Surgery of the anorectum and the perianal region in small ... · PDF file1 Surgery of the...
Transcript of Surgery of the anorectum and the perianal region in small ... · PDF file1 Surgery of the...
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Surgery of the anorectum Surgery of the anorectum and the perianal region in and the perianal region in
small animalssmall animals
Surgery of the anorectum Surgery of the anorectum and the perianal region in and the perianal region in
small animalssmall animals
Dr. T. Németh, DVM, PhDDr. T. Németh, DVM, PhD
Associate ProfessorAssociate Professor
Dr. T. Németh, DVM, PhDDr. T. Németh, DVM, PhD
Associate ProfessorAssociate Professor
SurgicalSurgical anatomyanatomy((AnorectumAnorectum))
SurgicalSurgical anatomyanatomy((AnorectumAnorectum))
�� Zona cutaneaZona cutanea–– Circumanal glandsCircumanal glands
–– Anal sacsAnal sacs
�� Zona intermediaZona intermedia�� Zona columnarisZona columnaris�� Linea anorectalisLinea anorectalis
Surgical anatomySurgical anatomy(Perineum)(Perineum)
�� m. coccygeusm. coccygeus�� m. levator anim. levator ani�� m. sphincter ani ext.m. sphincter ani ext.�� m. sphincter ani int.m. sphincter ani int.�� m. obturatorius int.m. obturatorius int.�� a., v. pudenda int.a., v. pudenda int.�� n. pudendusn. pudendus
General diagnostic considerations of General diagnostic considerations of the anorectal and perianal diseases I.the anorectal and perianal diseases I.
�� AnamnesisAnamnesis–– generally chronic historygenerally chronic history
–– tenesmus in defecationtenesmus in defecation
–– fecal deviationfecal deviation
–– local signs local signs (pruritus, formal deviation…)(pruritus, formal deviation…)
–– General signs General signs (alimentary, septicus…)(alimentary, septicus…)
General diagnostic considerations of General diagnostic considerations of the anorectal and perianal diseases II.the anorectal and perianal diseases II.
�� Physical examinationPhysical examination
–– inspectioninspection
–– palpationpalpation
�� superficialsuperficial
�� rectal (RDP)rectal (RDP)
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General diagnostic considerations of General diagnostic considerations of the anorectal and perianal diseases the anorectal and perianal diseases
III.III.
�� SupplSuppl. . examinationsexaminations–– BloodworkBloodwork, , urinalysisurinalysis ((gengen. . statestate))
–– FineFine needleneedle aspirateaspirate//cytologycytology ((tumourstumours))
–– XX--rayray / / pospos. . contrastcontrast rectogrrectogr., ., cystogrcystogr. . ((rectalrectal fistulationfistulation, , perinealperineal herniahernia))
–– RectoscopyRectoscopy((rectalrectal tumourstumours))
–– US US ((perinealperineal herniahernia//prostateprostate, , perinealperineal tumourtumour//lnnlnn.).)
–– CT / MRICT / MRI
General considerations of anorectal General considerations of anorectal and perianal surgery I.and perianal surgery I.
�� Preoperative dutiesPreoperative duties–– evacuation of rectum (enema)evacuation of rectum (enema)
–– antimicrobial prophylaxisantimicrobial prophylaxis
�� enteralenteral
�� parenteralparenteral
General considerations of anorectal General considerations of anorectal and perianal surgery II.and perianal surgery II.
�� SurgerySurgery–– atraumatic handling atraumatic handling
–– preservation of ext. anal sphincter anipreservation of ext. anal sphincter ani
–– monophil suture materialsmonophil suture materials
General considerations of anorectal General considerations of anorectal and perianal surgery III.and perianal surgery III.
