Ebook Anorectal surgery - Made easy: Part 1

(BQ) Part 1 book “Anorectal surgery” has contents: History of surgery, embryology, anatomy , physiology, evaluation of patient with anorectal disorders, clinical examination, investigations, preoperative work-up, constipation, obstructed defecation syndrome.

Anorectal Surgery

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • Panama City • London • Dhaka • Kathmandu

Anorectal Surgery

Ajit Naniksingh Kukreja MS FICS(USA) FIAGES LLB

Ratandeep Surgical Hospital and Endoscopy Clinic

Nakshatra, IInd Floor

Jaypee Brothers Medical Publishers (P) Ltd.

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© 2013, Jaypee Brothers Medical Publishers

All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher.

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

This book has been published in good faith that the contents provided by the author tained herein are original, and is intended for educational purposes only While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or ap- plication of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the author Where appropriate, the readers should consult with a specialist

con-or contact the manufacturer of the drug con-or device.

Anorectal Surgery Made Easy ®

First Edition: 2013

ISBN 978-93-5025-719-7

Printed at

Dedicated to

Late Smt Parvati Kukreja Late Ramkishan Kukreja Late Shri Pursusingh Kukreja

Naniksingh Pursusingh Kukreja Parivar, INDIA

Considering the prevalence of anorectal diseases and developments

in anorectal disorders, there are surprisingly few books on Anorectal Surgery

The goal of every good medical textbook is to teach excellence

in medicine This is the main purpose of this book Anorectal Surgery Made Easy—With DVD This book specifically attempts

to draw together all up-to-date strands of relevant information Everything a trainee, practicing surgeon or proctologist needs

to know

The book is written at a level appropriate for both medical students (Undergraduate and Postgraduate), Surgeons and Proctologists

The book is clearly set out in twenty-one chapters starting with History of Surgery and covers the whole spectrum of new frontiers in management of anorectal disorders Sections describe the clinical manifestations, diagnosis, and treatment of each condition Useful tables, pictures, tips, notes and caution warnings are included

The chapters themselves are comprehensive yet free of unnecessary detail

Only key references are included so that readability is not inhibited by overly dense text

This book will answer a lot of common questions and some odd ones that bring an interesting approach to managing patients with anorectal problems Once you get started reading the book, you will learn to think in nontraditional ways, ways that will help you manage problems that might previously have been very hard for you to manage

Discretion dictates, that I cannot credit individually those who have had an influence on my writing In any case, great as

that influence has been, my first word of thanks goes to my entire family I am indebted to my family who has, as always, given me the selfless support and far more encouragement than I deserve Primary acknowledgment must go to the many dedicated scientists who have discovered the principles of surgery The scientific literature acknowledges individual contributions, but textbooks cannot adequately pay such tribute I am indebted to all these unnamed investigators

I would like to take this opportunity to thank all those who have contributed so generously their experience, and time, in order to produce this work

Not to forget my philosophers, teachers and guides, relatives, friends, staff, well wishers and last but not least my patients

I am confident that this textbook will enjoy wide recognition, and hope that it will become a reference work for proctologists around the globe

No matter, how you choose to use this book, I wish you a lot of joy, and hope to get some feedback from you at my email address: info@ratandeep.com

Ajit Naniksingh Kukreja

I am grateful to Smt HariDevi and Shri Naniksingh Pursusingh Kukreja and Family, Smt Devi and Shri Lekhraj Pursusingh Kukreja for guiding me to conceptualize, develop and complete this title Indeed, without the help and will of the family, nothing would have been accomplished

Rev Dadaji JP Vaswani, Bhai Chamnjeet Singh Lal, Swami Purshottampriyadas Ji for showering their blessings

The effort of Dr Jyotsna Ajit Kukreja, Dr Preeti Ratansingh Kukreja, Dr (In Making) Renuka Ajit Kukreja, Anamika Ajit Kukreja and Late Ms Rekha Christian in coordinating the process

is acknowledged

This book is a fruit of cooperation and relentless dedication of many individuals and institutions They include my patients who provided the opportunity and encouragement to explore these ideas

