Very Useful for surgical Resident as well as MBBS Students.

1. Dr Anil Kumar
Assistant Professor
Department of Surgical Disciplines.
All India Institute of Medical Sciences, Patna
Email: dranil4@gmail.com

2. Objective to Learn:
 Gross Anatomy & Physiology of Anal Canal
 Examination & Investigation in Anal canal
 Anal fissure- Causes, Types & Management
 Fistula in Ano- Causes, Types & Management.
 Summary.

3. Anal canal Anatomy:

4. Anal Canal
 Length= 3.8 to 4.0 cm
 Zona Columnaris: Upper ½- lined by Simple columnar
 Zona Hemorrhagica: Upper part of lower half ( above the
Hilton’s white line) – Stratified squamous non-keratinizing
epithelium
 Zona Cutanea: Lower part of lower half( below the
Hilton’s white line)- Stratified squamous keratinizing
epithelium

6. Anorectal Bundle or Ring:
Demarcating Line B/W the
Rectum & Anal Canal.
Can be felt Posteriorly-
Thickened Ridge
Formed by- Puborectalis, Deep
Ext Sphicter,Conjoined long
Muscle & Internal Sphincter

7. Puborectalis Muscle:
 Maintain the angle b/w
rectum & anal canal
 Gives off fiber to the
longitudinal muscle layer.
 Position, Length as well as
angle of the anorectal Junction
- integrity & strength of the
Puborectalis muscle sling.

8. Development of Anal Canal:
 Fusion of Post-allantoic gut ( upper) with the
Proctodeum( lower part)
 Pectinate or Dentate line is the junction of these two.
 Anal valves of Ball - Remnants of the proctodeal
membrane
 Column of Morgagni- Mucosa at dentate line folded in
longitudinal column.

9. Pectinate line
(dentate line)
anal sinus
anal valve
Remnanats of
Proctodeal M.

10. Image of Anal Sphincter:
Deep External
Sphincter.
Sub cutaneous
External Sphincter
Superficial External
Sphincter
Circular
muscles of
Rectum
Longitudinal
muscle of
Rectum
Internal anal S
Conjoined
longitudinal
muscle

11. External & Internal Sphincter:
External Sphincter Internal Sphincter
Muscle Single muscle k/as Goligher
Muscle
Continue of the Circular muscular
coat of the rectum
Color Red Pearly white
Nerve Pudendal Nerve Autonomic nervous system-
Intrinsic non-adrenergic & non-
cholinergic fiber
Types of
Muscle
Somatic Voluntary Muscle Non-striated Involuntary Muscle
Parts/fts Deep, Superficial and
Subcutaneous portion
Always lie in the tonic state of
contraction

12. Blood Supply of Anal Canal
 Superior Rectal Artery Right & Left Branch
 Middle Rectal Artery
 Inferior Rectal Artery
Superior R.A
Middle R.A
Inferior. R.A

13. Venous Drainage:
Upper Half- Superior Rectal Vein IMV Porto
mesenteric venous system
- Middle rectal vein Internal Iliac Vein
Lower Half- Inferior rectal vein & Subcutaneous peri -
anal plexus of veins Internal Iliac Vein
Lymphatic Drainage:
Upper Half- Post Rectal LN Para aortic nodes
Lower Half- Superficial Deep Inguinal LN

14. Venous system of Anal Canal:
SUPERIOR RECTAL
VEIN
MIDDLE RECTAL
VEIN
INFERIOR
RECTAL VEIN

15. Anal Canal
Above the dentate line Below the dentate line
Development Post-allantoic gut Proctodeum
Epithelium Cuboidal/Columnar Squamous without sweat & hair
gland
Name Surgical anal canal Anatomical anal canal
Color Pink Skin Colour
Nerve Parasympathetic: painless Spinal nerves: very painful
Venous
Drainage
Portal System Systemic-Ext iliac vein
Lymphatic
Drainage
Para-aortic Superficial & Deep inguinal LN

16. Examination of Anal Canal:
 Relaxed Patient
 Informed Consent
 Private environment
 Good Light
 Position – Left Lateral Position/ Sims’s Position- most
commonly used.

