
good result and has become very popular.
o Delormes operation is better option in young individual
with complete prolapse.
o In elderly perineal proctectomy with anterior and posterior
ree ng of the sphincter muscle is accepted method now. It is
similar to Altemeier technique (It is perineal rectosigmoidec-

tomy). Here entire prolapsed rectum and redundant sigmoid

is resected through perineum prior to ree ng of the sphincter.
o Anal encircling surgeries using synthetic wires/mesh/suture
materials are limited to extremely ill patients and elderly
who will not withstand perineal proctectomy.
o Choice of procedure depends on age, sex, operative risk,
pelvic oor defect, degree of incontinence, history of
constipation.
SurgeryTypes
Abdominal Procedures
Laparoscopic rectopexy
o It is ideal and good approach to x the rectum to sacrum.
o Laparoscopic posterior mesh rectopexy (LPMR) is the
procedure done. Prior bowel preparation is needed. Head
down, low lithotomy position is needed. Ports are placed
as shown in diagram. Sigmoid colon is held with left sided
port. Surgeon does dissection from right side. Peritoneum
on the right of the rectum is opened from sacral promontory downwards to reach presacral avascular plane. Care
should be taken to avoid injury to autonomic nerves, ureters.
Dissection is extended down as posterior mobilisation
into the pelvis with adequate mobilisation of the rectum.
Lateral ligaments are either divided or left alone. Anterior
mobilisation is also important. Anterior mobilisation along
the Denonvilliers fascia is done 5 cm below the peritoneal
re ection. 15 10 cm polypropylene mesh is placed in the
presacral space deep to rectum which is xed to presacral
fascia along the sacrum and sacral promontory. Mesh is
sutured to rectal wall also on both sides using interrupted
polypropylene sutures. Only partial wrapping of mesh is
done. Peritoneum is closed using vicryl.
o Many advocate laparoscopic mobilisation and xation of

mobilised rectum to sacral promontory using polypropylene

sutures without mesh.
o Laparoscopic sigmoid resection and rectopexy (Laparoscopic resection rectopexy, LRR) is done when there is
rectal prolapse with constipation, with excess redundant
sigmoid colon with kinking.
Wells operation
o Polyvinyl alcohol sponge is wrapped around the mobilised
rectum and is xed to sacrum. Infection, stula formation
is high.
o Polypropylene mesh is used as a modi cation now instead
of polyvinyl sponge; wrapping is only partially done to
reduce the incidence of constipation.
Ripstein operation
After mobilisation of the rectum, 5 cm width Te on mesh sling
is passed around the rectum to x it behind to fascia 5 cm below
and in front of the sacral promontory. Sling is also xed in front
and laterally to rectum.
Golighers operation
Rectum is entirely mobilised up to anorectal ring and its posterior muscular layer is xed to presacral fascia using interrupted
polypropylene sutures.
Devadhar rectal plication
Through abdominal approach, junction between thicker lower
part and thinner upper part of the intussusception is identi ed.
A purse string suture using silk is placed in front and laterally;
further 3-4 interrupted submucosal Lambert sutures are placed
to create reverse intussusception.
Lahauts operation
Rectosigmoid is mobilised fully; mobilised loop of rectosigmoid is passed in front through posterior rectus sheath behind
the rectus muscle; extraperitonealisation is done to pull the

rectus forward to prevent descent.

Rosoe Graham operation
o After mobilisation of the rectum, levator muscles are exposed
and sutured in front of the rectum along with removal of
pouch of Douglas.
Fig. 25.24: Laparoscopic rectal prolapseports.
Patience is the companion of the wisdom.
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o In Dumphy operation it is done through combined abdomi-

noperineal approach with perineal rectosigmoidectomy.

Both procedures control prolapse well but not incontinence.
Muir low anterior resection
In a redundant rectosigmoid with prolapse, rectosigmoid resection is done; excision of redundant pouch of Douglas is done;
rectum is xed to sacrum behind.
Perineal Procedures
Delormes operation (Mucosal sleeve resection and plication)
After prior bowel preparation, under spinal anaesthesia, in
lithotomy position, completely prolapsed rectum is held
with Babcocks forceps. 1 in 2,00,000 adrenaline solution
is injected into the submucosal plane of the rectum to cause
haemostasis. By making longitudinal incision, with sharp
scissor and cautery dissection, mucosa is stripped off from
the deeper muscular layer from 1 cm below the anal margin
to the apex of the prolapsed rectum. Muscular layer of
rectum is plicated using absorbable vicryl 2 zero interrupted
sutures all around; approximately 12-15 plication stitches are
needed. These sutures are tied after nishing the passage of
all sutures. Cut end of the mucosa of the apex is sutured to
anal margin using interrupted vicryl sutures. It is technically
easier. But incontinence may persist and recurrence chance
is high.
Perineal posterior xation of the rectum of LockhardtMummery
Retrorectal space is dissected through perineal approach and
posterior rectal wall is sutured to sacrum and coccyx, additionally placing a retrorectal gauze pack to stimulate adhesions.
Wyatt operation
Through perineal post anal approach dissected retrorectal space
is placed with a Marlex/mersilene mesh which is sutured high

to the sacral promontory and rectal wall laterally.

Mickulicz Miles perineal transanal rectosigmoidectomy/
amputation of prolapse
Prolapsed rectum is excised and sigmoid is sutured to the anal
margin.
Altemeirs rectosigmoidectomy
After rectosigmoidectomy, colonic anastomosis and pelvic
oor is supported by suturing puborectalis muscle in front of
the rectum using nonabsorbable sutures.
Anal encircling
o In 1891, Thiersch did anal encircling using silver wire
to provoke inammatory brosis as well as to give
mechanical support to the anal ori ceThiersch wiring.
It is done under local anaesthesia. Two small incisions
are made at lateral parts of the anal canal. Silver wire
is passed around deeper to these incisions and tied after
placing the index nger into the anal canal. Wire can be
removed after 12 months. Polypropylene, nylon are the
other materials that can be used. Complications: Pain due
to wire erosion, infection, faecal impaction, incarceration, high recurrence of 50% or more. In children with
rectal prolapse, temporary wiring along with Goodsalls
ligature or injection sclerotherapy using thick catgut are
often advocated.
o Supralevator high encirclement of anal ori ce (of Notaras)
is done above the level pf levator muscles by placing Te on
or nylon ribbons through anterior and posterior incisions. It
gives better support and will not cut through. Thoralsksen
modi ed this by placing plastic/mersilene tape around the
bowel high up.
Procedures for repair of rectal prolapse
Perineal operations Abdominal operations:

Open/Laparoscopic
Mucosal sleeve resection
(Delorme)
Suture rectopexy
Goligher, Lahaut,
Devadhar, Rosoe Graham
Perineal
rectosigmoidectomy
(Altemeier)
Prosthetic or mesh
rectopexyanterior/
posteriorWells, Ripstein
Posterior xation of the
rectum of LockhardtMummery
Resection rectopexy
Muirs
Wyatt operation Anterior resection
Mickulicz Miles
perineal transanal
rectosigmoidectomy/
amputation of prolapse
Lahauts operation
Anal encircling (Theirsch)
Complications of Surgery
o Injury to hypogastric nerve causing impotence.
o Bladder dysfunction.
o Bleeding from sacral venous plexus.
o Injury to rectum and colon causing faceal stula.
o Constipation after rectopexy is a known complication.
o Recurrence of prolapse.
o Improper correction of continence occurs in 50% cases.

o Infectionproctitis/pelvic abscess, etc.

ANORECTAL MALFORMATIONS (ARM)
o It is due to imperfect fusion of the post-allantoic gut with
the proctodaeum.
o Incidence is one in 4500 newborns.
Figs 25.25A and B: Anorectal malformation with stula in
(A) Females and, (B) Males.
AB
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Clinical Features
o New born presents with inability to pass meconium,

abdominal distension, features of intestinal obstruct ion,

improper anal dimple, sometimes with com plaints of
passing meconium per urethra.
Fig. 25.26: Anal stenosis.
Fig. 25.27: Anorectal malformation, Cloaca type.
o It can be associated withcardiac anomaly, tracheooesophageal stula, renal anomalies, spinal anomalies.
VATER/VACTERL anomaly.
o Most common ARM in boys is rectobulbar stula with
stula beginning distal to puborectalis from distal rectum
to bulbar urethra.
o Most common ARM in females is rectovestibular stula.
Investigations
1. Wangensteins i nvertogram: Usually done 6-12 hours after
birth, so as to allow air to reach the rectal pouch. A metal
coin (marker) is strapped at the presumed site of anus and
X-ray is taken. Length between the rectal pouch and anal
dimple marker is more than 2.5 cm in high anal stula.
a. In l ow stula, rectal pouch is distal to the Stephens line
(Pubococcygeal line).
b. In intermediate, pouch is at the level of ischial spine
(Kellys point).
c. In high stula, rectal pouch is proximal to the Stephens
line.
2. Murugassus t echnique: Through visible anal dimple, meconium is aspirated by passing a needle into the rectal pouch
in sitting propped up position. Watersoluble iodine dye is
injected. Lateral X-ray is taken to study the level through
Stephen line and Kellys point.
3. U/S abdomen.
4. Evaluation of cardiac function is also important.
5. MRI spine.

Fig. 25.28: Stephens line.