Further thanks goes to my teachers Dr SM Patel, Dr KL Sheth and Dr RL Vadi for their blessings

The entire team of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who gave the most careful reading of the book, and advice based on years of experience

As have many others, I feel compelled to mention Smt Jyoti and Shri Prakash Kandhari, Smt Sulochana and Shri Ratansingh Kukreja, Smt Varsha and Shri Jitendra Kukreja, Smt Sheela and Shri Dilip Kukreja, Smt Sunita and Shri Dharmendra Kukreja, Smt Geeta and (Late) Shri Ramkishansingh Kukreja, Smt Pooja (Anjali) and Shri Hemant Lakhani, Smt Dhara and Shri Hero Bhojwani, Smt Urvashi and Shri Jenish Puri, Smt Unnati and Shri Girish Kandhari, Kirti Kukreja, Trilochan Kukreja, Kush Kukreja, Karuna Kukreja and Pradeep Kukreja and all Kukreja family kids

and kins for creating an enjoyable environment for writing the book And finally my coordinates, friends and staff at Ratandeep Surgical Hospital and Endoscopy Clinic for their emotional support.

Clinical Significance of Third Sacral Vertebra 18

Endoscopic and Surgical Significance of Rectum 18 Vascular Supply of Rectum and Anal Canal 23

The Venous Drainage of the Rectum 25

The Lymphatics 27

The Nerve Supply to the Anorectal Region 27

The Sphincters 30

The Corrugator Cutis Ani Muscle 32

The Internal Sphincter 33

The Longitudinal Muscle 34

Milligan’s Septum 34

The Anorectal Muscle Ring 35

The Anococcygeal Ligament or Body 36

The Levator Ani Muscle 36

The Pelvic Triangles 39

The Perineopelvic Spaces 39

Function of Internal Anal Sphincter 48

Function of External Anal Sphincter 49

Neurophysiology (Defecation Reflex) 50

5 Evaluation of Patient with Anorectal

Disorders 52

History Taking in Patients with Anorectal Disorders 52

Evaluation of a Patient with Anorectal Disease 63

Digital Rectal Examination 70

Digital Rectal Examination Work-up in

Fistula in Ano 74

Examination Under Anesthesia 74

Fecal Occult Blood Test 75

Pathology and Clinical Use 82

Radiology in Patients with Anorectal Disorders 84 Normal Findings 86

Pathology and Clinical Use 87

Dynamic MRI Defecography 97

MRI Normal Findings 98

Pathology and Clinical Use 98

11 Biofeedback 232

A Standard Biofeedback Training Protocol 232

Efficacy of Biofeedback Therapy 239

12 Functional Anorectal Disorders 241

Levator Ani Syndrome 243

Proctalgia Fugax 246

Perineal Descent Syndrome 253

Pruritus Ani 255

Perianal Infection 258

Colorectal and Anal Disease 260

Systemic Disease and Psychological Factors 262

General Control Measures 267

Solitary Rectal Ulcer Syndrome 270

Internal Anal Sphincter Physiology 292

Acute Fissure in Ano 293

Radiofrequency Coagulation and Excision 333

Doppler Guided Hemorrhoidal Artery Ligation 335

Stapled Hemorrhoidectomy 348

Surgical Hemorrhoidectomy 354

Milligan-Morgan (Open) Hemorrhoidectomy 357

The Harmonic Scalpel and Ligasure 361

Atomizer Wand 362

Thrombosed Internal Hemorrhoids 364

Thrombosed External Hemorrhoids 364

Hemorrhoids in Special Situations 366

Future and Controversies 419

Special Situations and Considerations 420

Anal Fistula Plug 424

Ligation of Intersphincteric Fistula Tract (LIFT) 426 Video-Assisted Anal Fistula Treatment (VAAFT) 427

Contents xvii

Management Options in Special Situations 450

Recurrent Pilonidal Disease 450

Factors Maintaining Fecal Continence 475

Causes of Anal Incontinence 475

found in Vedas which are at least 6000 BC old There were originally

four main books of spirituality, which included among other topics, health, astrology, spiritual business, government, army, poetry and spiritual living and behavior These books are known as the four