�� PostoperativePostoperative dutiesduties–– ParenteralParenteral / / enteralenteral feedingfeeding / / dietdiet
–– analgesiaanalgesia
–– contcont. of . of antibacterialantibacterial therapytherapy
–– protectionprotectionof of operationoperationsite (site (collarcollar, , cleaningcleaning))
Most important diseases of the Most important diseases of the regionregion
�� Anal/rectal prolapsAnal/rectal prolaps
�� Anal sacculitisAnal sacculitis
�� Perianalis fistulaPerianalis fistula
�� Anal and rectal tumoursAnal and rectal tumours
Anal/rectal prolapsAnal/rectal prolaps
�� IncidenceIncidence
–– result of diseases with defecation tenesmus of result of diseases with defecation tenesmus of frequent defecationfrequent defecation
–– commonly in combination with commonly in combination with intussusceptionintussusception
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Anal/rectal prolapsAnal/rectal prolaps
�� DiagnosisDiagnosis
–– assesment of vitality of assesment of vitality of the prolapsed gutthe prolapsed gut
–– reponability (?)reponability (?)
–– diagnosis of the primary diagnosis of the primary disease (enteritis)disease (enteritis)
Anal/rectal prolapsAnal/rectal prolaps
�� TherapyTherapy–– Treatment of primary Treatment of primary
diseasedisease
–– 1. reposition 1. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ purse purse string suturestring suture
–– 2. reposition 2. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ colopexycolopexy
–– 3.3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
�� TherapyTherapy–– Treatment of primary diseaseTreatment of primary disease
–– 1. reposition 1. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ purse string suturepurse string suture
–– 2. reposition 2. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ colopexycolopexy
–– 3. 3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
�� TherapyTherapy–– Treatment of primary diseaseTreatment of primary disease
–– 1. reposition 1. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ purse string suturepurse string suture
–– 2. reposition 2. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ colopexycolopexy
–– 3. 3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
�� TherapyTherapy–– Treatment of primary diseaseTreatment of primary disease
–– 1. reposition 1. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ purse string suturepurse string suture
–– 2. reposition 2. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ colopexycolopexy
–– 3. 3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
�� TherapyTherapy–– Treatment of primary Treatment of primary
diseasedisease
–– 1. reposition 1. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ purse purse
string suturestring suture
–– 2. reposition 2. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ colopexycolopexy
–– 3. 3. resection resection
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Anal/rectal prolapsAnal/rectal prolaps
�� TherapyTherapy–– Treatment of primary Treatment of primary
diseasedisease
–– 1. reposition 1. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ purse purse
string suturestring suture
–– 2. reposition 2. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ colopexycolopexy
–– 3. 3. resection resection
Anal/rectal prolapsAnal/rectal prolaps
�� TherapyTherapy–– Treatment of primary diseaseTreatment of primary disease
–– 1. reposition 1. reposition ⇒⇒⇒⇒⇒⇒⇒⇒ purse string suturepurse string suture
–– 2 reposition 2 reposition ⇒⇒⇒⇒⇒⇒⇒⇒ colopexycolopexy
–– 3. 3. resection („’pull through”)resection („’pull through”)
Rectal resectionRectal resection
„„ PullPull--through”through”Rectal resectionRectal resection
„„ PullPull--through”through”Rectal resectionRectal resection
„„ PullPull--through”through”Rectal resectionRectal resection
„„ PullPull--through”through”
Rectal resectionRectal resection
„„ PullPull--through”through”Rectal resectionRectal resection
„„ PullPull--through”through”Rectal resectionRectal resection
„„ PullPull--through”through”Rectal resectionRectal resection
„„ PullPull--through”through”
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Rectal resectionRectal resection
„„ PullPull--through”through”Rectal resectionRectal resection
„„ PullPull--through”through”Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
�� IncidenceIncidence
–– mainly in dogsmainly in dogs
–– primary or secondaryprimary or secondary
–– combined with allergodermatitiscombined with allergodermatitis
Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
�� DiagnosisDiagnosis
–– Local signsLocal signs�� Increased amount of Increased amount of
contentcontent
�� Local irritationLocal irritation
�� abscess / phlegmone / abscess / phlegmone /
cystcyst
–– Systemic signsSystemic signs
�� prurituspruritus
�� septic signsseptic signs
�� allergic reactionsallergic reactions
Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
�� TherapyTherapy–– conservativeconservative
–– surgicalsurgical
Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
�� Conservative therapyConservative therapy–– precise evacuation of the sac (rectally!!!)precise evacuation of the sac (rectally!!!)