Wingspread classi cation of anorectal malformations
(Wingspreadname of the place where the conference was held)
Low Intermediate High
It is below the level of pelvic oor,
(Puborectalis). Easy to diagnose and
treat with good outcome. It may be
It occurs at the level of puborectalis,
with or without stula
It can be with or without a stula into
the bladder urethra, uterus, vagina It
may be:
Covered anus Anorectal agenesis
Anovestibular stula Rectal atresia
Anal stenosis Cloaca (only in females, with
con uence of rectum, vagina, bladder
and urogenital sinus)
Anal membrane.
We make a living by what we get; we make a life by what we give.
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Treatment
1. In l ow stula, single stage reconstruction is done under G/A
with very good results.
i. Anoplasty.
ii. Anovestibuloplasty.
iii. Anal dilatation.
iv. Incision of anal membrane.
2. In high stula, initial colostomy is done. Later de nitive
procedure, i.e. Pull through operation through puborectalis
and anastomosis of rectal pouch to create the anal canal is
done. Closure of colostomy is done later.
Posterior sagittal anorectoplasty is commonly done
procedure.
Note:
Level of rectal pouch and normal/abnormal sacrum are the deciding
factors for good results.
Complications
Infection
Faecal stula
Stenosis
Colitis

 Malnutrition
Faecal incontinence
PILONIDAL SINUS/DISEASE
(Jeep Bottom; Drivers Bottom)
Pilushair; Nidusnest
o It is of infective origin and occurs in sacral region between
the buttocks, umbilicus, axilla.
o It is epithelium lined tract, situated short distance behind
the anus, containing hairs and unhealthy diseased granulation tissue. It is due to penetration of hairs through the skin
into subcutaneous tissue. It forms granuloma/unhealthy
granulation tissue in the deeper plane.
o Types of hair (H), force of hair insertion into subcutaneous
tissue (F), vulnerability of the skin (V) are the three factors
that cause pilonidal sinus. Number of hairs collected, acuteness of root end of hairs, type of hairtough/silky, shape
of hairstraight/curled, scaliness of hair are the deciding
features of hair. Cut hairs from above descend into cleft
and stay there to get buried deep into pilonidal sinus.
Depth, narrowness, friction movements in the natal cleft;
soft/macerated skin with erosions, splits, wide skin pores,
wounds, presence of moisture and sweat are other factors.
o It is common in hair dressers (seen in interdigital clefts),
jeep drivers.
o It is common in 20-30 years of age. It is common in males
and mostly affects hairy men.
Fig. 25.30: Typical site of pilonidal sinus in the sacral region. Note
the primary and secondary sinuses.
Fig. 25.31: Recurrent pilonidal sinus. 25-40% of pilonidal sinuses
can recur.
Commonest site: Interbuttock sacral region.
Pathology

.sunis ladinolip fo sepyt dna etiS :92.52 .giFFig. 25.32: Specimen of typical
excised pilonidal sinus. Note the tuft of hair.
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Hair penetrates the skin

Dermatitis

Infection

Pustule formation


Sinus formation

Hair gets sucked into the sinus by negative pressure in the area

Further irritation and granulation tissue formation

Pus forms

Multiple discharging sinus

Primary sinus occurs in the midline.
Secondary sinus occurs laterally (paramedian).
Note:
Theories like Preen gland, medullary canal vestige, traction
dermoid, inclusion dermoid are no longer accepted. Now it is
considered as acquired condition.
Remember about pilonidal sinus
Congenital theory is no longer considered; it is an acquired entity
Hair follicles have never been demonstrated in the wall of the
sinus (only hairs have found)
Number, sharpness, nature, shape of hairs; depth and narrowness
of the natal cleft; friction movements; nature of the skin, moisture
and sweating are the factors predisposing pilonidal sinus
Hair need not be local, tract always traverses cephalad
Male preponderance74%, male sex hormone effect, hairy
body, more sweat and maceration
Occurs in young20-29 years, who are having active pilosebaceous glands
Dark hairedstiff hairs, rare in Negroes
Obese and overweightdeep natal cleft
Prolonged sitting
Many procedures for treatment are available with each one

having their own advantages and disadvantages

Fig. 25.33: Pilonidal sinusprimary and secondary sinuses are clearly seen.
Clinical Features
o Dischargeeither sero sanguinous or purulent.
o Painthrobbing and persistent type.
o A tender swelling seen just above the coccyx in the
midline (primary sinus); and on either sides of the midline
(secondary sinus).
o Tuft of hairs may be seen in the opening of the sinus.
o Presentation may be as an acute exacerbation (abscess),
or as a chronic one.
o It causes recurrent infection, abscess formation which
bursts open forming recurrent sinus with pain, discharge
and discomfort.
Complications
o Chronic pilonidal sinus can cause occasionally sacral
osteomyelitis, necrotising fasciitis and rarely meningitis.
o It is not a life threatening condition but often it can be a
morbid disease because of high recurrence rate.
Treatment
In acute phase initiallydrainage of the abscess and antibiotics; later de nitive treatment is undertaken.
Figs 25.34A and B: Pilonidal sinusoperative jack knife position.
De nitive treatment:
o In prone position (jack knife position, i.e. prone with
buttocks elevated) excision and primary closure is done
under general anaesthesia or local anaesthesia. All sinus
tracks, unhealthy granulation tissues with hairs are removed
completely. Methylene blue is injected to demonstrate the
multiple tracks properly.
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Trust your hopes, not your fear.

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o Excision and skin graftinghas got high recurrence rate.
o Excision with Z plastygood result.
o Excision with multiple Z plasty.
o Karydakis excision through a semilateral incision and
lateralised suturing of the wound away from the midline
gives good result.
o Excision with closure using Limberg (Rhomboid) buttock

 ap (single or double rhomboid aps)good result.

o V-Y gluteal advancement ap.
o Bascom technique of excision through lateral approach is
a good method. Through small lateral incision or multiple
small lateral incisions 2-4 mm sized sinus is approached
and pus is drained; hairs are removed with only minimal
excision of sinus done. Cavity walls are not excised. Lateral
small wounds are either sutured or left open for spontaneous
healing.
o Lahey and Cattells relaxing skin incisions on one buttock
to relieve tension on main wound sutures with later closure
of secondary wounds by sutures or advancement.
o Davies and Starr buttock skin ap rotation into the defect
and secondary defect is closed at a later period.
o After excision of entire sinus completely, wound is left
open to granulate and heal by epithelialisation with regular
dressings.
o Buies marsupialisation of the sinus trackafter making
incision on the sinus track, edge of the laid opened area is
sutured to the skin edge all round using silk or vicryl. This
reduces healing time and promotes healing.
o Lord and Millars limited excision of primary track for 0.5
cm depth with removal of tuft of hairs, debris and unhealthy
granulation tissue using tiny brush and nylon bristle.
o Injection of phenol to the track destroys the epithelium
after removal of the tufted hairs. Phenol is allowed to be
in contact with epithelium for 3 minutes to create a blanch
in the track ori ce.
Fig. 25.36: Z plasty is done for pilonidal sinus. It gives good result.
Multiple Z plasties are also used.
Nonoperative treatment/prevention of recurrence after surgery :
o Regular shaving of natal cleft to have meticulous hair

control. Laser, depilatory cream, electrolysis are other

methods used.
o Proper perineal hygiene.
Causes for high recurrence rate
Improper removal
Overlooking of existing diverticulum
Entry of new tuft of hairs
Breakage of scar
Note: Condition has got high recurrence rate (20%)
PILES/HAEMORRHOIDS
If bile or phlegm be determined to the veins in the rectum, it heats the
blood in the veins: and these veins becoming heated attract blood
from the nearest veins, and being gorged the inside of the gut swells
outwardly, and the heads of the veins are raised up, and being at
the same time bruised by the faeces passing out, and injured by the
blood collected in them, they squirt blood, most frequently along
with the faeces, but sometimes without faeces.
Hippocrates, (460-375 BC)
Figs 25.35A to G: Rhomboid-Limberg ap for pilonidal sinus. It gives good result.
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Piles = a ball or mass, Haemorrhoids = blood to ooze, Figs
= a fruit (Anjoora).
o The word Haemorrhoids is derived from Greek word
Haima (bleed) + Rhoos ( owering), means bleeding. The
pile is derived from the Latin word Pila means Ball.
o It is downward sliding of anal cushions abnor mally due to
straining or other causes.
o Anal cushions (Thomson, 1975) are aggregation of blood
vessels (arterioles, venules), smooth muscles and elastic
connective tissue in the submucosa that normally reside
in left lateral, right posterolateral and right anterolateral
anal canal.
o Piles can be mucosal or vascular (Graham Stewart, 1963).
Vascular type is seen in young; mucosal is seen in old.
o Present concept is weakening of Parks ligament which is
the lower end of the external sphincter.
Types
Internalabove the dentate line, covered with mucous

membrane.
Externalbelow the dentate line, covered with skin.
Interno-externaltogether occurs.
Fig. 25.37: Anatomical locations of
internal and external piles.
Fig. 25.38: Parts of pilesplum coloured internal part and black
cutaneous external component.
Classication I
Primary haemorrhoids: Located at 3, 7, 11 oclock positions,
related to the branches of the superior haemorrhoidal vessel which
divides on the right side into two; left side it continues as one.
Fig. 25.39: Positions of haemorrhoids.
Secondary haemorrhoids: One which occurs between the
primary sites.
Classi cation II
First degree haemorrhoids
Piles within that may bleed but does not come out
Second degree haemorrhoids
Piles that prolapse during defecation, but returns back spontaneously
Third degree haemorrhoids
Piles prolapsed during defecation, can be replaced back only
by manual help
Fourth degree haemorrhoids
Piles that are permanently prolapsed
Piles begin as pedicle and it is located at the origin of the
internal pile, i.e. at the level of anorectum.
Fig. 25.40: Degrees of haemorrhoids.
Aetiology
o Hereditary.
o Morphologicalweight of the blood column without valves
causes high pressure. Veins in the lower rectum are in loose

submucosal plane, but the veins above enter the muscular

layer, which on contraction increases the venous congestion below (more preva lent in patients with constipa tion).
Superior rectal veins have no valves (as they are tributaries
of portal vein) and so more congestion.
o Other causes are straining, diarrhoea, constipation, hard
stool, low bre diet, overpurgation, carcinoma rectum,
pregnancy, portal hypertension (rare cause). During pregnancy factors causing haemorrhoidsraised progesterone
relaxes the venous wall and reduces its tone, enlarged uterus
compresses the pelvic vein, and constipation is common
problem.
To different minds, the same world is a hell, and a heaven.
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Figs 25.41A to F: Different types of prolapsed piles.
o Bulging of haemorrhoidal plexus (anal corpus cavernosum,
by Stelzner) occurs due to raised luminal pressure and
transmission of arterial pressure; pressure in rectal ampullary pump (Wannas) during straining raises the portal as
well as systemic pressure causing obstruction to venous
out ow causing haemorrhoids. Disruption of suspensory
tissues which hold plexus in position (sliding lining theory);
raised basal anal pressure; unsupported superior haemorrhoidal vein in the loose submucosal connective tissue in
the anorectum when passes through the muscular coat gets
constricting effect leading into congestion of haemorrhoidal
plexusare the other theories of haemorrhoid formation.
o Idiopathic cause: It is very dif cult to pinpoint the cause
for production of piles.
AB
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Fig. 25.42: Thrombosed prolapsed pile. Note the colour of the
thrombosed pile. It is very painful and tender.
An arterial pile is haemangiomatous condition of superior
rectal artery entering the pedicle of internal haemorrhoid which
will bleed profusely.
Clinical Features
o The prevalence rate of piles is 4.4% in the world, in about
10 million people.
o It may occur at any age but mostly seen in the age between
30 to 65 years.
o Incidence is equal in both the sexes.
o Bleeding1st symptomSplash in the panbright red
and freshoccurs during defecation.
o Mass per anum.
o Dischargea mucoid discharge.
o Pruritus.
o Painmay be due to prolapse, infection or spasm.
o Anaemiasecondary.
o On inspection, prolapsed piles will be visualized.