Vedas; Rik, Sama, Yajur and Atharva

The Atharva Veda Lists the Eight Divisions of Ayurveda

Internal Medicine, Surgery of Head and Neck, Ophthalmology and Otorhinolaryngology, Surgery, Toxicology, Psychiatry, Pediatrics, Gerontology or Science of Rejuvenation, and the Science of Fertility The Vedic Sages took the passages from the Vedic Scriptures relating

to Ayurveda and compiled separate books dealing only with Ayurveda

One of these books, called the Atreya Samhita is the oldest medical

book in the world!

Quoting Herodotus: The practice of medicine is very specialized

among Indians Each physician treats just one disease The country is full

of physicians, some treat the eye, some the teeth, some of what belongs to the abdomen, and others internal diseases

The art of surgery in Indian medicine is known as Salyatantra Originating from foreign bodies of all origins denoted as Salya,

especially the arrows which was the most common and most dangerous foreign body causing wounds and requiring surgical treatment (Salya—broken parts of an arrow and such other sharp weapons; tantra—maneuver)

Sushruta was a great surgeon of ancient India, though there is considerable controversy about his age Sushruta is stated to be

the son of Vishvamitra in the Sushruta Samhita Sushruta was sent

Fig 1.1: Sushruta

to study Ayurveda with special emphasis on Salya (Surgery) under

Divodasa Kashi Raja Dhanvantari of the Upanishadic age

Surgery was widely used in Indian medicine In the ancient World, Indian surgeons performed the most elaborate operations Over 121 different steel instruments (Fig 1.2) were used to sew-up wounds, drain fluid, remove kidney stones and to perform plastic surgery An official punishment for adultery was to cut-off your nose,

so surgeons had plenty of opportunities to reconstruct and refine noses

Indian surgery has great potentialities for research The Indian technique of rhinoplasty has earned many laurels outside the country Similarly, plastic surgery as a whole, management of injuries, and some simple measures as substitutes of surgical manipulations have of late been brought to light

Sushruta the father of Indian Surgery (Fig 1.1) is the author

of the Sushruta Samhita, the work known after his name, and one of the most authentic reference in Indian medical literature There are references to accidental loss of leg of Vispala who was

History of Surgery 3

Fig 1.2: Ancient Indian surgical instruments; 1 Simhamukha swastika;

2 Kanka mukha svastika; 3 Dvitala yantra; 4 Arsa yantra; 5 Bhagandara yantra; 6 Vadisa sala; 7 Darbhakrti khala mukha sala; 8 Karna sodnana;

9 Garbha sanku; 10 Ardha-chandra-mukha sala; 11 Mallaka samputa;

12 Alabu yantra; 13 Ghati yantra; 14 Yoni vraneksana; 15 Vrana vasti;

16 Vasti yantra; 17 Suvasti yanta; 18 Uttara vasti; 19 Mandalagara sastra;

20 Karapatra; 21 Vrddhipatra; 22 Utpala patra; 23 Kusapatra; 24 mukha sastra; 25 Antar-mukha sastra; 29 Vadisa; 30 Danta sanku; 31 Esani; 32 Yantra sataka for phlebotomy; 33 Dhumanadi; 34 Yantra sataka for lithotomy; and 35 Fracture immobilization bed

Sarari-immediately provided an iron leg-prosthesis to walk with The origin of the surgery can be traced back to the earliest times (Table 1.1), probably back to the Indus Civilization

The Rigveda mentions many a surgical feat of the celestial twin

medical experts, The Ashvins Amongst the eight divisions of

medical knowledge (Ayurveda), surgery was considered the first and

the most important branch

As early as 1200 BC, Agnivesha took the Herculean task of gathering, pruning, emphasizing and compiling the Kalpas, small monographs into textbooks of medicine As most of the references on ancient medicine and surgery were in form of Kalpas

The ancient Indian medical practitioners were categorized into

either: the Salya-cikitsakas (surgeons) or the Kaya-cikitsakas

(physicians) Surgery had not yet been incorporated into the

encyclopedic tradition as represented by the Agniveshatantra

Sushruta had put in lot of efforts to get surgery achieve a leading position in general medical training

