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Proctology

SMF Bedah
RSUD Budhi Asih
Jakarta

Topik yg akan dibicarakan


Hemorroid
Fisura Ani
Para-anal fistula

Hemoroid

Hemoroid :
Yunani : Haima (darah)+Rhoos (aliran) Aliran
darah

Galen dan Hippocrates

: Varices

HAEMORRHOIDS
Introduction:
Most common ailments to afflict mankind

It is not simply Varicose veins


Accurate prevalence are difficult

Teori Varices
Varices daerah Anal
MORGAGNI (1974)
Quenu : Infeksi dan trauma ringan saat
defekasi
Hipertensi portal : jarang hemoroid
Histologis (-)

Teori Hiperplasia Vaskuler


STELZNER (1963)
Hubungan arterio-venous di
submukosa rekti
Jaringan erektil (Corpus Cavernosum
recti)
Histologis (-)

Teori Anal Cushions


THOMSON (1975)
Anal cushions (AC) telah ada sejak
lahir
AC terdiri dari pembuluh darah, M.
Treitz, jaringan ikat
3 AC left lateral, right postero lateral
HAAS (1983) hemoroid adalah proses
degeneratif dari aparatus yang
menyokong mukosa dan sub mukosa

HAEMORRHOIDS
Anatomy
Knowledge of anal canal improve treatment

Anal cushion:
vascular submucosa
connective tissue
Treitz / Park muscle

Anal Cushions
Arterio-venous channels

HAEMORRHOIDS
Anatomy(2)
11

Anal cushion Function:


3
defecation process
anal continence
seal anal outlet

Anal cushion position


3,7,11 direction

Anal cushion

Function of Anal
Cushions
Control faecal continence
External anal sphincter
(solids)
Internal anal sphincter
(liquids)
Anal cushions
(liquids & gas)

Penyebab Hemoroid
Degenerasi jaringan penunjang yang penyebab utama
adalah
dapat terjadi karena sembelit, diare, diet, herediter
atau defisiensi fungsi m. sphincter ani interna
Defisiensi FS sphincter ani interna
Resting Anal pressure
setiap defekasi perlu tenaga
berakibat buruk bagi jaringan penunjang mukosa dan
sub mukosa
Wanita hamil
venous dilatation, konstipasi dan
venous stasis

HAEMORRHOIDS
Etiology :

Faeces compression

Anal rotation

INSIDEN

Bernstein : 50 80 % orang dewasa


Gold berg : 5% penduduk barat
Wanita > Pria
Hunt dan Johansen : kaitan dengan hipertensi
portal diragukan
Lur2 & Golzner : wanita multipara 46%

Diagnois
Keluhan: perdarahan, nyeri, prolaps,
gatal, soiling
Colok dubur
Anuskopi
Hemoroid Interna : diatas linea dentata
Hemoroid Eksterna : dibawah
lineadentata
Dibagi dalam 4 derajat

Haemorroids Grading

External or perianal skin tags

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External or perianal skin tags

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External or perianal skin tags

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Internal hemorrhoids

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Internal hemorrhoids

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Internal hemorrhoids

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Internal hemorrhoids

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Management of Haemorrhoids

Exclude other
colorectal diseases
(e.g. cancer), anorectal varces

Penatalaksanaan
I. Pencegahan (prevention)
II. Medikamentosa (Non-invasive)
III. Invasive

Pencegahan
Hindari konstipasi kronik
Hindari makanan pedas
Diet Bulk Laxatives (metamucil)
Jangan mengedan sewaktu defeksi
Jangan memakai pencahar

Medikamentosa (Non-invasive)
Menghentikan perdarahan, gatal, nyeri
Memperbaiki defekasi : suplemen fiber
dan pelincir fecer (stool softener)
Diosmin

Invasive
1.
2.
3.
4.
5.

Skleroterapi
Rubber band ligation
Cryosurgery
Coagulation
Doppler ultrasound guides hemorroid
artery ligation
6. Terapi operasi

Rubber band ligation

3 haemorrhoids banded at
one session

Haemorrhoidectomy
Effective ~ 5% recurrence
BUT:

Pain
Bleeding
Incontinence
(usually faecal impaction)

Stapled
Haemorrhoidectomy

Interruption of superior haemorrhoidal vessels


External skin tags shrivel
No painful perianal wounds
Longo 6th World Congress Endosc Surg 1998

HAEMORRHOIDS
Complications:

Int.Piles trombosis

Fisura Ani

Fisura Ani
Disebabkan oleh luka di bag post anal
kanal yg tidak sembuh- sembuh
Umumnya disebabkan kotoran yg
keras, pd saat lewat merobek mukosa
anal-kanal

Diagnosis
Anamnesis
Nyeri pd saat BAB, akibatnya BAB jarang
& makin nyeri krn feses makin keras
BAB berdarah, spt garis

Pemeriksaan Fisik
Inspeksi tdp jar Granulasi di Jam 6
Ingat nyeri, jangan RT, lbh baik inspeksi

Anal fissure

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Anal fissure

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Anal fissure

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Anal fissure

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Anal fissure

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Anal fissure

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Penatalaksanaan
Akut
Medikamentosa, sbg besar sembuh
Laxan, diet tinggi serat, obat topikal

Kronis
Sdh terdpt jar granulasi, skin tag
Terbaik adalah Ox Lat Sfingterotomi

FISTULA IN ANO
Para-anal fistel

FISTULO IN ANO
Surgical treatment
for fistula in ano
have been recorded
since Hippocrates in
the 5th century BC;
and still commonly
encountered in
modern colo-rectal
practice

FISTULA IN ANO
A granulating tract between the anorectum and perineum
May consist of primary and secondary
tract
Sometimes tract become occluded and
a sinus remains
Some have been associated with a
previous ischiorectal abscess

FISTULA IN ANO
Etiology and pathogenesis

Anal gland theory


Congenital
Pelvic sepsis
Perineal injuries
Operations for anal disease
Crohns disease
Tuberculosis
Actinomycosis
Venereal infections
Malignancy

Abscess and fistula

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FISTULA IN ANO
Classification

Simple and complex


Horizontal and vertical tract
Inter-sphincteric
Trans-sphincteric
Supra-sphincteric
Extra-sphincteric

Abscess and fistula

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FISTULA IN ANO
Fistulas opening
Goodsalls rule

Site of internal
opening

Abscess and fistula

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FISTULA IN ANO
Assessment
Clinical : palpation and digital examination
Identifying the fistula tract
- methylene blue
- probing the tract
Fistulography
Intra anal ultrasonography
Magnetic Resonance Imaging (MRI)
Anal manometry

Abscess and fistula

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Abscess and fistula

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FISTULA IN ANO
Principles of treatment
To define the anatomy of the fistula
tract and any secondary extensions
To drain any coexisting pus
To excise the fistula tract
To lay open the wound

FISTULA IN ANO
Surgical techniques
For low fistulas
- fistulotomy
- fistulectomy
- excision and primary suture
- excision and skin grafting
For high fistulas
- seton
- fistulectomy and closure of the defect
- mucosal advancement flap
- fibrin glue

FISTULA IN ANO
Summary
Assessment very careful of all
anorectal fistula tract
Low trans-sphincteric and intersphincteric fistulas are excised and the
tracts laid open
High trans-sphincteric and anterior
fistulas are managed by using a seton