17. Image for different position:
Lithotomy
Sim’s PositionSim’s position
Knee elbow position

18. P/R Examination:Inspection
 Skin Lesion- Psoriasis
-Lichen planus
- Warts
-Candidiasis&Herpes simplex
 Whether anus is closed
or patulous
 Position of the anus/perineum
 Evidence of piles/
sentinel tag
( Anal fissure or SCC) Psoriasis

19. P/R:Gloves,jelly etc………
 Sling of puborectalis- Posteriorly at the apex
 Posterior surface of the prostate gland with median
sulcus( Male) & Uterine cervix( in female)-Anteriorly.
 Intrarectal, Intraanal or extraluminal mass.
 Sphincter length
 Resting tone
 Voluntary squeeze
 Examining finger – Mucus, Blood, Pus
 Stool Color.

20. Proctoscope:

21. Proctoscopy:
 Position: Left lateral position
 Inspection of the distal rectum and anal canal
 Injection in Hemorrhoids
 Banding of Piles mass
 Biopsy of mass

22. Sigmoidoscopy:
Mainly used for Rectal
examination
But Also recommended
in Fissure &
Hemorrhoids
Cos Colitis & Rectal
Carcinoma is frequently
A/W Fissure &
Hemorrhoids.

23. Physiology of Anal canal:
 Cerebral
 Autonomic nervous system
 Gastrointestinal system( Especially Rectum)
 Pelvic floor
 Anal sphincter mechanism

24. Physiology
 Structural Integrity of the sphincter- Endoluminal USG
 Neuromuscular Function –(a) Assessment of conduction
velocity along with the Pudendal nerve or
-(b) Needle Electromyogram(EMG)-Slightly Painful.
 Evacuation Proctography or Dynamic Proctography:
- In Rectal Sensorimotor dysfunction( Overflow of
rectal content)

25. Dynamic Proctography:
 Radio-opaque pseudo-stool is inserted into the rectum
 Rest, Squeeze and than bear down to evacuate the
rectal contents under real-time imaging.
 Can be combined with EMG & Pressure studies

26. Dynamic Magnetic Resonance
Proctography:DMRP:
 More popular
 More expensive
 Less physiological

27. Anal Fissure:
 Longitudinal tear in the anal canal
 Site: Posterior midline (90%) and Anterior midline in
10% case especially in female.

28. Etiology & Predisposing factors of
Anal Fissure:
 Age: Young adult & middle aged man
 Gender : Male > Female
 Posterior midline is the commonest site because-
-Maximum stretching on this site
- Less tissue here
-Minimal tissue perfusion

29. Etiology of Anal Fissure
 Main cause-Trauma–Strained evacuation of Hard stool
or
 Less commonly - Repeated passage of stool ( diarrhea)
 Anterior anal fissure in 10% cases – Mostly in Women
that occurs following vaginal delivery

30. Predisposing Factors: FISSURE
 Faces – Hard
 Ischemia
 Surgical procedure- Haemorrhoidectomy
 Sphincter hypertonia
 Underlying disease – Crohn’s , TB, L.V, Syphilis etc
 Repeated Childbirth
 Enthusiastic usage of ointments and abuse of luxatives.

31. C/F of Anal Fissure:
 Severe anal pain during the defecation
 Blood streak outside the stool
 Bleeding P/R- Bright
 Mucous Discharge
 Constipation
 Itching

32. Chronic Anal Fissure: Findings:
 Hypertrophied Anal Papilla- Proximally
 Sentinel tag- Distally
 Thickened edge
 Exposed internal sphincter i.e Ulcer overlying the
fibers of internal sphincter

33. D/D –Especially if ectopic site i.e
other than Posterior –midline:
Crohn’s Diseases Kaposi’s Sarcoma
Tuberculosis B-Cell Lymphoma
Lymphogranuloma Venereum CMV
Syphilis Chlamydia
HIV Chancroid
HSV SCC

34. Confirmation of Diagnosis:
 Adequate clinical examination under G/A
 Proctoscopy
 Sigmoidoscopy
 Take Biopsy
 Do Culture

35. Treatment: Conservative & Surgical
 Conservative treatment helpful in most of cases
 Main objective to treat Constipation.
-Add the fiber to the diet
-Encourage water intake
-Laxative to make the stool soft
 Application of local anesthetic- Lignocaine jelly
 Antibiotics- Ofloxacine + Orinidazole

36. Conservative :Hot Seitz Bath

37. Conservative Treatment:
 Drugs that release the Nitric oxide donor- Glyceryl
Trinitrate( GTN) 0.2 % & Diltiazam 2%.
 GTN 0.2% - QID at Anal Margin
- S/E- Headache and Recurrence
 Diltiazam 2%- BD at anal margin
 - M/A- Produces NO – Relaxation of the internal
Sphincter- reduces the spasm, pain & Increase the vascular
perfusion to promotes healing

