Dept Of Surgery
Anatomy and Physiology
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? The rectum is approximately 12 to 15 cm in length.
? Three distinct submucosal folds, the valves of Houston, extend
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into the rectal lumen.? At S4, the rectosacral fascia (Waldeyer's fascia) extends
forward and downward and attaches to the fascia propria at
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the anorectal junction.
? Anteriorly, Denonvil iers' fascia separates the rectum from the
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prostate and seminal vesicles in male and from the vagina infemale.
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? The dentate or pectinate line marks the transition point betweencolumnar rectal mucosa and squamous anoderm.
? The 1 to 2 cm of mucosa just proximal to the dentate line shares
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histologic characteristics of columnar, cuboidal, and squamous
epithelium and is referred to as the anal transition zone.
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? The dentate line is surrounded by longitudinal mucosal folds, knownas the columns of Morgagni, into which the anal crypts empty. These
crypts are the source of cryptoglandular abscesses
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Arterial supply? The superior rectal artery arises from the terminal branch of
the inferior mesenteric artery and supplies the upper rectum.
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? The middle rectal artery arises from the internal iliac artery
? The inferior rectal artery arises from the internal pudendal
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artery, which is a branch of the internal iliac artery.? A rich network of collaterals connects the terminal arterioles
of each of these arteries, thus making the rectum relatively
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resistant to ischemia
Venous drainage
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? The superior rectal vein drains into the portal system via theinferior mesenteric vein.
? The middle rectal vein drains into the internal iliac vein.
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? The inferior rectal vein drains into the internal pudendal vein,
and subsequently into the internal iliac vein.
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? A submucosal plexus deep to the columns of Morgagni formsthe hemorrhoidal plexus and drains into all three veins
Lymphatic drainage
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? Paral els the vascular supply? Lymphatic channels in the upper and middle rectum drain
superiorly into the inferior mesenteric lymph nodes
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? Lymphatic channels in the lower rectum drain both
superiorly into the inferior mesenteric lymph nodes and
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lateral y into the internal iliac lymph nodes.Indications for Rectal Examination
? Assessment of the prostate (particularly symptoms of outflow
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obstruction).
? When there has been rectal bleeding (prior to proctoscopy,
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sigmoidoscopy and colonoscopy).? Constipation.
? Change of bowel habit.
? Problems with urinary or faecal continence.
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? In exceptional circumstances to detect uterus and cervix(when vaginal examination is not possible).
Procedure
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? The finger is then moved through 180?, feeling the walls of therectum.
? With the finger then rotated in the 12 o'clock position, helped
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usually by the examiner bending knees in a half crouched
position and pronating the examining wrist, the anterior wall
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can be palpated.? Rotation facilitates further examination of the opposing the
walls of the rectum. In men, the prostate will be felt anteriorly.
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In women, the cervix and a retroverted uterus may be felt with
the tip of the finger.
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? It is important to feel the walls of the rectum throughout the360?. Small rectal wall lesions may be missed if this is not done
carefully.
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Examination of the Prostate Gland
? Normal size is 3.5 cms wide, protruding about 1
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cm into the lumen of the rectum.? Consistency: it is normal y rubbery and firm with a
smooth surface and a palpable sulcus between
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right and left lobes.
? There should not be any tenderness.
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? There should be no nodularity.External Inspection
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? Skin disease.