o On P/R examination, only thrombosed piles can be felt.

o Through proctoscopy, exact position can be made out as a
bulge into the proctoscope.
o Points to be noted during proctoscopy:
The numbers, degrees and size.
The surface and appearance of piles.
Features chronicity of the prolapse.
Fig. 25.43: Proctoscopic view of the internal pile (grooved
proctoscope).
Causes for bleeding per anum
Piles Carcinomarectum
Fissure-in-ano Carcinomacolon
Polyps Diverticulitis
Ulcerative colitis Intussusception
Amoebic colitis Vascular anomaly of the
colorectum
Fistula-in-ano Mesentericischaem ia
One should look for other rectal lesion such as external
tags, anal papillae and ssure, proctitis.
Figs 25.44A to C: Different positions of piles and parts.
ABC
We do not see things as they are, we see them as we are.
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Any gynaecological, genitourinary or abdominal conditions likecarcinoma of rectum, polyps, tumours,
features of ulcerative colitis should be identi ed.
Presence of other discharge like blood, pus, mucous.
o Sigmoidoscopy or colonoscopy or barium enema should
be done if there is any suspicion of asso ciated malignancy.
Differential Diagnosis
o Carcinoma.
o Rectal prolapse.
o Perianal warts.
Investigations
o Haematocrit.
o Colonoscopy to evaluate proximally for any cause.
o Barium enema X-ray.
Complications
o Profuse haemorrhage which may require blood transfusion.
o Strangulationpiles is being gripped by anal sphincter.
o Thrombosispiles appear dark purple/black, feels solid

and tender.
o Ulceration.
o Gangrene.
o Fibrosis.
o Stenosis.
o Suppuration, leads to perianal or submucosal abscess.
o Pylephlebitis (Portal pyaemia) is rare, but can occur in 3rd
degree piles after surgery.
Treatment
Preventive Therapeutic/curative
Dietmore
bre/liquid
Laxatives
Medicallocal applications; sitz bath,
diet, laxatives, drugsanalgesics
Parasurgical
Sclerotherapy
Banding
Cryotherapy
Infrared coagulation (IRC)
Laser therapy
Doppler guided haemorrhoidal artery
ligation (DGHAL)
Surgical
Open haemorrhoidectomy
Closed haemorrhoidectomy
Stapled haemorrhoidopexy
Anal stretchingRecamier, Lords
1. Nonoperative:
o Sitz bathmeans the patient has to sit in warm water
with the anal region dipped in water for 20 minutes, 2-3
times a day.This reduces the oedema, pain and promotes

healing.
Fig. 25.45: Prolapsed, strangulated piles.
o Local applications to reduce pain, itching and oedema can
be used.
o Antibiotics, laxatives, anti-in ammatory drugs are bene cial.
o Fibre diet 35 gram/day, plenty of water. Fibre alternatives (bulk-forming agents e.g. ispaghula husk, sterculia,
methylcellulose) can be used to supplement a high- bre
diet; squatting position may reduce the incidence of piles;
plenty of liquid intake.
o Laxatives such as lactulose solution which soften bowel
motions and relieve the constipation. Bulk laxatives such
as psyllium mucilloid, Konsyl or polycarbophil may be
necessary.
2. In case of in amed, permanently prolapsed, oedematous
piles, initially, manual stretching of the anal canal sphincter
is tried. This prevents congestion of anal cushions and
relaxes the anal sphincter, as a result of which the prolapsed
piles gets reducedLords dilatation (8 ngers). Once
oedema subsides, in 1-2 weeks, formal procedure is done.
Complications of anal dilatation (3-4 ngers dilatation)
Incontinencerectalusually temporary
Infection
Haemorrhage/haematoma
Prolapse rectum
3. Injection-Sclerosant therapy:
o It is done in 1st degree and early 2nd degree piles
(internal)outpatient procedure.
o Using proctoscope and Gabriel syringe, 3-5 ml of 5%
phenol in almond oil is injected into the submucosal plane
just above the anorectal ring to the pedicle. All three piles

can be injected separately3-5 ml to each site in single

sitting. Technique can be repeated after 6 weeks. This
technique is not done in the presence of sepsis or prolapse.
o The drug causes brosis in the submucosal region (sclerosis
leading to mucosal xation on to deeper planes and occlusion of lakes) and thereby xation of the anal cushions
which do not prolapse, causes strengthening of the vessel
wall and obliteration of the vessel lumen.
o It is quick and painless; gives 95% cure rate in 1st degree
piles; done on OP basis.
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o Contraindications arethrombosed/prolapsed piles,

presence of proctitis/ ssure/ stula-in-ano, pregnancy and
diabetes mellitus.
o Sclerotherapy has not gained popularity, oily solution is
dif cult to handle and inject.
o Complicationsrecurrence (15%), hypochondriac pain due
to entry of drug into the portal system, tenesmus, mucosal
sloughing/ulceration, submucosal abscess, anal canal pain,
anal stricture.
o Inadvertent deep injection can precipitate pelvic abscess,
prostatitis, impotence, rectovaginal stula.
Fig. 25.46: Gabriel syringeIt is used for injection sclerotherapy for
internal piles using 5% phenol in almond/olive oil (almond/vegetable
oil acts as a vehicle which holds phenol for long period of action). It is a
stainless steel syringe with two metallic nger brims near the proximal
end. One more metallic nger brim is present on the proximal end of
the piston to place thumb while injecting.
Fig. 25.47: Barrons band instrument for 1st and early 2nd degree piles.
Fig. 25.48: Cryosurgery instrument set up for cryohaemorrhoidectomy.
4. Barrons banding:
o It is done for 2nd degree piles. It causes ischaemic necrosis
and piles fall off.
o At one time only two piles can be banded. Repeat banding
can be done only after 3 weeks.
o Band should be placed 2 cm above the dentate line.
o Usually 2 bands are used for pile mass to take care of
breakage. Tissue sloughs off in 1-2 weeks leaving an ulcer
which heals by scarring.
o Equipment is inexpensive, simple to perform; done without
anaesthesia on OP basis; results are consistent, stops
bleeding and tackles the prolapsing anal cushion.
Fig. 25.49: Cryo instrument for cryosurgery.

Fig. 25.50: Cryosurgery for piles. Note the probe, grooved

proctoscope, freezing the internal pile mass.
o It is contraindicated in ssure/ stula/proctitis.
o Complications: if applied low into skin it causes severe
pain; discomfort; secondary haemorrhage, ulceration.
Note:
Suction banding is used presently. Suction is used to suck the internal
pile into the banding gun.
5. Cryosurgery:
o Using nitrous oxide (98) or liquid nitrogen (196),
extreme cold temperature is used to coagulate and cause
necrosis of piles which gets separated and falls off subsequently.
o It is relatively painless and can be done on OP basis.
o All masses can be tackled at one sitting.
o This is carried out with the help of a cryoprobe. Nitrous
oxide is preferred since it produces adequate freezing.
Nitrous oxide delivery system/cryoprobe does not
require special rewarming circuit. Liquid nitrogen
produces quick destruction and damage of sphincter
muscle; also needs special rewarming circuit for its
release and is costlier.
o The patient is put in lithotomy position; cryoprobe is
applied in the longitudinal axis of internal pile above the
dentate line; the pressure must be maintained above 700
lb continuously; the rapid adhesion with freezing (white
area formation on piles) occurs; traction and slight rotation in both directions is done to draw entire pile mass
Life is ten percent, to make it and ninety percent, how you take it.
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to come in contact with the probe; when entire tissue
is frozen in 20-30 seconds, the probe is detached after
warming (defrosting/thawing). Procedure is repeated on
other pile masses.
o Advantages: It is reasonably painless, simple, safe, can be
done on OP basis, with less bleeding.
o Disadvantages: It causes profuse watery discharge, itching,
pain if skin is frozen; marked oedema of adjacent skin,
incontinence occasionally.
6. Infrared coagulation:
o Here heat is used to burn the piles so as to allow it to

fall off.
o Pulses of infrared radiation are applied through a handheld
applicator. The specic infrared wavelengths produce
chemical changes that cause blood coagulation within the
haemorrhoid itself, which causes the haemorrhoid to seal,
shrivel, shrink or slough off. Source of infrared rays of 14
volt Wolfram halogen lamp with a gold plated re ector rays
are transmitted from ber optic cable which terminates in
a probe or pistol for coagulation.
o In left lateral position, the probe is applied at the base of
pedicle above the dentate line and bursts are given in clover
leaf fashion. Timer is set at 2 secs giving a depth of 2 mm;
total time taken 2-5 minutes. It is done in 1st, 2nd, and 3rd
degree piles.
o It produces a discrete area of necrosis (coagulates tissue
proteins and evaporates water from the cells) which heals
to form a scar; reduces or eliminates blood ow through
the haemorrhoid thereby shrinking it and mucosa becomes
xed to the underlying tissue.
o Often 3 or 4 sittings are needed at 1 month intervals.
o It does not cause noncontact coagulation; does not cause
interference with electromagnetic devices such as pacemakers. It is contraindicated in external pile, proctitis.
Long-term results are not good. Equipment is expensive;
multiple sessions are needed.
7. Laser therapy for pilesfor 3rd degree piles.
o Nd-YAG , diode and carbon dioxide lasers can be used but
are expensive and tedious.
o The intense beam of light interacts with tissue and can
be used to cut, coagulate or ablate the tissue, sealing off
nerves and tiny blood vessels can be done by laser beam.
By sealing super cial nerve endings patients have minimum