–– parenteral antibioticsparenteral antibiotics
–– analgesia/NSAIDsanalgesia/NSAIDs
AnalAnal sacculitissacculitis / / ParaproctitisParaproctitis�� SurgerySurgery ((analanal sacculectomysacculectomy))
„closed”„open”
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AnalAnal sacculitissacculitis / / ParaproctitisParaproctitis
�� Surgery (anal sac removal)Surgery (anal sac removal)
Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis
�� Surgery (anal sac removal)Surgery (anal sac removal)
PerianalPerianal fistulafistula / / furunculosisfurunculosis
�� IncidenceIncidence / / AetiologyAetiology–– inin GermanGerman shepherdshepherd and and itsits mongrelsmongrels↑↑↑↑↑↑↑↑
–– IrishIrish settersetter, Labrador, , Labrador, CollieCollie
–– uncertainuncertainaetiologyaetiology::�� immuneimmune--mediatedmediated ((autoimmuneautoimmune))
�� DecreasedDecreased activityactivity of of mucosalmucosal and and circulatingcirculating IgAIgA
�� hyperaktívhyperaktív local local immuniyimmuniy ((IgAIgA, , IgGIgG, , BB--andand TT--lymphocy teslymphocytes, ,
CD3+, CD3+, macrophagesmacrophages, , plasmaplasma cellscells, IL, IL--2, INF2, INF--γγγγγγγγ))
–– concurrentconcurrent chronicchronic colitiscolitis
–– AnalogyAnalogywithwith human human Crohn’sCrohn’s--diseasedisease (?)(?)
Perianal fistula / furunculosisPerianal fistula / furunculosis
�� DiagnosisDiagnosis–– breedbreed
–– typical chronic, nontypical chronic, non--
healing, recurring healing, recurring analis fistulous tractanalis fistulous tract
–– concurrent colitisconcurrent colitis
Perianal fistula / furunculosisPerianal fistula / furunculosis
�� DiagnosisDiagnosis–– breedbreed
–– typical chronic, nontypical chronic, non--
healing, recurring healing, recurring analis fistulous tractanalis fistulous tract
–– concurrent colitisconcurrent colitis
Perianal fistula / furunculosisPerianal fistula / furunculosis
�� TherapyTherapy
–– Currently no effective causative treatment !!!Currently no effective causative treatment !!!
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Perianal fistula / furunculosisPerianal fistula / furunculosis
�� TherapyTherapy–– conservativeconservative (!!!)(!!!)–– surgicalsurgical (!?)(!?)
PerianalPerianal fistulafistula / / furunculosisfurunculosis�� ConservativeConservative therapytherapy (!!!)(!!!)
–– ProtocolProtocol #1 (Michigan #1 (Michigan StateState University)University)�� dietdiet�� PrednisolonePrednisolone�� AzathioprineAzathioprine
–– ProtocolProtocol #2 (Ontario #2 (Ontario VeterinaryVeterinary College)College)�� dietdiet�� CyclosporineCyclosporine
–– ProtocolProtocol #3#3�� #1 #1 oror #2 + #2 + TacrolimusTacrolimus ointmentointment topicallytopically
PerianalPerianal fistulafistula / / furunculosisfurunculosis
� Surgery• Previous failed techniques
cryo-surgery (UK)soft lasertail amputation (USA)castration (???)
