Anal fissure hemmorids pilonidal sinus ppt.pptx

perianal diseases

1. Anal Fissure, Pilonidal Sinus and Hemorrhoids

2. Anal canal Anatomy:

3. 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

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

5. Image of Anal Sphincter: Deep External Sphincter. Sub cutaneous External Sphincter Superficial External Sphincter Circular muscles of Rectum L o n g i tud inal muscle of Rectum Internal anal S Conjoined lo n g i tud inal muscle

6. 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

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

8. 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 D r a i na g e Portal System Systemic-Ext iliac vein Lymphatic Drainage Para-aortic Superficial & Deep inguinal LN

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

10. 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

11. 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

12. 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.

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

14. 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

15. 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

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

17. 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

18. Conservative :Hot Seitz Bath

19. Conservative Treatment: Dru g s tha t r elease th e Ni t ri c o xid e d o n o r - G l y c e r y l 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

20. 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

21. 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

22. 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.

23. 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

24. 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

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

26. Hemorrhoids Pathophysiology Factors involved in the development of haemorhhoidal disease: Venous obstruction Prolapse of vascular cushions Heredity Geographical and dietary factors Anal sphincter tone Anal and rectal sensation Defecation habits

27. Epidemiology Gender: In hospital based studies Men > women In community based studies men = women Age: Increase with age Socioeconomic status and occupation: > high socioeconomic group > heavy laborer and occupations with prolonged sitting or standing

28. B: First-degree bleeding without prolapse C: Second-degree Prolapsed, reduced spontaneously D: Third-degree prolapsed, requiring manual reduction E: Fourth-degree fibrosed permanently prolapsed Reference : Sabiston Textbook of Surgery, 18th Edition

29. Bleeding Prolapse and lump Pain and discomfort Discharge and pruritis

30. External Anoderm Swell, discomfort, dif icult hygiene Pain? -> Thrombosed Pain? -> painless Bright red bleeding Prolapse associated with defecation Internal

31. Thrombosis and infection of internal cushions Anemia Perianal dermatitis Thrombosis of external vascular channels

32.  Conservative; Medical Invasive therapy Injection sclerotherapy Rubber band ligation Cryotherapy Photocoagulation Surgical; Open haemorrhoidectomy Closed haemorrhoidectomy White head haemorrhoidectomy Laser haemorrhoidectomy Diathermy haemorrhoidectomy Stapled haemorrhoidopexy

33. Reference : Sabiston Textbook of Surgery, 18th Edition GRADE SYMPTOMS AND SIGNS MANAGEMENT First degree Bleeding; no prolapse Dietary modifications Second degree Prolapse with spontaneous reduction Rubber band ligation Bleeding, seepage Coagulation Dietary modifications Third degree Prolapse requiring digital reduction Surgical hemorrhoidectomy Bleeding, seepage Rubber band ligation Dietary modifications Fourth degree Prolapsed, cannot be reduced Surgical hemorrhoidectomy Strangulated Urgent hemorrhoidectomy Dietary modifications

34. Useful in 1 st and 2 nd degree 70% success rate Sclerosant causes aseptic inflammation and fibrosis in 2-3 weeks. Gabriel syringe and needle 5% phenol in almond oil (3ml in each cushion) 2.4% anhydrous qunine urea with ph 2.6. Knee chest or left lateral position Rt posterior cushion (7oclock) should be injected 1 st .

35. Used for 2 nd degree 80% success rate Principle is mucosal fixation by ulceration. Band produces ischemic necrosis with sloughing and ulceration. Ligators Barron ligator Suction band ligator Mc Giveny ligator Preparation and position: Bowel should be empty An assistant to hold proctoscope Knee chest position

36.  Indications: 3 rd degree haemorrhoids 2 nd degree haemorrhoids which have not been cured by non operative methods Fibrosed haemorrhoids Interno- external haemorrhoids when the external haemorrhoids are well defined. Preparation: 1 enema night before surgery another 1 hour before surgery Pts with severly prolapsed haemorrhoids should be spared from enema. Anesthesia: Any type of anesthesia If L/A 0.25% bupicain with 1:200,000 adrenalin

37.  Less post op discomfort Minimum in patient and virtually no out patient care No loss of continence No need of subsequent anal dilation Relative contra indications: Crohn’s disease Portal hypertention Lymphoma Leukemia Bleeding diathesis

38. Pilonidal sinus

39. Definition: Infection of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttocks. NOT a true cyst

40. History 1833- hair cotining cyst located just below the coccyx Mayo 1880- Hodge coined the term “pilonidal” Nest of hair In 19 th and 20 th century – considered to be congenital

41. What causes pilonidal sinus??? Midline holes – Hair follicles that have enlarged Pulling forces between sacrum and skin Force concentrate on 1- 2 mm area where the narrow gluteal crease comes in close contact with the sharp angle of sacrum Weakest point of skin gives way first– Skin at the bottom of the follicle. Primary cause – “Pit” Secondary casue – “ Hair follicles”

42. Risk factors Overweight/ obesity Local trauma or irritation Sedentary lifestyle/prolonged sitting Deep natal cleft Family history

43. Pathogenesis Hair and inflammation – inciting factors On sitting/bending natal cleft stretches-  breakage of follicles-  opening of a pore/pit-  collection of debris -  pilonidal sinus -  abscess Proof?? Pilonidal tract extends cephalad. Cavity contains hair, debris or granulation tissue .

44. Clinical manifestations Patient presentation: Acute onset mild to severe pain (sitting/bending) Intermittent mucoid/purulent/bloody discharge Recurrent / persisting pain Fever / malaise

45. Physical examination and diagnosis One/more pits in the natal cleft +/- painless sinus opening cephalad and lateral to cleft Tender mass or sinus draining mucoid/bloody or purulent fluid Diagnosis Clinical Finding a pore/sinus in the natal cleft No imaging required

46. Surgical treatment Drainage with/ without excision Marsupialisation Excision with primary closure Excision with grafting Sinus extraction Sclerosing injections

47. Karydakis surgery Karydakis believed that hair insertion is the cause for pilonidal sinus Low recurrence rates due to: Wound placed away from midline Resulting new natal cleft was shallower Problems Sutured taken over the presacral fascia causing pain Patients requiring GA Prolonged hospital stay

48. Z- plasty