postoperative discomfort. Laser is used for dissecting and

excising pile masses.
o It is done for internal haemorrhoids.
o Advantagesless operative time; less intraoperative and
postoperative bleed and pain; rapid healing; quick recovery;
done under LA/SA; less complications; minimal pain,
constipation and urinary retention.
o Disadvantagesneeds skill; sphincter should be taken care
of; non contact burning can occur; secondary haemorrhage
can occur due to heat tissue destruction; and also injury to
sphincter can occur.
Figs 25.51A to C: Laser surgery for pilesCO2 laser and
diode laser.
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8. Doppler guided haemorrhoidal artery ligation (DGHAL)
o DGHAL is an advanced instrument that works under
Doppler guided ultrasound. It is painless, 20-minute
procedure that cures all degrees of haemorrhoids. It causes
choking and blocking of the blood supply of piles. It is done
using proctoscope with an incorporated Doppler probe.
o This proctoscope is inserted and used to locate the haemorrhoidal arteries by an audible signal. Once located, a needle
holder is inserted into the lumen of the proctoscope and the
artery ligated with a gure of eight absorbable suture into
the submucosa. The procedure is repeated until no more
Doppler signals are identi ed.
o Advantages: Anaesthesia is not needed; blood loss, pain,
residual problems are minimal; done as day care surgery;
early return for work; may be safe in diabetic, cardiac, old
age patients, and in pregnancy.
o It is under trial and too early to con rm the ef cacy.
9. Stapled haemorrhoidopexy (Antonio Longo)
o It is circumferential excision of the mucosa and sub-mucosa
4 cm above the dentate line using circular haemorrhoidal
stapler passed per anally (MIPHminimally invasive
procedure for haemorrhoids).
o Advantages areit is less painful; less blood loss; faster
recovery; short hospital stay and equally ef cacious.
o It is done only for prolapsed piles.
Figs 25.52A and B: Stapler haemorrhoidopexy. It is minimally invasive

procedure for haemorrhoids. It is high mucosal rim excision including

vascular pedicles using circular (single use) staplers. It is done for
prolapsed piles.
This procedure avoids wound in the sensitive peri of
anal skin thereby reducing the postoperative pain. Using
stapling gun, a unique circular stapler which reduces the
degree of prolapsed piles by excising a circumferential
strip of mucosa from the proximal anal canal. The strip
of mucosa and sub mucosa is excised circumferentially
above the dentate line. The veins leading to the haemorrhoids are thus incorporated in this excision. Activation
of the gun also simultaneously recovers the cut mucosa
and sub mucosa by stapling the edges together.
Disadvantagesneed for experience in advanced
surgical skill; costlier; may cause a full-thickness excision of the rectal wall; may injure the anal sphincter.
Improper purse string can cause incomplete doughnut
leading to severe haemorrhage.
Contraindication: Associated anorectal disease like
ssure, stula in ano.
Note:
Doughnut should be sent for histology for muscular layer;
proper doughnut should not contain muscular layer.
10. Open operative methods: Still gold standard.
Indications
3rd degree piles
Failure of nonoperative methods
Fibrosed piles
Haemorrhoidectomy is the best treatment for haemorrhoids
The haemorrhoidectomy is performed using an open or closed
technique. The open technique is commonly used in U.K. and
is known as Milligan-Morgan operation. The closed technique

(Hill Ferguson) is more popular in U.S.A. Both involve ligation

and excision of the haemorrhoid, but in the open technique the
anal mucosa and skin are left open to heal by second intention,
and in the close technique the wound is sutured. Ef cacy of
surgery is 95% with 2-5% recurrence rate.
Methods are:
o Ligation and excision of pilescommonly done procedures
(Milligan-Morgan) (Open method).
Under anaesthesia, in lithotomy position, initially the
sphincter should be dilated to reduce the postoperative
pain. Later skin is held with Allis forceps, internal pile
is held with artery forceps. Skin is cut in V shaped
manner and internal sphincter is separated and pushed up.
Pedicle is trans xed with vicryl or catgut and distal part is
excised. All the three piles can be dealt in a single sitting.
Postoperatively, sitz bath, antibiotics, laxatives, analgesics, local applications are given. Often few nger dilatation of the anal canal is required to prevent stenosis.
o Submucosal haemorrhoidectomy of Parksapproach is
above the skin through submucosal plane.
o Hill-Ferguson closed method: Here patient in prone position, under GA/caudal anaesthesia, retraction is done
using Hill-Ferguson retractor. Incision is made around pile
mass, pedicle is dissected to its proximal base; it is ligated
with trans xation using 2 zero vicryl or silk; mucosa and
anal skin is sutured using 3 zero vicryl/dexon after proper
haemostasis using cautery.
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Fig. 25.53: During haemorrhoidectomy, skin part is held with Allis
forceps; internal pedicle is held with artery forceps. A V cut is placed
over the outer skin up to mucocutaneous junction. Dissection is
deepened to visualise the internal sphincter. Once pedicle is dissected,
it is transxed using vicryl suture material. Distal tissue is excised.
Technique is repeated on other sites also.
Postoperative complications
Paindue to spasm, nerve irritation, muscle injury
Retention of urinecommonest50%
Reactionary or secondary haemorrhage

 Anal stricture
Anal ssure
Recurrence
Anal discharge for sometime
Incontinence for faeces or gas
Ectropion (Whitehead deformity)
11. Management of strangulated/thrombosed/gangrenous
piles: Here initially conservative treatment is done using
warm water sitz bath; antibiotics; elevation; bed rest; saline
compression dressing; analgesics. This reduces the oedema
and piles shrink. Later in 4-5 days haemorrhoidectomy is done.
Doing haemorrhoidectomy immediately may precipitate portal
pyaemia and also increases risk of developing anal stricture.
12. Newer methods: Using ultrasound or controlled electric
energy (Harmonic scalpel or ligasure), haemorrhoidectomy
can be done with less postoperative pain. But tissue charring
may precipitate secondary haemorrhage.
EXTERNAL PILES
Causes
o As a part of internal piles.
o Sentinel pile associated with anal ssure.
o Anal skin tags.
Treatment
o The cause is treated.
o Sitz bath.
o Excision.
Fig. 25.54: Typical external pile. It causes
haematoma, abscess, pain, itching.
Problems
o Pruritus ani.
o Perianal haematoma.
o Perianal abscess formation.

ANAL FISSURE (FISSURE-IN-ANO)

o It is an ulcer in the longitudinal axis of the lower anal canal.
o Commonly it occurs in the midline, posteriorly (more
common in males), but can also occur in the midline anteriorly (more common in females).
o 95% of anal ssures in men are posterior; 5% are anterior.
80% of anal ssures in females are posterior; 20% are
anterior. Anterior anal ssure is common in females.
o It is super cial, small but distressing lesion.
o Fissure ends above at the dentate line.
Fig. 25.55: Anatomy of anal canal with ssure-in-ano.
It is commonly posterior.
Internal Sphincter
o The internal sphincter is formed from a thickening of the
smooth muscle of circular coat of upper end of anal canal.
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Circular muscle is the continuation of the inner coat of the
rectum. This involuntary muscle commences where the
rectum passes through the pelvic diaphragm and ends just
within the anal ori ce, where its lower border can be felt.
o The internal anal sphincter is 2.5 cm long and 2 to 4 mm
thick. The internal sphincter is closed by a sheath of striped
muscle.
o Spasm and contracture of this muscle play a major part in
ssure and several other anal infections.
External Sphincter
It can be divided into three partsdeep, super cial and subcutaneous portion. It is considered to be one muscle.
o Deep part encircles the upper end of anal canal and has no
bony attachment.
o Super cial part is attached posteriorly to the coccyx, anteriorly inserted into the mid-perineal point in the male, in
female it fuses with the sphincter vagina.
o Subcutaneous part encircles the lower end of the anal canal
and has no bony attachment.
Causes
o Because of the curvature of the sacrum and rectum, hard
faecal matter while passing down causes a tear in the anal
valve leading to posterior anal ssure.
o Anterior anal ssure is common in females due to lack of
support to pelvic oor.
o Hard stool; diarrhoea; increased sphincter tone; local
ischaemia; trauma; sexually transmitted diseases.

o Other causeshaemorrhoidectomy, Crohns disease, venereal disease, ulcerative colitis, tuberculosis.

Types
o Anal ssure can be acute or chronic.
Acute Anal Fissure
o It is a deep tear in the lower anal skin with severe sphincter
spasm without oedema or in ammation.
o It presents with severe pain and constipation.
Chronic Anal Fissure
o It has got in amed, indurated margin with scar tissue.
o Ulcer at its inferior margin is having a skin tag which is
oedematous, acts like a guardsentinel pile.
o Proximally hypertrophied anal papilla is observed.
o It can cause repeated infection brosisabscess formation stula formation.
o Chronic ssure is less painful than acute one.
o Multiple ssures are seen in in ammatory bowel disease,
homosexuals and venereal diseases.
o Chronic ssure can cause complications likeabscess,
stula formation.
Fig. 25.56: Chronic ssure-in-ano with ulcer and sentinel
(pile) skin tag.
Fig. 25.57: Parts of chronic ssure-in-ano. Ulcer in the lower anal
canal; sentinel pile below and hypertrophied papilla above.
Fig. 25.58: Fissure-in-ano with sentinel pile.
Success is never nal and failure is never fatal.
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Fig. 25.59: Lateral ssure-in-ano.
Clinical Features
o Common in middle aged women, not in elderly.
o Pain is severe in nature in acute type, whereas less severe
in chronic.
o Constipation, bleeding and discharge.
o P/R examination and proctoscopy is not possible in acute
ssure-in-ano. General anaesthesia is required for examination.
o In chronic ssure, ulcer is felt with button like depression,
induration and often sentinel pile.
Differential Diagnosis
o Carcinoma anal canal.
o In ammatory bowel disease.

o Venereal diseases.
o Anal chancre (painful).
o Tuberculous ulcer.
o Proctalgia fugax.
Treatment
General measures for anal ssure
Adequate uid intake (6-8 glasses of liquids)
Fiber rich diet (vegetables, fruits, brown rice)
Bulk forming agents (psyllium husk, bran)
Stool softeners (lactulose)
Local anaesthetic agents (lignocaine 5%)
Sitz bath
Avoid constipation
Once recovers, regular anal dilatation
In an acute case
o Lords dilatation is done under G/A to relax the sphincter.
It is the manual dilatation (Lord, 1969) of the anus under
general anaesthesia with relaxation using four ngers of
each hand (8 ngers) to cause vigorous stretching of the
anal canal to break the circular constricting band in the wall
of the anorectum.
o Later, use of laxatives, xylocaine surface anaes thetic application, and anal dilatation with nger can be carried out for
certain period.
o Bed rest; 2% nifedepine ointment.
o Stretching of the anal sphincter (Recamier, 1829) using
two ngers of each hand (4 ngers) under anaesthesia is
also an alternative one. It is better than Lords dilatation as
complications are less.
For chronic ssure
o Dorsal ssurectomy with sphincterotomy is done under
anaesthesia. Specimen should be sent for biopsy to rule

out carcinoma, tuberculosis, etc. Here transverse bres

of internal sphincter is divided in the oor of the ssure.
o Lateral anal sphincterotomy
Here internal sphincter is divided partially away from
the ssure either in right or left lateral positions (also
gives a good result).
Here closed or open methods (Notaras) are used.
Sphincterotomy is done below the dentate line. In closed
method no 11 blade is inserted into the intersphincteric
groove to pass upwards. Blade is moved medially to
cut lower 1/3 or 1/2 of the internal sphincter. In open
method skin is incised laterally, external to anal verge.
Hypertrophied band of lower part of internal sphincter
is dissected and divided. Wound is left open.
Haematoma, perianal abscess, bruising, stula, incontinence are the complications of lateral sphincterotomy.
o Topical nitroglycerine 0.2% is also used to relax the
sphincter. It causes severe headache.
o Botulinum toxin 25 units injected into the internal sphincter.
It causes temporary denervation of the internal sphincter;
reducing its tone, improving the blood supply and control of
ischaemia. It causes temporary incontinence for atus (10%).
o Diltiazem (2%), L arginine are the other agents used.
o Regular anal dilatation is also often important to prevent
recurrence.
SENTINEL PILE
(sentinel means guard)
o It is commonly associated with Fissure-in-ano of chronic
type wherein, in the lower part of ssure, skin enlarges and
appears like guarding the ssure.
Fig. 25.60: Perianal haematomait should be drained to remove clot.
Small haematoma may resolve on its own. Larger one if not drained

will form an abscess.