• Current surgical recommendation �„Anoplasty”
fistulectomyparaproctectomycryptectomy (zona columnaris)
Anal / Rectal tumoursAnal / Rectal tumours
�� IncidenceIncidence–– hepatoid circumanal gland tumours hepatoid circumanal gland tumours
(hyperplasia, adenoma, anapl. carcinoma)(hyperplasia, adenoma, anapl. carcinoma)⇒⇒⇒⇒⇒⇒⇒⇒ in male dogsin male dogs
–– Anal sac tumours (adenocarcinoma) Anal sac tumours (adenocarcinoma) ⇒⇒⇒⇒⇒⇒⇒⇒ in female dogsin female dogs
–– rectal adenoma / adenocarcinomarectal adenoma / adenocarcinoma
Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
�� DiagnosisDiagnosis–– inin malemale dogsdogs–– testosteronetestosterone
dependencydependency–– multilocalmultilocal perianalperianal
lumpslumps ((anusanus, , basebase of of tailtail))
–– commoncommon ulcerationulceration–– RDPRDP–– finefine needleneedle aspiratesaspirates / /
cytologycytology
Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
�� DiagnosisDiagnosis–– in male dogsin male dogs–– testosterone testosterone
dependencydependency–– multilocal perianal multilocal perianal
lumps lumps (anus, (anus, base of base of tail)tail)
–– common ulcerationcommon ulceration–– RDPRDP–– fine needle aspirates / fine needle aspirates /
cytologycytology
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Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
�� DiagnosisDiagnosis–– in male dogsin male dogs–– testosterone testosterone
dependencydependency–– multilocal perianal multilocal perianal
lumps lumps (anus, (anus, base of base of tail)tail)
–– common ulcerationcommon ulceration–– RDPRDP–– fine needle aspirates / fine needle aspirates /
cytologycytology
Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
�� TherapyTherapy–– castration (!)castration (!)–– (oestrogen inj.)(oestrogen inj.)–– excision of tumourexcision of tumour–– histopath (!)histopath (!)–– postop. antibioticspostop. antibiotics–– local cleansinglocal cleansing
Anal /Rectal tumoursAnal /Rectal tumoursHepatoid circumanal tumoursHepatoid circumanal tumours
�� TherapyTherapy–– castration (!)castration (!)–– (oestrogen inj.)(oestrogen inj.)–– excision of tumourexcision of tumour–– histopath (!)histopath (!)–– postop. antibioticspostop. antibiotics–– local cleansinglocal cleansing
Anal /Rectal tumoursAnal /Rectal tumoursRectalRectaltumourstumours
�� DiagnosisDiagnosis–– bloody fecesbloody feces–– tenesmustenesmus–– RDP RDP (pelvic lymphonodes)(pelvic lymphonodes)
–– rectoscopyrectoscopy–– (US)(US)–– cytologycytology
Anal /Rectal tumoursAnal /Rectal tumoursRectal tumoursRectal tumours
�� TherapyTherapy–– „pull„pull--open”open”–– excision of excision of
tumour tumour (electrocautery)(electrocautery)
–– histopath.histopath.–– antibioticsantibiotics–– dietdiet
„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
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„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture „„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture „„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture „„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
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„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture „„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture
RectalRectal tumourstumours
�� TherapyTherapy–– DorsallyDorsally positionedpositioned
intrapelvicintrapelvic localisationlocalisation::–– „„dorsaldorsal rectalrectal
approachapproach””
RectalRectal tumourstumours
�� TherapyTherapy–– LaterallyLaterally positionedpositioned
intrapelvicintrapelvic localisationlocalisation::–– „„laterallateral rectalrectal
approachapproach””
RectalRectal tumourstumours
�� TherapyTherapy–– CaudalCaudal intrapelvicintrapelvic
localisationlocalisation::–– „„pullpull--throughthrough””rectumrectum resectionresection
RectalRectal tumourstumours
�� TherapyTherapy–– CranialCranial intrapelvicintrapelvic
localisationlocalisation::–– „„ventralventral rectalrectal
approachapproach withwith pubicpubicosteotomyosteotomy””