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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””