Sushruta Samhita, the composition of Sushruta, known after his

name, is the transalation of what he learnt at the feet of his preceptor Divodasa Dhanvantari There are references that along with Sushruta, Aupadhenava, Vaitarana and others too had their instruction from Divodasa Dhanvantari and they also had with their own limitations

prepared a treatise on Salyatantra Amongst these compositions,

only the Sushruta Samhita has remained the only treatise for two of

the eight branches of Ayurveda, namely Salya and Salakya

The progress of internal medicine saw a steep rise, where as surgery declined and was ultimately practiced by some traditional families, and the knowledge was limited to theory only The reason being:

• Abandonment of dead body dissection

• Relegation of the manual work to inferior artisans gradually deprived those who studied the work of Sushruta of practical knowledge

The Sushruta Samhita is in two parts: The Purvatantra in five sections and the Uttaratantra These two parts together cover—

Salya and Salakya, the main essence of the Samhita

History of Surgery 5

Table 1.1: Landmarks in history of anorectal surgery

Hippocrates 400 BC Treated hemorrhoids with white-hot iron or by

burning them off and treated fistulas by use of seton (The earliest writings on the subject of symptomatic hemorrhoids occurred in 400 BC

by Hippocrates In these writings, symptomatic hemorrhoids were described as the result of infection of the veins within the rectum with stool, causing the temperature within the vein to rise and the vein to swell Successful treatment could

be obtained by cauterizing the hemorrhoids with

a red-hot iron) Clysters 1379 Clysters described the procedure for fistulotomy

and use of setonJohn Arderne 14th

Century 14th Century John Arderne, described

Herbert Mayo 1833 Herbert Mayo described pilonidal sinus as a

disease that involved a hair-filled cyst at the base

of the coccyxAmussat 1835 Described surgery for imperforate anus

1859 Coccygodynia described

Billroth 1879 Performed sigmoid resection and exteriorization of

the proximal bowel as permanent colostomy Fistulotomy 1879 Performed sigmoid resection and exteriorization of

the proximal bowel as permanent colostomyHodge 1880 Hodge coined the name “pilonidal”, from the Latin

pilus that means hair and nidus that means nestThiersch 1891 Thiersch described the Thiersch perineal procedure

for management of rectal prolapse

J W Matthews 1899 Became one of founders of American Proctologic

Society And was popularly known as “the Father of proctology”

Delorme 1900 Delorme described the sleeve re section for

management of prolapse rectum

Contd

Table 1.1: Landmarks in history of anorectal surgery

Wolff 1900 Wolff reported carcinoma in pilonidal sinusNoble 1902 Noble described endorectal advancement flaps for

management of rectovaginal fistula

1935 Proctalgia Fugax describedMilligan and

Morgan 1937 Milligan and Morgan in United Kingdom descibed open hemorrhoidectomyEisenhammer 1951 Internal sphincterotomy was first described Ferguson 1952 Ferguson described closed hemor rhoidectomy for

management of hemorrhoidsBarron 1963 Barron described rubber band ligation for

management of hemorrhoidsPark et al 1966 Parks et al described perineal descent syndromeMadigan

and Morson 1969 Distinctive characteristics of solitary rectal ulcer described Parks 1976 Parks refined the classification system for fistula in

ano that is still in widespread useStephens and

Smith 1984 Classified anorectal anomalies as high, intermediate, low cloacal, and rare

1992 Rome Criteria I for constipation defined

1995 Sacral nerve stimulation first described for

management of fecal incontinence

K Morinaga 1995 Conceived of a novel approach in form of

Doppler Guided hemorrhoidal artery ligation for management of hemorrhoids

1995 Longo described stappled hemor rhoidectomy for

management of hemorrhoids

1999 Rome Criteria II for constipation defined

Contd

History of Surgery 7

Along with other specialties like medicine, pediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs and psychiatry