? Skin tags
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? Genital warts? Anal fissures
? Anal fistula
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? External haemorrhoids
? Rectal prolapse
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? Skin discolouration with Crohn's disease? External thrombosed piles
Internal Inspection
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? Simple piles (but best examined atproctoscopy)
? Rectal carcinoma
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? Rectal polyps? Tenderness
? Diseases of the prostate gland
? Malignant or inflammatory conditions of the
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peritoneum (felt anteriorly)Contraindications
? Imperforate Anus
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? Unwilling patient
? Immunosuppressed patient
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? Absence of anus following surgical excision? Stricture
? Moderate to severe anal pain
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? Prolapsed thrombosed internal hemorroids
Rectal Prolapse
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? Also termed `rectal procidentia'
? Protrusion of the rectum beyond the anus
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? 6:1 female to male predominance? Peak incidence is in the 6th -7th decades of life
Risk factors:
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? Chronic constipation? Chronic diarrhea
? Mental retardation
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? Female sex
Anatomic abnormalities seen in patients with
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rectal prolapse? Deep rectovaginal or rectovesical pouch
? Lax pelvic floor musculature
? Failure of normal relaxation of the external sphincter
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? Redundant sigmoids? Pudendal nerve injury
Classification of rectal prolapse
? Partial: prolapse of rectal mucosa only
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? Complete: prolapse with all layers
? Grade 1: occult prolapse
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? Grade 2: prolapse to but not through anus? Grade 3: any protrusion through anus
Presentation
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Primary complaint is their rectum coming out
May mistake it as haemorrhoids
? Tenesmus
? Bleeding
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? Mucus discharge? Constipation
? Fecal incontinence
? Sensation of incomplete evacuation
Complications of prolapse
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? Ulceration
? Strangulation
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? Urinary and fecal incontinence? Spontaneous rupture with evisceration
Evaluation
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? Rectal prolapse can be incarcerated and
represent a surgical emergency
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? So, rule out incarceration? History
? When does it occur?
? Associated symptoms
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? Pts general health and associated medical problems? Association with psychiatric illness
? Physical exam
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? Colonoscopy? Rule out additional pathology, such as a neoplasm
which may be causing the prolapse
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? Anorectal manometry and pudendal nerve terminal
motor latency (PNTML) should be considered in
patients with fecal incontinence
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? Patients with constipation should undergo colonic
transit studies
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? Dynamic pelvic floor MRI? Endorectal ultrasound
? Cinedefecography
Nonoperative Management
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? High fiber diet? Biofeedback may be helpful for patients with internal
intussusception and inappropriate pelvic floor
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contraction
? Does not play a significant role in the treatment of
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rectal prolapseSurgery
Abdominal approach
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? The first step is mobilization of the rectum? Involves dissection between the mesorectum and the
presacral fascia
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? Mobilization is taken down to the level of the levators
? Anterior mobilization should be taken to the level of the
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vagina or seminal vesiclesRectopexy
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Ripstein procedure? First described in 1952
? After mobilization of the rectum is undertaken, a piece of
prosthetic mesh is placed around the anterior wal of the
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rectum
? Done at the level of the peritoneal reflection
? low recurrence rates: 0-9.6%
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? high rate of complications: up to 52%? One of the more disastrous complications is mesh erosion
into the rectum
Wells' posterior Ivalon rectopexy
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? First described in 1959
? Low recurrence rates: 3.0-6.0%
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? Morbidity rate of up to 19%? Complications: mesh erosion resulting in fistula
formation
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Suture rectopexy
In 1959, Cutait proposed suture rectopexy
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without the implantation of mesh.
Suture rectopexy with resection
? First described by Frykman in 1955
? Combined resection with rectopexy
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? Recommended for rectal prolapse patients with a long, redundantsigmoid colon
? It has decreased rates of post-operative constipation
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? For patients with a long, redundant sigmoid and significant pre-opconstipation, it is the procedure of choice
? Recurrence rates of 0-5%
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? Additional theoretical advantage of prevention of sigmoid volvulus? Complication rates shown to be similar to rectopexy alone
Laparoscopy
? Similar recurrence rates and functional
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outcomes compared to similar open procedures
? Longer OR times but shorter hospital stays
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? Cost analysis shows decreased costs due toshorter hospital stays
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Anal encirclement
procedure (1871)
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Commonly referred toas the Thiersch
procedure
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Mucosal sleeve
resection (1900)
Commonly referred to as
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the Delorme procedure
Perineal
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rectosigmoidectomy
? differs from the
Delorme procedure in
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that it is full thickness
Conclusion
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? Rectal prolapse is a complicated diseaseprocess due to a combination of factors
? Thorough pre-operative workup is required to
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determine the appropriate procedure