Surgical anatomy- anal canal
18/3/2018
by:
Dr. Belal Mansoor
Taiz university
Overview
Introductions
Location , extent , Dimensions of anal canal
Embryology
The anorectal ring ,The puborectalis muscle
Anal sphincters & The intersphincteric plane
The epithelium and sub epithelial structures(internal).
Blood supply ,Lymphatic drainge ,& Nerve supply
Clinical aspects
The anal canal
• The anal canal remains an area of medicine
and surgery plagued by obscurity and
limited provider knowledge.
• Many conditions are in fact common and
benign, but some lead to incapacitating
interference with the patient’s daily life.
SABISTON TEXTBOOK of SURGERY 20th EDITION
The anal canal
• Therefore, attempts to improve our fund of
knowledge of the anatomy and function of the
anal canal and the basic physiology of the
pelvic floor.
» should facilitate accurate diagnosis and
management of both common and rare
conditions.
SABISTON TEXTBOOK of SURGERY 20th EDITION
The anal
canal
The surgical The anatomic
anal canal anal canal
The surgical anal canal
• The surgical
anal canal:
– It begins at the
anorectal
junction
– terminates at
the anal verge.
The surgical anal canal
• The muscular
junction between
the rectum and anal
canal can be felt
with the finger as a
thickened ridge – the
anorectal ‘bundle’or
‘ring’.
Bailey & Love’s 26th EDITION
The surgical anal canal- Dimensions
• The surgical anal
canal measures
2 to 4 cm in
length and is
generally longer
in men than in
women.
Schwartz’s Principles of Surgery
Tenth Edition
The anatomic anal canal
• The anatomic
anal canal
extends from
the dentate or
pectinate line
to the anal
verge.
Posteriorly:
Anteriorly:
In the male,: the perineal body,, the membranous part of the urethra, and the bulb of
the penis
Anteriorly: In the female ,: the perineal body ,the lower part of the
vagina
Laterally: The fat-filled ischiorectal fossae
The anal canal below the pectinate
line develops from the proctodeum
(ectoderm), while that above the
pectinate line develops from the
endoderm of the hindgut.
• The congenital anomaly
in which the anal canal
fails to communicate
with the exterior is
known as imperforate
anus.
Imperforate anus is a congenital anomaly in which
the anal canal fails (completely or incompletely) to
open to the exterior.
• The anal canal is completely extraperitoneal.
The Anorectal Ring
• The anorectal ring
marks the junction
between the
rectum and the
anal canal .
• It is formed by the joining of :
the puborectalis muscle
the deep external sphincter,
conjoined longitudinal muscle
the highest part of the internal sphincter
The Anorectal Ring
• The
anorectal
ring
• The anorectal ring can be clearly felt digitally, as a thickened
ridge , especially on its posterior and lateral aspects.
the puborectalis muscle
• At rest, the puborectalis muscle creates a
“sling” around the distal rectum, forming a
relatively acute angle that distributes intra-
abdominal forces onto the pelvic floor.
• With defecation, this angle straightens,
allowing downward force to be applied along
the axis of the rectum and anal canal.
• Nonrelaxation of puborectalis results in
straining and incomplete evacuation.
Anal sphincters
The internal sphincter
external sphincter
The external sphincter
• Voluntary sphincter
• Composed of skeletal muscle. Surrounds
entire length of anal canal
• Consists of 3 parts – Subcuatneous Superficial
& Deep
• Nerve supply:
– Inf. Rectal br. Of pudendal n.
– Perineal br. of 4th sacral n.
The external sphincter
• Consists of 3 parts
deep
superficial
subcutaneous
The parts blend with one other to form a continuous tube.
The external sphincter
The deep external anal sphincter : ring, together wiht the puborectalis muscle.
Superficial : elliptical ,and attached to coccyx
Subcutanenous :ring
The external sphincter
• Anorectal sphincter
tone can be assessed
during digital rectal
examination (DRE)
when the patient is
asked to squeeze the
examining finger.
The intersphincteric plane
• Between the external sphincter muscle
laterally and the longitudinal muscle
medially exists a potential space, the
intersphincteric plane.
• The plane can be opened up surgically to
provide access for operations on the
sphincter muscles.