Though the Sushruta Samhita is compilation of the science of surgery, it also incorporates the relevant aspects of other disciplines too Because Sushruta himself was of the opinion that if you want

to master your faculty you should have sound knowledge of allied branches

The Samhita consists of five books in an encyclopedia:

making a total of one hundred and twenty chapters

Of special mention are:

The Nidana-sthana that provides knowledge of etiology, signs

and symptoms of important surgical diseases and those ailments, related to surgery

The Sarira-sthana which provides knowledge of the rudiments

of embryology and anatomy of human body along with instructions for venesection (cutting of veins), the positioning of the patient for each vein, and protection of vital structures (marma) along with the essentials of obstetrics

The Cikitsa-sthana deals with the principles of management of

surgical conditions including obstetrical emergencies along with a few chapters on geriatrics and aphrodisiacs

Needing special mention is Uttaratantra also named Aupadravika

briefly dealing with a lot of complications of surgical procedures like fever, dysentery, cough, hiccough, kurmi-roga, pandu, kamala, etc Sushruta was always of the opinion that anyone who wants to master surgery should study anatomy by practical observation of the various structures composing the body This is dealt with in

detail in the Sarira-sthana of the Sushruta Samhita He practiced a

phasewise approach to study embryology before anatomy and in those prehistoric days he recommended human body dissection

Sushruta in his book, has described over 120 blunt and sharp surgical instruments, (Fig 1.2) 300 surgical procedures and classifies human surgery into eight categories He was of the feeling that a surgeon, by his own experience and intelligence, may invent and add new instruments to make surgical procedures simpler There is also

a mention of 14 types of bandaging capable of covering almost all the regions of the body are described for the practice of the student

on dummies Procedures of surgical importance in modern surgery like cauterization by Ksharas (alkaline substances) or Agni and application of leeches were used abundantly Thermal cauterization for therapeutic purposes has been advocated by heating various substances and applying them at the desired sites

Sushruta has described surgery under eight heads: (Fig 1.3)

• There is description of different methods of management of both hemorrhoids and fistulae

• Different types of incision to remove the fistulous tract like

langalaka, ardhalangalaka, sarvabhadra, candraadha (curved)

and kharjurapatraka (serrated) are described for management of

different type of fistula

Embryology

Objectives of Studying Embryology

1 General understanding of the early events of human development

2 Understand the key divisions, events and time course of human development

3 Understand the concept of mixed embryonic origins of different tissues and organs

4 General understanding of the term “critical periods” of development

5 Understand the “critical period” in development

The hindgut gives rise the rectum, and the upper part of the anal canal apart from the distal third of the transverse colon, the descending colon, the sigmoid

The cloacal membrane ruptures at the end of the seventh week, creating the anal opening for the hindgut and a ventral (Fig 2.1) opening for the urogenital sinus

The tip of the urorectal septum forms the perineal body between the two, proliferation of ectoderm closes the caudalmost region of the anal canal at this time, and this region recanalizes during the ninth week

The caudal part of the anal canal is supplied by the inferior rectal arteries, branches of the internal pudendal arteries as it originates in the ectoderm

The cranial part of the anal canal is supplied by the superior rectal artery, a continuation of the inferior mesenteric artery, the artery of the hindgut as it originates in the endoderm

Just below the anal columns, the junction between the endodermal and ectodermal regions of the anal canal is delineated

by the pectinate line

– Abnormal partitioning of the cloaca by the urorectal septum into the rectum and anal canal posteriorly and the urinary bladder and urethra anteriorly results in anorectal malformations.

Fig 2.2: Rectovestibular fistula in female

• Malformations are caused by abnormalities in formation of the cloaca, due to ectopic positioning of the anal opening and not to defects in the urorectal septum

– Approximately 50% of children with rectoanal atresias have other birth defects

High (Supralevator) Anomalies (40%)

• Also known as anorectal agenesis

• There is absence of anal canal and rectum ends above levator ani muscle

• Also persistence of cloaca (bladder, genital tract and bowel empty into single narrow channel that opens onto perineum with small orifice)

• These ganglia are derived from neural crest cells that migrate from the neural folds to the wall of the bowel