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o It can cause perianal haematoma, abscess formation,
discomfort.
o The chronic ssure is treated along with excision of the
sentinel pile.
o There may be low grade infection and lymphatic oedema.
Haematoma/abscess can develop in it.
Fig. 25.61: Lithotomy position used for all perineal surgeries like for
ssure, piles, stula, and APR.
Fig. 25.62: Sitz bath is used after perineal surgeries like for piles, ssure,

and stula. Patient sits in warm water bath with perineum dipped in the
water. Often small quantity of antiseptics or KMNO4 is added.
ANORECTAL ABSCESS
o Most common causative organism is E. coli (60%). Others
are Staphylococcus, Bacteroides, Streptococcus, B. proteus.
Commonly occurs due to infection of anal gland in perianal
region. 95% of anorectal abscesses are due to infection of
anal glands in relation to cryptscryptoglandular disease.
o Common in diabetics and immunosuppressed.
Fig. 25.63: Anatomy of anorectal abscess.
o Other causes:
Injury to anorectum.
Cutaneous infection (e.g. Boil).
Blood born infections.
Many anorectal abscesses are associated with anal
stulas.
Fissure-in-ano.
Perianal haematoma.
Post anorectal surgery.
Crohns disease.
Tuberculosis.
Differential diagnosis of anorectal abscess
Periurethral abscess
Bartholin abscess
Tuberculous abscess
Investigations
o MRI is the investigation of choice for anorectal abscess.
o Perineal and anal US is also very useful.
o Investigations relevant to speci c cause may be done.
o Proctosigmoidoscopy is needed to identify secondary cause
in anorectum.
Classication

1. Perianal.
2. Ischiorectal.
3. Submucous.
4. Pelvirectal.
5. Fissure abscess (in relation to ssure-in-ano).
Perianal Abscess (60%)
o This usually results due to suppuration of anal gland or
suppuration of thrombosed external pile or any infected
perianal condition.
o It lies in the region of subcutaneous portion of external
sphincter.
Fig. 25.64: Perianal abscess. Note the swelling and inammation.
Our senses dont deceive us; our judgement does.
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Clinical Features
o Severe pain in perianal region with dif culty to sit.
o Tender, smooth, soft swelling in the region.
Fig. 25.65: Sites of anorectal abscess.
Treatment
o Sitz bath, antibiotics, analgesics, local application of anaesthetic agents and laxatives.
o Drainage under G/A.
Fig. 25.66: Perianal abscess showing pus oozing out.
Ischiorectal Abscess (30%)
Surgical Anatomy
Ischiorectal fossa (pyramidal shape 5 cm depth and 2 cm
width) lies between anal skin and levator ani. Right and left
communicates with each other. Laterally, it is related to fascia
covering obturator internus; medially to levator ani and external
sphincter; posteriorly sacrotubercous ligament and gluteus
maximus; anteriorly urogenital diaphragm; below, the oor by
skin. Above it is related to lunate fascia and pudendal neurovascular bundle in pudendal canal (Alcocks canal).
o Commonly it is due to extension of low inter muscular anal
abscess, laterally through external sphincter.
o But often it can be blood or lymphatic born.
o Fat in the fossa is more prone for infection because it is
least vascularised.
Fig. 25.67: Anatomy of ischiorectal fossa. Note the boundaries and
Alcocks canal.
o Fossa communicates with that of opposite side through post-

sphincteric space and so horse-shoe like abscess can occur.

o It presents with tender, indurated, brawny swelling in the
skin over the ischiorectal fossa with high fever.
o Swelling is not well-localised and uctuation is absent in
ischiorectal abscess.
Treatment
Under G/A in lithotomy position, through a cruciate incision a
portion of skin is excised (de roo ng) and pus is drained. Pus
is sent for C/S and presence of any internal opening to rectum
should be looked for (for possibility of an existing stula).
Fig. 25.68: Cruciate incision is used for drainage of ischiorectal
abscess.
Submucous Abscess (5%)
o It occurs above the dentate line, which can be drained with
sinus forceps, through a proctoscope.
o Aching pain in the anorectum with signi cant perineal
discomfort.
o On digital examination (P/R), tender, soft, smooth swelling
in the lower rectum and anal canal.
o It may be missed clinically as there is no obvious swelling
externally.
o Treatment is proper antibiotics; incision and drainage under
general anaesthesia.
Pelvirectal Abscess
o It is situated between the upper surface of levator ani
and pelvic peritoneum. It is almost like a pelvic abscess,
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occurs secondary to appendicitis, salpingitis, diverti culitis,
Crohns.
o U/S abdomen is done to rule out the above factors.
o Treated accordingly, after thorough investigations for
diabetes, Crohns and other conditions.
Problems with anorectal abscess
Recurrent abscess formation
Fistula formation
FISTULA-IN-ANO
o It is a track lined by granulation tissue which connects
perianal skin super cially to anal canal; anorectum or
rectum deeply.
o It usually occurs in a pre-existing anorectal abscess which
burst spontaneously.
Fistula-in-ano can be:
o Cryptoglandular90%.

o Non cryptoglandular (other causes)10%.

Cryptoglandular Hypothesis
o The intersphincteric space is the surgical plane between the
internal and external sphincters and is found between the
longitudinal muscle and external sphincter, where it exists
as a sheet of fat containing loose areolar tissue. The fat lled ischioanal fossa lies lateral to the sphincter complex
and is traversed by a network of broelastic connective
tissue. Proximal half of the anal canal is characterized by
longitudinal mucosal folds, the anal columns of Morgagni.
The distal aspect of each column is linked to its neighbour by a small semilunar fold (the anal valves), which
in turn forms small pockets (the anal sinuses, or crypts of
Morgagni). The distal undulating limit of these valves is the
dentate (pectinate) line, which also marks the most distal
aspect of the anal transitional zone, a histologic junction
between anal squamous and rectal columnar epithelium.
The dentate line lies 2 cm proximal to the anal verge and
is important landmark in stula-in-ano because the anal
glands empty into the crypts that lie proximal to the valves.
These glands secrete mucus to lubricate anus, and are the
source of infection. These glands present in the subepithelium, internal sphincter, and two-thirds of these glands are
located within the intersphincteric space. It is the infection
of these intersphincteric glands that initiates the stula in
ano, known as the cryptoglandular hypothesis.
o These glandular infection leads into an intersphincteric
abscess due to blockage of the draining duct by infected
debris. This abscess may resolve by spontaneous drainage
into the anal canal or may progress to an acute anorectal
abscess. Treatment of this abscess is incision and drainage;
but source of infection in the intersphincteric space persists,

leading into development of a stula in ano. Acute anorectal

abscess and stula in ano are believed to be acute and
chronic manifestations, respectively of the same disease.
o While most stulas start as a simple single primary tract,
recurrent infection eventulally causes formation of extensions (secondary tracts). Extensions may be intersphincteric, ischioanal, or supralevator (pararectal). The ischioanal
fossa is the commonest site for an extension. Extensions
also occur in the horizontal plane known as horseshoe if
there is rami cation on each side of the internal opening.
Fig. 25.70: Anatomy of anal glands (Cryptoglands of Morgagni).
Other causes are (Non-cryptoglandular)
Tuberculosis
Carcinoma
Crohns disease
Ulcerative colitis
Lymphogranuloma venereum
Hydradenitis suppurativa
Traumatic
Figs 25.69A to C: Ischiorectal abscess drainage done under general anaesthesia.
Note the cruciate incision placed and pus gushing out.
ABC
Two types of mankind are there; Hosts and Guests; on either way you are in
trouble.
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Plenty of lymphoid aggregates surround the anal glands,
which explain the high incidence of anal stula in Crohns
disease.
Fig. 25.71: Anatomy of stula-in-ano.
Classications
Standard (Milligan
Morgan, 1934;
Goligher 1975)
Park`s classi cation (1976)
Subcutaneous
commonest
Low analcommon
Submucous
High anal
Pelvi rectal
Intersphincteric commonest

70%
Transphincteric 25%
Supralevator/
suprasphincteric 4%
Extrasphincteric 1%
It can be:
1. Low level stulasthese open into the anal canal below
the internal ring.
2. High level stulasthese open into the anal canal at or
above the internal ring.
Fig. 25.72: Classication of stula-in-ano (Standard classication).
Fig. 25.73A
Figs 25.73B to D
Figs 25.73A to D: Parks classication of stula-in-ano
(A) Intersphincteric stula. (B) Transphincteric stula. (C) Supralevator
stula. (D) Extrasphincteric stula.
It can be:
o Simple stula without extensions.
o Complex stula with extensions.
A
B
C
D
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It can be with:
o Single external opening.
o Multiple external openings which are often seen in tuberculosis, ulcerative colitis, Crohns disease, LGV, hidradenitis
suppurativa, actinomycosis.
LOW-LEVEL FISTULAS
Clinical Features
o It has a prevalence of 0.01% and is common in young adult
males (2:1, male to female).
o It presents with seropurulent discharge (65%), along with
skin irritation and one or more external opening may be
present with induration of the surrounding skin.
o Often it may heal super cially but pus may collect beneath
forming an abscess which again discharges through same
or new opening.
o Ischiorectal fossa on each side, most often com municates
with each other behind the anus causing horseshoe stula.
Figs 25.74A and B
Fig. 25.74C

Figs 25.74A to C: Fistula-in-ano (simple type)

typical look and site.
Fig. 25.75: Complex stula-in-ano.
Goodsalls (1900) Rule
o Fistulas with an external opening in relation to the anterior
half of the anus is of direct type.
o Fistulas with external openings in relation to posterior
half of the anus, has a curved track may be of horse-shoe
type, opens in the midline posteriorly and may present
with multiple external opening all connected to a single
internal opening.
o P/R examination shows indurated internal open ing usually
in the midline posteriorly.
o Most of the stulas are on posterior half of anus.
o Probing in the ward and stulogram in the ward before
surgery using Lipiodol is not advisable as it may cause
A
B
C
You never get the second chance to make the rst impression.
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recrudescence of inammation. It can be done with
adequate precaution. Probing is done under general anaesthesia gently with care without creating extensions.
Fig. 25.77: Anterior stula-in-ano with probe in place. Anterior low
stula has got straight track. Both internal and external openings
are seen.
Investigations
o Chest X-ray, ESR and barium enema X-ray.
o If required stulogram is done only under anaesthesia.
o MRI/MRI stulogram ideal.
o Endorectal U/S (US perineum) is useful to assess deeper
plane.
o Discharge study, methylene blue dye study, biopsy.
o Colonoscopy often when ulcerative colitis/Crohns is
suspected.
o Speci c blood test.
Tuberculous stulas do not have induration, will have pale
granulation tissue with watery discharge and they are most
often multiple. Here, the infection occurs in lymphoid tissue
over the lower part of anal canal, around anal gland opening.