38. Conservative Treatment
 Botulinum toxin injection
 Site of Inj- Internal Sphincter
 M/A- Inhibits presynaptic release of Ach from
cholinergic nerve endings- Paresis of Striated muscle
and release the spasm .
 Other use- Achalasia cardia, Sphincter of Oddi
dysfunction, Frey Syndrome

39. Operative procedure for FIA.
 Anal Dilatation
 Posterior division of the exposed fibers of the internal
sphincter in the base of the fissure.
 Lateral Anal Sphincterotomy of Notaras
 Anal advancement Flap

40. Anal Dilatation: Lord’s Anal
Dilatation
 Position- Lithotomy
 Under G/A
 Manual 4 to 8 finger sphincter dilatation
 Useful in Young men with very high sphincter tone
 Risk: Incontinence.

41. Posterior division of the exposed
fibers of the internal sphincter in
the base of the fissure
 Indication – if fissure is associated with
INTERSPHINCTERIC FISTULA
 Disadvantage- Prolonged healing
- Passive anal leakage because of
resulting ‘ Keyhole gutter deformity’.

42. Lateral Anal Sphincterotomy:
 Position- Lithotomy
 Anesthesia- Regional or G.A
 Palpate the distal internal sphincter with the help of
bivalved speculum at the intersphincteric groove.
 Give a small longitudinal incision in right or left lateral
position

43. Lateral Anal Sphincterotomy
Cut the Mucosa
Get the sub- mucosal & Intersphincteric planes
Allow the Exposure of Internal sphincter
Cut the Internal sphincter up to the apex of the fissure
Closed the wound with the absorbable suture

44. Complications of LAS:
 Hemorrhage
 Hematoma
 Bruising
 Perianal Abscess
 Fistula
 Incontinence.

45. Anal Advancement Flap:
 Very useful in women and those with Normal or Low
Resting Anal Pressures (persistent, chronic, non healing
fissure)
 Excised the edge as well as base of the fissure.
 Inverted house shaped flap of Perianal skin is mobilized
to cover the fissure.
 Post-op instruction- Stool softeners, Bulking agent &
Topical sphincter relaxants.

46. Fistula-in-ano:
 Chronic abnormal communication
 Between the Internal opening (anorectal lumen) &
External opening on the skin of the perineum or
buttock
 Lining is Granulation tissue.
 Commonest cause – Non-specific, Idiopathic & Crypto
glandular & Inter-Sphincteric anal gland infection.

47. Fistula-in-ano:Aetiopathogenesis
Persistent anal gland Infection
Anorectal Abscess
Rupture inside as well as outside
Fistula

48. Fistula-in-ano:Underlying
Condition –CISTULA+ ARF
Carcinoma
Ileitis-Crohn’s
Schistosomiasis
Tuberculosis
Ulcerative colitis
L. Venereum
Anal Fissure
Abscess
Actinomycosis
Rectal Duplication
Foreign Body

49. Fistula-in-ano:Clinical features
 Intermittent purulent discharge
 Pain
 External opening as sinus or Ulcer
 Bleeding/PR(sometimes)

50. Types of Fistula in ano:Standard
 Low type- Internal opening below the anorectal ring.
 High Type-Internal opening above the anorectal ring.
 Importance – Low type fistula- fistulotomy without
damage to sphincter
- High type fistula – Staged operation

51. Park’s Classification:
 Based on relationship of fistulous tract to the anal
sphincters- 4 types.
 Intersphincteric Fistula
In vast majority of Cases.
 Trans sphincteric Fistula
 Supra Sphincteric Fistula
 Extra Sphincteric Fistula

52. Park’s Classification

53. Intersphincteric Fistula:
 Most common type
 Incidence= 45%
 Don’t cross the external sphincter

54. Trans-sphincteric Fistula:
 2nd Most common type
 Incidence=40%
 It’s track crosses both external & Internal sphincter
 Passes through the Ischio-rectal fossa to reach the
skin of the buttock

55. Supra-sphincteric Fistula:
 Very Rare
 Cause- Iatrogenic
 Very similar to high level
T-S Type.

56. Extra-sphincteric Fistula:
 Run without specific
relation to the sphincter
 Cause- Trauma or Pelvic
Disease.
 Originates in the rectal
Wall
 Tracks lateral to both
Sphincters

57. Clinical Assessment/Investigation:
A. Complete the General advise like
-Obstetric history
-Gastrointestinal history
-Surgical history
-Continence history
-Proctosigmoidoscopy examination

58. Clinical Assessment/Investigation
B.Important point about fistula
1. Site of the internal opening & External opening.
2. Course of the primary track
3. Presence of the secondary extension
4. Presence of other associated condition.