• Congenital megacolon occurs due to mutations in the RET gene,

a tyrosine kinase receptor involved in crest cell migration

Fig 2.4: High imperforate anus on radiography

Embryology 15

Fig 2.5: Congenital megacolon

• In most cases the rectum is involved, and in 80% the defect extends to the midpoint of the sigmoid

• In only 10 to 20% are the transverse and right-side colonic segments involved, and in 3% the entire colon is affected

Anatomy

Rectum

• The rectum extends from the level of the third sacral vertebral body to the anorectal line

• It differs from the sigmoid colon for its specialized role in defecation and continence in combination with the anal canal

• The circumference varies from 15 cm at the rectosigmoid junction,

to 35 cm or more at ampullary portion, its widest portion

• The anorectal junction lies opposite the apex of the prostate in males and is 2 to 3 cm in front of and slightly below the tip of the coccyx

• The posterior bend is called the perineal flexure of the rectum

• The angle rectum forms with the upper anal canal is called the anorectal angle

• Though both the ends of rectum lie in the median plane, The rectum itself deviates in three lateral curves (Fig 3.1):

Anatomy 17

Fig 3.1: The curves of the rectum

• There are three-folds of mucosa and circular muscle in rectum, called the valves of Houston, one on right and two on left

• The crescentic transverse mucosal folds of the rectum serve

to support the weight of the feces and to prevent excessive distention of the rectal ampulla so care should be taken while performing a sigmoidoscopy

• Peritoneal covering:

1 Upper one third: Front and sides

2 Middle one third: Sides only

3 Lower one third: Beneath peritoneum of pelvic floor.

• The muscular coat of the rectum as in entire colon is arranged

in outer longitudinal and inner circular layers of smooth muscle Though the three teniae coli of the sigmoid colon, come together so that the longitudinal fibers form a broad band on the anterior and posterior surfaces of the rectum which converts to fibrous layer in the sphincters

• The complete circular muscles thickens below to form the internal anal sphincter

Clinical Significance of Third

• The ampullary portion extends from the third sacral to the pelvic diaphragm at the insertion of the levator ani

Anatomy 19

Fig 3.2: Relations of rectum

Fig 3.3: Relations of rectum: female and male

Relations

• The relations of rectum have a diagnostic significance while performing a per rectum examination (Figs 3.2 and 3.3)

• They are important in ascertaining the spread of rectal growths

• They also provide important landmarks in operative removal of the rectum

• Sacrum

• Coccyx

• Anococcygeal body

• The edge of the anal orifice, the anal verge or margin (anocutaneous line of Hilton) (Fig 3.4), marks the lowermost edge of the anal canal and is sometimes the level of reference for measurements taken during sigmoidoscopy.

• Most schools prefer the dentate line as a landmark because it

is more precise The difference between the anal verge and the dentate line is usually 1 to 2 cm

• The epithelium distal to the anal verge acquires hair follicles, glands, including apocrine glands, and other features of normal skin, and is the source of perianal hidradenitis suppurativa, inflammation of the apocrine glands

• The anal canal is 4 cm long formed of two distinct parts (Table 3.1) demarcated by the dentate [Pectinate] line (Fig 3.4)

• It begins at the anorectal junction and ends at the anal verge [from pelvic floor-puborectalis to anal orifice]

• The mid anal canal represents the junction between the endoderm and the ectoderm

• There are three mucosal cushions with arteriovenous plexuses (Fig 3.4)

Fig 3.4: Anal canal—general description

Table 3.1: Difference between the two halves of anal canal

Origin: Endoderm Origin: Ectoderm

Mucosa: Columnar Mucosa: Squamous

Appearance: Columns, valves and cushions Appearance: Skin

Innervation: Autonomic Innervation: Somatic

Arterial supply: Superior rectal artery Arterial supply: Inferior rectal arteryVenous drainage: Portal Venous drainage: Systemic

Lymphatic drainage: Para-aortic lymph nodes Lymphatic drainage: Superficial

inguinal lymph nodesCommon site for hemorrhoids No hemorrhoids here

Malignancy: Adenocarcinoma Malignancy: Squamous cell carcinoma