surgery on the anal canal
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SURGERY ON THE ANAL CANAL
Principles & Practice
Dr.Shivananda Prabhu,
Professor of General Surgery,
KMC, Mangalore.
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Golden Rule
Save Continence at all cost
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Problems
Lack of Training
Bottom Case
Lack of Understanding of Pathology
of Procedure
Lack of Interest
Not one more Haemorrhoidectomy
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Pre-requisites
Before embarking on Anal surgeryunderstand
The parts
The pathology
The procedure
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Beware!!!
More sinister disease may underlie analproblems . eg. Ca Rectum, Crohns
Anal Disease may coexist
Evaluation may need E.U.A
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Anatomy
Note Arrangement of
sphincters Position of anal
glands
Layout of the
mucosa Vascular supply
Ischiorectal fossa
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Pathology
Piles
Fissure
Fistula
Abscess
Polyp
Mucosal Prolapse Pilonidal Sinus
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Haemorrhoids
Large section ofpopulation affected
Loss of support of
anorectal cushion
Is there varicosity ofveins?
Causes
Straining
Gravity
Internal Vs External pile
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Treatment
Conservative methods like banding,sclerotherapy etc are safe
Butare they effective enough?
Excision SurgeryFerguson Closed
Milligan Morgan Open
Do not damage the Internal Sphincter
Avoid blind ligation
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MIPH
Era of staplers Based on loss of anal cushion
support theory
Easier to learn
Advantages Less pain
Minor pile masses treated at thesame time
Less chance of anal stricture
Disadvantages ?Long term efficacy
Less effective when external pileis big
Expensive
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Fissure
Breach in the anal mucosa Acute
Chronic
Pathology
Orgin ill understood ?Trauma
Ischaemia leads topersistance
Spasm of the sphincter maynot be entirely due to pain
90 % occurs at 6 o clockposition
Off the midline fissure
Suspect
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Treatment
Trial of conservative treatment + Life stylemanagement
Lords Dilatation
Effective when done exactly right
Mostly underdilated
Fissurectomy no longer done
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Sphincterotomy
Better lateral
Internal sphincter is cut till dentate line
Dont do sphincterotomy if sphincter is already
lax
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Fistula
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Etiology
Cryptoglandular abscess
Can spread along many pathways
Delination may need Clinical examination ( Goodsalls rule)
Proctoscopy
USG
MRI
?Fistulogram
Probing mentioning to be condemned
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Procedure
Fistulotomy
Seton
Cutting Non Cutting
Endorectal advancement
?Colostomy Fibrin Glue
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Remember
Sphincter is the most at risk in surgery for
fistula
Even experts consider fistula as difficult
problem
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Perianal abscess
Usually infection from anal glands Submucous
Subcutaneous
Ischiorectal
Supralevator
Can be bilateral
C/f may be vague Treatment is I & D
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Postop problems after anal
surgery
Pain may be due to sphincter spasm
Bleeding Urinary retention
Incontinence Beware !!!
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Conclusion
Good anal surgery means improved
quality of life for large pool of patients
Popular surgeon
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Thank You
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