The longitudinal muscle
The longitudinal
muscle is a direct
continuation of the
smooth
muscle of the outer
muscle coat of the
rectum.,
At the anorectal junction the outer longitudinal layer of
rectal m. become fibro elastic and, together with some
striated muscles fibres of puborectalis , forms he conjoint
longitudinal coat which runs down between the two
sphincters.
The internal sphincter
• When exposed during life, it is pearly-white in
colour and its circumferentially placed fibres
can be seen clearly.
The anal
sphincter
mechanism :
allows maintains
defecation . continence.
The Defecation
• Defecation has four components:
1. mass movement of feces into the rectal vault.
2. rectal–anal inhibitory reflex, by which distal
rectal distention causes involuntary relaxation of
the internal sphincter;
3. voluntary relaxation of the external sphincter
mechanism and puborectalis muscle;
4. increased intra-abdominal pressure.
The Continence
• Continence requires:
normal capacitance,
normal sensation at the anorectal transition zone,
puborectalis function for solid stool,
external sphincter function for fine control,
internal sphincter function for resting pressure.
THE INCONTINENCE
• INCONTINENCE:
– is the inability to prevent elimination of rectal contents.
• Etiologies include :
– (1) mechanical defects,
– sphincter damage from obstetric trauma,
fistulotomy, and scleroderma affecting the external
sphincter;
– (2) neurogenic defects,
– spinal cord injuries, pudendal nerve injury due to
birth trauma or lifelong straining, and systemic
neuropathies such as multiple sclerosis; and
– (3) stool content-related causes,
– such as diarrhea and radiation proctitis.
Interior of anal canal
Interior of anal canal
Interior of anal canal
The anal valves join together the
lower ends of the anal columns
most important landmark both morphologically and surgically
The pectinate line
• The pectinate line is not
seen on inspection in
clinical practice,
but under anesthesia the
anal canal descends
down, and the pectinate
line can be seen on slight
retraction of the anal
canal skin.
The anal sinuses are furrows in the anal canal, that separate
the anal columns from one another. The anal sinuses end
below in small valve-like folds, termed anal valves.
The glands themselves are located
at varying depths in the anal canal
wall
The pecten:
is a smooth area of hairless
stratified epithelium that lies
between the anal valves superiorly
and the inferior border of the
internal anal sphincter inferiorly.
ANAL FISSURE:
it is a split in the anoderm. (a longitudinal tear in
the mucosa and skin of the lower third of the anal
canal).
90%occur posteriorly (comparatively low
blood flow)
ANAL FISSURE
If surgery is required,
lateral internal
sphincterotomy is 90%
successful.
Blood supply
• The blood supply is based on embryology:
• ■ Hindgut: Inferior mesenteric artery (IMA)
• ■ Distal anus: Internal pudendal artery
branches
arterial supply
– above dentate line:
• superior rectal artery (from inferior mesenteric artery);
• small contributions from middle rectal artery (directly
from internal iliac artery) and median sacral arteries
– below dentate line:
• inferior rectal artery (from internal pudendal artery).
venous drainage:
• continuous with rectal venous plexus (i.e. rich anastomoses).
– above dentate line:
• superior rectal vein to inferior mesenteric vein (portal
venous system)
– below dentate line:
• inferior and middle rectal veins to internal iliac veins
• The anal canal is a site of portosystemic anastomosis.
Haemorrhoids (‘piles’)
Haemorrhoids (piles) are engorged vascular cushions found within the
submucosa of the anal canal that exist in three columns in the anal canal:
•right anterolateral,
• right posterolateral,
•and left lateral.
Innervation
• above dentate line and internal anal sphincter
– Sympathetic L1,L2: from pelvic plexus ……. Cause
contraction
– parasympathetic S2,S3,S4( cause relaxsion )and
afferent sensory: pelvic splanchnic nerves
• below dentate line and external anal sphincter
– inferior rectal branches of the pudendal nerve
last
SUMMARY
• The anorectal area consists of a relatively
small but complex region where multiple
anatomic and physiologic interactions occur
to help aid continence and defecation.
References
• Short Practice Of Surgery Bailey & Love’s 26th Edition
• Sabiston Textbook Of Surgery 20TH Edition
• Schwartz’s Principles Of Surgery Tenth Edition
• Netter’s Surgical Anatomy 2ND Edition
• Clinical Anatmy BY Regions ,Snell 9TH Edition
• Last Anatomy 2011 .
• Cracking The Mrcs Viva 2007.
• Slideshare ,Google .