Fig. 25.78: Fistulogram X-ray showing track.

Fig. 25.79: MR stulogram.
Fig. 25.80: Multiple stulas-in-ano. It may be Crohns disease;
carcinoma or HIV. Biopsy should be done prior to formal therapy.
MRI of perineum is of great help in such patients to anatomically
evaluate the stula-in-ano.
Fig. 25.76: Goodsalls rule. Anterior stulas are having straight track.
Posterior stulas are having curved track with internal opening in
the posterior midline.
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Differential diagnosis for stula-in-ano

 Urethral stula in male

Chronically infected Bartholins gland
Pilonidal sinus
Hidradenitis suppurativa
Carcinoma
Crohns tuberculosis, ulcerative colitis
Fig. 25.81: Probing of the stula track during
surgery to nd out its inner opening.
Treatment
Principles in
management
Procedures
Identify the cause
cryptoglandular or
other
Delineate exactly
the stula anatomy
MRI/EUS
Identify relation
of stula to anal
sphincter
Drain all sites of
infection
Eradicate track
and secondary
extensions
Preserve anal
incontinence
function
The primary objectives
are to eradicate
the tract and drain

all associated sites

of infection while
simultaneously
preserving anal
continence
Laying open the stula
stulotomy with curetting
Fistulectomy
Gluing of stulanot much
useful
Mucosal ap procedure
Fistulectomy with primary repair
Fistulectomy with primary repair
with episiorectopexy
Fistulectomy with secondary
repair
Anal stula plug repair (AFP)
LIFT Technique (Ligation of
intersphincteric stula track)
Seton technique (Latin
setaa bristle)
Colostomylay open,
stulectomy, later closure of
colostomyfor high type
VAAFT procedure (Video
assisted anal stula track
ligation)
o Fistulectomy
Under G/A or spinal anaesthesia, probe is passed through
external opening up to the internal opening which is felt
as an induration. Fistula is opened along the probe using
a knife. Fibrous track along with unhealthy granulation

tissue and additional external openi ngs are excised.

Specimen is always sent for histopathology.
Fig. 25.82: Methylene blue injection to delineate track on table in
stula-in-ano.
Postoperativelysitz bath, antibiotics, analgesics, laxatives are given.
Fistulectomy for low level stulas do not cause rectal
incontinence.
Proper curetting of the infected anal gland area is
essential.
o Fistulotomy
It is done in low anal stula. It is technically easier. After
passing the probe through the entire stulous track, incision
is made over the probe to cut and lay open the stulous track.
It is allowed to granulate and heal from the oor/surface.
Technique is safer, easier and can be done on outpatient basis.
o Advancement aps are used occasionally to get better
resultmucosal ap procedure.
o Gluing of the stula track is tried but success rate is not
good. Fibrin glue is a multicomponent system containing
mainly human plasma brinogen and thrombin. Once
prepared it is injected into the stula track which hardens in
few minutes and lls the entire track. Success rate is 70%.
o Anal stula plug (AFP) repair: Surgisis anal stula plug
(porcine small intestine submucosa, SIS) is used with 85%
success rate in simple stula. It contains naturally derived
extracellular matrix which acts as scaffolding, ingrowth of
tissue, remodeling.
o LIFT technique (Ligation of intersphincteric stula track):
Under anaesthesia in lithotomy position, intersphincteric
space is reached through a transverse incision. Fistula running
across is identi ed and ligated using vicryl on either side. Part

is excised; outer part is curetted through external opening.

o VAAFT procedure (Video assisted anal stula track ligation): Fine specialized endoscope is passed through the
outer opening into the stula track; with continuous irrigation stula track is cleaned and wall is cauterized. Inner
opening is ligated through vicryl from luminal side.
His heart cannot be pure whose tongue is not clean.
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HIGH-LEVEL FISTULAS

o Its upper opening is at or above the anorectal ring. It is

dif cult to treat.
Common causes are:
Crohns disease
Ulcerative colitis
Trauma
Carcinomas
Foreign body
o Incontinence may follow after lay opening of these stulas.
Investigations
o Barium enema X-ray, colonoscopy, chest X-ray, biopsy.
Treatment
o Requires staged procedureinitial colostomy is done
followed by de nitive procedure. This prevents sepsis and
promotes faster healing.
o Later closure of colostomy is done.
Seton Technique
o A silk or linen ligature is passed across the stula and left
in place with a tie.
o Striated muscle super cial to stula track is encircled with
Seton material and tied securely and left in situ to create
ischaemic necrosis, dividing the muscle slowly without
allowing it to spring apart avoiding gutter deformity.
Even though internal sphincter is divided in this, causing
adequate laying open of entire stula track, it will wellpreserve the sphincter function and pressure.
o This allows the stula to granulate and heal from above and
to close completely. Usually takes longer duration to heal.
o It is done for intermediate and intersphincteric stula. It
is used prior to de nitive procedures like stulectomy or
advancement ap.
Fig. 25.83: Seton technique for intersphincteric stula-in-ano. It is

kept for 3 months. It can be tight or loose seton depending on the

indications. It promotes formation of granulation tissue, healing by
brosis and track recedes downwards.
o Seton can be kept for 3 months. It can be regularly replaced
by new silk or any material by rail road technique without
anaesthesia.
o Two types of setons are present.
Loose setons are used mainly to drain for long period
in recurrent/postoperative stulas and due to speci c
causes like Crohns. There is no tension in seton.
Cutting setons are used when enclosed muscle is needed
to cut (cheese wiring through ice effect). It is placed
tight.
ANORECTAL STRICTURES
Causes
Congenital

LGV (in females)

Fibrotic anal ssure Ulcerative colitis

Irradiation
Senility

Crohns disease
Carcinomas

Postoperative (surgery for piles, coloanal anastomosis)

Clinical Features
o Progressive constipation.
o On P/R examination, stricture can be felt as a tight ring.
o Features relevant of speci c cause.
Figs 25.84A and B: Anal dilator. Many proctology surgeries require
regular anal dilatation postoperatively. Note how to hold the dilator
to pass into the anus after applying lubricant.
A
B
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Investigations
o Barium enema X-ray, biopsy, colonoscopy
Treatment
o The cause is treated.
o Dilatation of the anal canal under general anaes thesia.
o Resection in severe recurrent cases.
CONDYLOMA ACUMINATA
o It is most common sexually transmitted anal disease. It is
common in homosexual men.
o Penile warts or female genital warts may be present.
o It is caused by Human Papilloma Virus (HPV).
o Pruritus, discharge, pain and bleeding are the features.
o Pinkish white warts in anal canal, often attaining large size

causing Buschke Lowenstein tumour.

o Large wart may block the anal canal ori ce.
o Whitening occurs on applying acetic acid on it.
o Biopsy con rms the diagnosis.
o Treatment is local application of 25% podophyllin cream;
surgical excision of the wart; intralesional injection of
interferon 2b.
o Malignancy should be ruled out by histology.
ANAL INTRAEPITHELIAL NEOPLASIA (AIN)
o It is dysplasia of anal or perianal epidermis.
o It is seen in individuals with HIV infection; HPV infection
(16, 18); individual who do anorectal intercourse.
Classi cation:
AIN Iabsence of keratocyte maturation and cellular atypia
observed in outer 1/3rd of epitheliumlow grade.
AIN IIcellular atypia observed in middle 1/3rdlow grade
squamous intraepithelial neoplasia.
AIN IIIcellular atypia full thicknesshigh grade squamous
intraepithelial neoplasia.
o 30% of anal warts will show AIN.
o It is raised scaly white/pigmented/cracked lesion.
o Biopsy con rms the disease.
o Treatment: Excision; topical imiquimod, 80% tricholoroacetic acid and oral retinoids.
MALIGNANT TUMOURS OF ANAL AREA
o Anal malignant tumours are < 2% of large bowel tumours. It
can be below the dentate line (SCC, 80% of anal tumours);
above the dentate line (Basaloid/transitional/cloacogenic).
o Causes may be HPV infection; HIV infection; AIN (Anal
intraepithelial neoplasia); organ transplant recipients;
immunosuppression.
Classi cation of tumours of anal area

It can be:
Benign
Malignant
It also can be:
Tumour of the anal canal (proximal to dentate line)SCC,
adenocarcinoma, melanoma
Anal margin tumour (distal to dentate line)ANI, Bowens
disease, Pagets disease, BCC, anal margin SCC
Figs 25.85A to C: Anal canal carcinoma. Squamous cell carcinoma
is commonest type80%.
Types
1. Squamous cell carcinoma is the commonest type.
Predisposing causes: Papilloma, irradiation, derma titis, long
standing stula-in-ano.
2. Basaloid carcinomait is rare, non-keratinising squamous
cell carcinoma. Highly malignant.
3. Muco-epidermoid carcinomaarises near squamo
columnar junction.
4. Basal cell carcinoma.
5. Melanomablue/black in colour mistaken for thrombosed
pilepoor prognosis (5 years10%).
6. Adenocarcinoma from the anal glands in a pre-existing
stula-in-ano.
A
B
C
God gives every bird its food, but he does not throw it into the nest.
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Features Investigations
Ulceration Biopsy from anal region
Bleeding FNAC of inguinal node
Pain, pruritus and discharge U/S abdomen
Irregular indurated mass MRI perineum is very
useful
Anovaginal stula in
females
P/R is a must to assess
upper extent of the
growth
Faecal incontinence in late
cases