59. Goodsall’s Rule:

60. Clinical Assessment/Investigation
C.Hydrogen peroxide
injection:
-Inject through the
external opening
-Find out the site
of internal opening

61. Clinical Assessment/Investigation
D.Gentle use of Probe

62. Clinical Assessment/Investigation
E. Manometry:
- Resting anal tone
- Functional anal sphincter length
- Voluntary squeeze

63. F: Endoluminal USG: Sphincter
integrity, tract & anal canal.

65. MRI :
 Gold Standard
 Demonstrate the
secondary extension

66. Fistulography:

67. Demonstration of Fistula in Ano on
CT

68. Management : Fistula in Ano:
 Fistulotomy
 Fistulectomy
 Setons- Loose & Tight Setons
 Biological Agent- Fibrin Glue
 Advancement Flap- To preserve both anatomy & Function .
 VAAFT: Video Assisted Anal Fistula Treatment.

69. Fistulotomy
 Laid open the track( John of Arderne)
 Indication : Intersphincteric & Transsphincteric
Fistula.
 Steps:
1. - Position - Lithotomy
2. - Anesthesia - G/A.
3. -Identified the internal opening

70. Fistulotomy: Steps Continue
4. Pass the probe through
E.O to E.O to the I.O
5. The track is laid open over
the probe.
6. Curette the granulation
tissue and sent for HPE.
7.Wound edges are trimmed
E.O
I.O
Probe
Laid
open

71. Fistulotomy:

72. FISTULECTOMY: Excision of
whole Fistulous tract:
Probe

73. Setons:Bristle material
 Thread
 Wire
 Proline
 Infant feeding tube
 Ksharsutra: kshar- corrosive & Sutra- Thread

74. Setons: Loose :
seton
Non-absorbable
Non-Degradable
Comfortable
No intent to cut
Ideal seton
No
tension

75. Uses of Loose Setons:
1 .Crohn’s Diseases & Problematic fistulae- To prevent
the incontinence.
2.Prior steps of an “Advanced technique” like
Fistulectomy, Advanced flap & Cutting Seton
3. Staged fistulotomy
4. Therapeutic strategy to preserve the external
sphincter in trans-sphincteric fistula

76. Purpose to use of Loose Setons:
Purpose:
- Eradicate the acute sepsis & Secondary extension
- To simplify the fistula
- Allow fibrosis

77. Tight/Cutting Seton
 Placed with intention to cut the enclosed muscles.
 Also k/as “ Cheese Wiring through the ice”
 Fistulous tract is replaced by a thin line of fibrosis.
 Types- Elastic & Self cutting
- Non elastic & tightened
- Ksharsutra- most commonly used.

78. Tie the kharsutra to the eye of
probe
E.O
Ksharsutra

79. Ksharsutra coming out through I.O
I.O
E.O

80. Cuting & healing simultaneously.

81. Biological Agent to fill the fistula.

82. Insertion of Fibrin Glue in the
fistula

83. VAAFT:Video Assisted Anal Fistula
Treatment
 Visualization of the F.tract with the Fistuloscope
 Aim is to find the correct position of Internal Opening.
 A stapler to close the Internal opening.
 Fistuloscopy is done under irrigation & F.tract as well as all
granulation tissues are coagulated
 Total closure of the Internal opening with inserting the
Cyanoacrylate

84. Home message:Fissure:
 Post-midline is the commonest site for Fissure ( 90% )
 Main cause is Constipation – hard stool i.e trauma
 Pain during defecation is the commonest complaint.
 Clinical examination is sufficient to diagnose it
 GTN & Diltiazam 2% local application along with diet
modification have an excellent result as equivalent to LAS.
FISTULA IN ANO:
 Persistent anal gland infection is the commonest cause of
Fistula in Ano

85. Home message:
 Goodsall’s rule is very useful in determining the site of external &
internal opening as well as about the fistulous tract.
 Intersphincteric type of fistula in Ano is the commonest type
( 45%)
 MRI is the gold standard for fistula imaging in complicated fistula
 Fistulotomy, Fistulectomy & Ksharsutra are common procedure to treat
it.
 VAAFT is the recent advance in Fistula surgery