AJCC staging
Tiscarcinoma in situ
Inguinal nodehard,
nontender
T1tumour < 2 cm
T2tumor 2-5 cm
T3 tumor > 5 cm
T4invasion into adjacent
organs like vagina/urethra
N1perirectal nodes +
N2unilateral internal
iliac/inguinal nodes
N3perirectal + inguinal/
iliac or bilateral nodes
M 0no distant spread
M1distant spread
present
Iliac nodes
Laterlate constipation
obstruction
o Squamous cell carcinoma of anal canal, usually present as
a fungating or ulcerative growth, which spreads to inguinal
lymph nodes.
Biopsy and FNAC of lymph nodes are the essential
investigations.
Treatment: Wide excision of the lesion with 3 to 5 cm
clearance and ilioinguinal block dissection for lymph
nodes are done. Follow-up radiotherapy is also often
given.
Nigro regime
Nigro Regime
Nigro Regime for Anal Carcinoma

(Norman Nigro, et al. 1974)

Initial radiotherapy for 3 weeks 3000 rads (30 Gy total) to
perineum and pelvis
Then chemotherapy5 FU, for 4-5 days; is a radiosensitizer,
started on 1st day of RT as 1000 mg/m2 continuous infusion.
Mitomycin C is 15 mg/m2 as single dose on 1st day of RT
Later after 3 weeks abdominoperineal resection (APR)
Chemoradiation is becoming popular for carcinoma
of anal canal.
Drugs used for chemotherapy are 5 FU, bleomycin,
vincristine, adriamycin.
In advanced growths radiotherapy is the only treatment.
o All other tumours: Abdominoperineal resection with
permanent colostomy is done.
Pagets
Pagets disease of breast
Pagets disease of anal marginof apocrine glands
Pagets disease of penis
Pagets test
Pagets disease of bone
ANAL MARGIN TUMOURS
It is the tumour below the level of dentate line.
1. Bowens disease.
2. Pagets disease.
3. Basal cell carcinoma.
4. Squamous cell carcinoma.
5. Verrucous carcinoma (Giant condyloma acuminat um or
Buschke-Lowenstein tumour).
6. Epidermoid carcinoma (SCC; cloacogenic/transitional/
basaloid carcinoma).
SACROCOCCYGEAL TERATOMA
o It is an uncommon tumour, but most common of the large

tumours in rst 3 months of life.

o More common in females.
o Retention of large amount of primitive toti-potential cell in
this region may be the reason for this tumour.
o It occurs between coccyx and rectum
o It is attached to coccyx, extends commonly down wards as
a huge mass, occasionally upwards into the pelvis.
Figs 25.86A and B: Sacrococcygeal teratoma, typical site
(Courtesy: Professer Suresh Kamath, MS, Mangalore).
A
B
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o It is a congenital condition arising from totipotent cells.
o X-ray and CT scan are must.
Complications Differential diagnosis
Ulceration Sacral meningocele
Infection Sacral chordoma
Urinary obstruction Postanal dermoid
Malignant changes
Fig. 25.87: X-ray of a patient with sacrococcygeal tumour
(Courtesy: Professor Suresh Kamath, MS, Mangalore).
Fig. 25.88: Recurrent chordoma of sacrum.
Treatment
o Excision soon after birth.
ANAL INCONTINENCE
Continence of anal canal is maintained by two factors:
o Normal rectal and colonic pressure and activity.
o Normal pelvic oor function.
Types
o Urge incontinencehere rectal and colonic pressure and
activity is increased but normal pelvic oor.
o True incontinencehere rectal and colonic pressure and
activity is normal but defective pelvic oor function.
o Full incontinencehere rectal and colonic pressure and
activity is reduced and also defective pelvic oor function.
o Temporarytreated by reassurance. Often seen after Lords
dilatation.
o Permanentneeds de nitive therapy.
Causes
Causes of anal incontinence
Denervationspinal injury, spina bi da
Damagechildbirth, wounds, surgeries
Descentrectal prolapse, perineal descent

 Debilityold age, diseases

DestructionRT, malignancy
Dementiasenility, psychosis
De ciencycongenital anomalies
o Irritable bowel syndrome, severe diarrhoea.
o Prolapsed piles, rectal prolapse.
o Old age, malnutrition, debilitating illness.
o Congenital anomalies.
o Trauma, surgeries, injury during childbirth in females.
o Spina bi da, spinal tumours, spinal injuries and surgeries.
o Malignancy, postirradiation.
o Psychological causes.
Evaluation of the patient
For speci c causes
Anorectal manometry
Per-rectal examination
Sigmoidoscopy
Electromyography
Defaecography
Perineometer to assess level and angle of anorectal junction
Treatment
o Suturing of the torn sphincter.
o Repair of puborectalis muscle and plication of external
sphincter.
o Encircling operations around anal canal to give support
using gracilis sling or mersiline sutures.
o Electrical stimulation of the puborectalis.
o Secca therapy: Temperature controlled radiofrequency
energy in the anal canal and distal rectum to create scarring and brosis of internal sphincter and adjacent tissues.
DESCENDING PERINEAL SYNDROME
o When a healthy person increases the intra-abdominal pres-

sure and relaxes the pelvic oor muscles, there will not be
any changes in the concavity of the perineum.
Diseases of the soul are more dangerous than those of the body.
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o In chronic ill-patients, malnourished, and people with
preprolapse, perineal descent can occur with obliteration
of the normal concavity of the perineum. It is called as
descending perineal syndrome.
o Levators got injured directly or indirectly causing weak-

ening of pelvic oor.

o Anal canal is situated many centimeters below the pubo
coccygeal line. Usually 3-4 cm low during straining.
o Defecography is ideal to evaluate such patients. Perineometer is also used.
o Presentations are tenesmus; incomplete evacuation; incontinence.
o Treatment is diet, laxatives, avoiding straining, and suppositories.
o Restoration of pelvic oor by various surgical methods
may be needed often with rectal resection and suspension.
o Total pelvic marlex mesh repair; transcoccygeal posterior
hitching of the rectum (Kraske); correction of cystocele,
rectocele and enterocele.
o Results are not very good as recurrence or residual problems
may persist.
PROCTITIS
It is in ammation of rectal mucosa often with the in ammation
of colon and anal canal.
Types
o Acute.
o Chronic.
o Nonspeci ccommon.
o Ulcerative proctocolitis as part of ulcerative colitis.
o Speci c
Bacillary dysentery.
Amebic proctitiscommon.
Combined amoebic and bacillary.
Gonococcal proctitis.
Lymphogranuloma inguinale (LGV).
Tuberculous proctitis.
Bilharzial proctitis due to schistosoma haema tobium.

 Enema induced proctitis especially of herbal enemas.

Clinical features
Pain per rectum and anum
Tenesmus
Passage of mucus and blood
Frequent urge to pass stool
Fever, loss of appetite
Pain and tenderness in left lower abdomen
P/R is tender
Investigations
o Sigmoidoscopy is more relevant than just proctoscopy.
o Stool study, stool culture.
o Mucosal biopsy.
o Serological tests.
o Relevant investigations like ESR, blood smear, and chest
X-ray.
Treatment
o Antibiotics, antiamoebic drugs like metronidazole.
o In severe cases, retention enema using metronidazole,
prednisolone, salazopyrin.
o IV uids, IV antibiotics and IV metronidazole are often
required.
o Treating the speci c causes like tuberculosis, gonococcal
infection and bilharzial infection.
PROCTALGIA FUGAX
o It is sudden severe recurring pain in the rectum of unknown
cause with segmental pubococcygeal spasm.
Features
o It is common in young people may be due to stress,
straining.
o Common at night, starts suddenly, lasts for few minutes
and then subsides spontaneously.

o Pain is unbearable and severe with often constipation.

o Gradually subsides on its own.
o Occasionally, only cutting of puborectalis muscle is
required but with danger of developing incontinence.
HIDRADENITIS SUPPURATIVA OF
ANAL REGION
o It is a chronic suppurativa condition of apocrine glands
of the skin in axilla/perineum/mons pubis/ thighs/scrotum
etc.
o Apocrine gland duct obstruction bacterial infection
multiple glands involvement secondary infection
(Staphylococcus aureus, streptococci) skin oedema,
multiple raised pustules multiple communicating stulae
formation.
o Disease does not extend above dentate line or into
sphincter.
o It is common in young obese females.
o Sinus; scarred areas; discharge; skin changes; pain and
tenderness; foul smelling uid are the presentations.
o Differential diagnosis areCrohns disease; stula-in-ano;
pilonidal sinus; tuberculosis; actinomycosis; LGV.
o Treatment:
Weight reduction; proper hygiene.
Antibiotics; analgesics.
Incision and drainage of abscess.
Laying open of all communicating tracks and regular
dressing.
Radical local excision of entire apocrine bearing perineal
skin with reconstruction using ap.
Recurrence is known to occur.
PRURITUS ANI
o It is intractable itching in and around anal canal.

o Skin is reddened, hyperkeratotic, cracked and moist.

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Causes
o Poor hygiene.
o Anal discharge due to ssure/ stula/piles/warts/ polyp.
o Trichomonas vaginalis infection of vagina in females.
o Parasites.
o Epidermophytosis.
o Allergic cause.
o Dermatitis/psoriasis.
o Intertrigo/erythrasma (Corynebacterium minutissimum).

o Diabetes mellitus; psychological cause.

Treatment
Proper cause should be assessed and treated. Good hygiene;
local steroid application; topical xylocaine; strapping of the
buttocks are needed.
GASTROINTESTINAL HAEMORRHAGE
(GI BLEED)
GI bleed is classi ed as upper GI and lower GI bleed.
o Upper GI bleed is bleeding above the level of ligament
of Treitz.
o Lower GI bleed is bleeding below the level of ligament
of Treitz.
Ligament of Treitz is a bromuscular band, which extends
from right crus of diaphragm to duodenoj ejunal exure
with upper part made up of striped muscle bres, lower part
smooth muscle bres and middle part with elastic bres.
Fig. 25.89: Anatomy of ligament of Treitz.
UPPER GI BLEED
It is considered as:
o Variceal.
o Nonvariceal.
Causes
o Peptic ulcer 55%. Ulcer bleeding is precipitated by NSAIDs,
steroids, alcohol. Ulcer bleeding is overall common in men.
But NSAID induced ulcer bleeding is common in females.
Duodenal ulcer (35%) more commonly bleeds than gastric
ulcer (20%)
o Gastroduodenal erosions.
o Oesophageal varices.
o Oesophagitis and erosions.
o Carcinoma stomach5%
o Mallory-Weiss syndrome5-15%.

o Vascular anomaliesDieulafoys syndrome (A-V malformation in the fundus of the stomach), Osler-Weber-Rendau
syndrome, Ehlers-Danlos syndrome.
o Aortoduodenal stula.
o Bleeding disorders.
o H/O drug intakeanticoagulants, clopidogrel, ecospirin.
Factors which aggravate the bleeding
Gastric acid which inhibits the platelet aggre gation
Pepsin, by its proteolytic action causes erosion of the ulcer
into the vessel. It also digests the clot, so as to aggravate the
bleeding
Mucosal blood supply pattern
Gastric motility
Alcohol, drugs
Major haemorrhage occurs when erosion of gastroduodenal
artery or left gastric artery or splenic artery occurs or when
bleeding occurs from varices
Clinical Features
Acute Bleed
o Features of shock.
o Haematemesis.
o Melaena.
Chronic Bleed
o Hypochromic microcytic anaemia, glossitis, koilony chia,
congestive cardiac failure.
o Mortality in upper GI bleed is 10%.
Investigations
o Gastroscopy to see the spurting vessel, oozing, clot in the
ulcer, collected blood in the lumen of the stomach.
o CT angiography of coeliac trunk and SMA.
o Hb%, packed cell volume, CVP measurement, blood
grouping and crossmatching. U/S abdomen.

o LFT; prothrombin time; platelet count; blood urea and

serum creatinine; serum electrolytes.
o Modied Forrest classication (refer Chapter 20
Stomach) and Rockall scoring system (better) is used. In
Rockall scoring system parameters used areage (60 [0],
60-79 [1], > 79 [2] Years); shock (none [0], pluse > 100
[1],) pluse > 100 with hypotension [2]); comorbidity (none
[0], IHD [2], renal/liver failure/advanced maligancy [3]);
condition diagnosed (Mallory Weiss [0], all but mailigancy
[1], upper GI maligancy [2]); endoscopic nding (none [0],
dark spot, blood/clot/visible vessel [2]). Score: < 3 low-risk;
3-8 moderate; > 8 high.
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Treatment
Treatment of upper GI bleed
General
MedicalPPI/tranexamic acid/octreotide
Endoscopic
CT angiography guided embolisation
Surgical
o General: IV uids, catheterisation, Ryles tube aspiration,
blood transfusion.
o Injection ranitidine IV 50 mg 8th hourly, or famotidine IV,
omeprazole IV, pantoprazole IV.
Figs 25.90A and B: Bleeding peptic ulcer (duodenal ulcer) is the
commonest cause of upper GI bleed. Oesophageal varix causes
dangerous severe life-threatening bleed.
o Anti brinolytics like tranexamic acid, EACA.
o Somatostatin or octreotide, PPI infusion.
o Endoscopic therapy (tamponade, laser, haemoclip, banding,
sclerotherapy, etc.) is the rst line of therapy in all upper
GI bleed. CT angiography guided transcatheter embolisation of artery (gastroduodenal) is very useful in bleeding
duodenal ulcer if endoscopic therapy fails. Persistent recurrent bleeding needs surgical intervention.
o For varices, vasopressin, propranolol, isosorbide dinitrate,
Sengstaken tube tamponade, sclerot herapy, Boeremacrile operation, Hasaab operation (devascula risation with
splenectomy), oesophageal transection, Siguira-Futagawa
operation or TIPSS.

o For peptic ulcer, saline wash with 1 : 2,00,000 adrenaline,

Nd:YAG laser therapy, cautery coagul ation, thrombin
injection, Finneys pyloroplasty, partial gastrectomy, ligation of gastroduodenal or left gastriartery, cytoprotectant
mesoprostil injection.
o The cause is treated, once acute episode is under control.
Prognosis
o Varices and gastric ulcer bleed has higher mortality.
o Bleeding duodenal ulcer has got better prognosis.
LOWER GI BLEED
o Bleeding in the GIT below the level of the ligament of
Treitz.
o Normal faecal blood loss is 1.2 ml/day. A loss more than
10 ml/day is signi cant.
Fig. 25.91: Causes of lower GI bleed.
Causes
o Angiodysplasia.
o Diverticular diseasecommonest cause in Western countries.
o Tumours of colon or small bowel.
o Anorectal diseaseshaemorrhoids, ssure-in-ano.
o Ulcerative colitis, Crohns disease.
o Colorectal polyps; rectal carcinomas.
o Intussusception.
o Tumours, either benign or malignant of colon or small
bowel.
o Meckels diverticulum.
o Ischaemic colitis.
o Stercoral ulcer.
o Infectious colitis.
o Mesenteric artery occlusion.
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Lower GI bleed can be:
Occult bleed: > 10 ml/day but not revealed
Overt bleed: Bleeding which is revealed
Overt acute
Overt acute massive (bleed > 1.5 litre/day)
Overt chronic
Common causes
Internal piles
Diverticular disease

 Neoplasia
In ammatory bowel diseases
Angiodysplasia
Classication
I. Bleeding may be:
Small bowel bleed: Polyp, Meckels diverticulum, mesenteric
ischaemia, intussusception; small bowel tumor.
Large bowel bleed: Angiodysplasia, carcinoma, colitis, diverticulitis, carcinoma.
Anorectal diseases: Piles, ssure-in-ano, carcinomas.
II. Bleeding may be:
Congenital: Polyps, Meckels diverticulum.
In ammatory: Ulcerative colitis, infective, amoebic, Crohns
disease.
Neoplastic: Adenomas, carcinomas, polyps.
Vascular: Angiodysplasia, mesenteric artery ischaemia, colitis.
Others: Piles, ssure-in-ano.
Angiodysplasia is common in caecum and ascending colon.
Bleeding more than 1.5 litres per day is called as acute
massive GI bleed.
Acute bleed occurs in:
Mesenteric ischaemia
Angiodysplasia
Ischaemic colitis
Meckels diverticulum
Intussusception
Acute episodes of ulcerative colitis
80% of acute bleed regress spontaneously
20% will become either massive or recurrent
Presentations
o Acute bleeding presents with features of shock.
o Chronic blood loss occurs in piles, ssures, colitis. Presents

with hypochromic, microcytic anaemia.

o Tenesmus, subacute obstruction, loss of appetite, decreased
weight, bloody diarrhoea is seen in carcinoma distal, large
bowel.
o Per-rectal examination is a must which may reveal polyp,
growth, ulcerations.
o Haematochezia.
o Mass palpable per abdomen in left or right iliac fossa or
mass of intussusception.
Blood with mucuscolitis, carcinoma
Fresh blood as splashes in the panpiles
Maroon coloured stoolMeckels diverticulum
Red currant jelly in stoolintussusception
Bright red blood in stoolpolyps
Investigations
o Hb%, packed cell volume, ESR.
o Bleeding time; clotting time; prothrombin time; platelet
count; blood urea and serum electrolytes.
o Occult blood in the stoolpositive faecal blood test using
Guaiac reagent.
o Barium enema.
o Proctoscopy for piles and sigmoidoscopy for rectosigmoid
diseases.
o Colonoscopy for colitis, carcinomas, polyps.
o Small bowel enema (enteroclysis).
Figs 25.92A and B: Sigmoid diverticula on colonoscopy. It is the
common cause of lower GI bleed in Western countries.
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o U/S abdomen.
o Mesenteric angiogram is very useful investigation in acute
bleed, especially in angiodysplasia.
o Technetium scan for Meckels diverticulum.
o Capsule endoscopy.
Treatment
o Endoscopic fulguration or therapeutic emboli sation or right
hemicolectomy (for angiodysplasia).
o Endoscopic polypectomy for polyps.
o Treatment for ulcerative colitis with mesacol enema or

drugs or total proctocolectomy with ileo-anal anastomosis.

o Surgical resection of colonic carcinoma.
o Massive resection of small bowel in mesenteric ischaemia.
o Sigmoid colectomy in sigmoid diverticula.
o Cause is treated.
o Proper exploration through a lengthy midline incision is
essential.
OBSCURE GI BLEED
o It is intermittent GI bleed for which no source has been
found endoscopically/radiologically.
o It is 5% common.
o Commonly, it is due to either missed common cause or
angiodysplasia.
o If it is angiodysplasia, angiography, nuclear scintigraphy,
capsule endoscopy; then angiographic embolisation or
resection of the part of the bowel is done.
o Enteroscopy, upper and lower GI scopies are needed in
other conditions.
o All other conditions are treated accordingly.
Haemoccultguaiac impregnated electrophoresis paper
Fecal test
Immunological test
Endoscopy
Gastroduodenoscopy
Proctosigmoidoscopy
Colonoscopyoften dif cult in acute bleed for clarity visualisation, if bleeding point is seen it can be controlled by cautery,
laser, haemoclips, injection sclerotherapy, heater probe etc.
But still it becomes the test of choice once bleeding has
controlled/stopped temporarily
Small bowel endoscopypush type (160 cm); Sonde enteroscope (275 cm, 5 mm diameter with balloon tip) are used.

Entire small intestine is visualised while withdrawing but

therapy or biopsy is not possible
Angiography
It identi es when bleeding rate is 0.5 ml / min; useful in active
bleed; in therapeutic embolisation, injection vasopressin can
be done. Embolisation of small bowel vessel may cause bowel
infarction which is dangerous and resection is needed in such
situation. Visualisation in angiography can be improved by
selective infusion of vasodilators like tolazoline and prostaglandins, using magnication lms, using vasoconstrictor
drugs
Angiogragraphic criteria in angiodysplasia areearly and
prolonged lling of draining veins; cluster of small arteries;
visualisation of vascular tuft
Nuclear scintigraphy
Identi es 0.1 ml/min of bleed ; Tc sulphur colloid scan is very
sensitive and is completed in 1 hour but increased uptake in
spleen and liver obscures bleeding point and needs repeated
administration due to rapid clearance; Tc labeled RBC recirulates and so effective for 1 day with better localisation
Advantages arehigh-sensitivity even with active continued
bleed; screening test prior to angiography
Problems areno speci city; therapy is not possible
Other methods
CT angiography; MR angiography
Aortography for aortoenteric stula
Intraoperative localisationon table enteroscopy; on table
Doppler; on table bowel lavage and colonoscopy
Investigations for GI bleed
Blood
Haematocrit, LFT, blood urea, serum creatinine
Serum ferritin, iron, binding capacity

 Coagulation pro leplatelet count, BT, CT, PT, APTT

Occult stool blood test (1-2 ml/day)
Benzidine test
Guaiac test