Surgery of the anorectum and the perianal region in small ... · Surgery of the anorectum and the perianal region in small animals Dr. T. Németh, ... –evacuation of rectum

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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, Dr. T. Németh, DVM, PhD, DipECVSDVM, PhD, DipECVS

Associate Professor and Head of SurgeryAssociate Professor and Head of Surgery

Dr. T. Németh, Dr. T. Németh, DVM, PhD, DipECVSDVM, PhD, DipECVS

Associate Professor and Head of SurgeryAssociate Professor and Head of Surgery

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

–– protectionprotection of of operationoperation site (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


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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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)


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


TherapyTherapy–– Treatment of primary diseaseTreatment of primary disease–– 1. reposition 1. reposition purse string suturepurse string suture


–– 3. 3. resection resection











diseasedisease




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diseasedisease






–– 2 reposition 2 reposition colopexycolopexy

–– 3. 3. resection („’pull through”)resection („’pull through”)

Rectal resectionRectal resection„„PullPull--through”through”


IndicationIndication–– Partial rectal resection between pubic bone and Partial rectal resection between pubic bone and

anorectal lineanorectal line–– necrosis, tumour, stricture, injurynecrosis, tumour, stricture, injury

SurgerySurgery–– preparation preparation (see general considerations)(see general considerations)

–– prolapsing of rectumprolapsing of rectum–– circumferential transectioncircumferential transection–– rectal resectionrectal resection–– interrupted monofilament absorbable stitchesinterrupted monofilament absorbable stitches

IndicationIndication–– Partial rectal resection between pubic bone and Partial rectal resection between pubic bone and

anorectal lineanorectal line–– necrosis, tumour, stricture, injurynecrosis, tumour, stricture, injury

SurgerySurgery–– preparation preparation (see general considerations)(see general considerations)

–– prolapsing of rectumprolapsing of rectum–– circumferential transectioncircumferential transection–– rectal resectionrectal resection–– interrupted monofilament absorbable stitchesinterrupted monofilament absorbable stitches







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A vastagbél sebészeteA vastagbél sebészete„„PullPull--through”through”

A vastagbél sebészeteA vastagbél sebészete„„PullPull--through”through”

VIDEOVIDEOVIDEOVIDEO

Anal sacculitis / ParaproctitisAnal sacculitis / Paraproctitis

IncidenceIncidence–– mainly in dogsmainly in dogs

–– primary or secondaryprimary or secondary

–– combined with allergodermatitiscombined with allergodermatitis


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


TherapyTherapy–– conservativeconservative–– surgicalsurgical

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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”

AnalAnal sacculitissacculitis / / ParaproctitisParaproctitis

Surgery (anal sac removal)Surgery (anal sac removal)


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

–– uncertainuncertain aetiologyaetiology:: immuneimmune--mediatedmediated ((autoimmuneautoimmune)) DecreasedDecreased activityactivity of of mucosalmucosal and and circulatingcirculating IgAIgA hyperaktívhyperaktív local local immuniyimmuniy ((IgAIgA, , IgGIgG, , BB--andand TT--lymphocyteslymphocytes, ,

CD3+, CD3+, macrophagesmacrophages, , plasmaplasma cellscells, IL, IL--2, INF2, INF--))

–– concurrentconcurrent chronicchronic colitiscolitis

–– AnalogyAnalogy withwith 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

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DiagnosisDiagnosis–– breedbreed–– typical chronic, nontypical chronic, non--

healing, recurring healing, recurring analis fistulous tractanalis fistulous tract

–– concurrent colitisconcurrent colitis


TherapyTherapy–– Currently no effective causative treatment !!!Currently no effective causative treatment !!!


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

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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


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


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


TherapyTherapy–– castration (!)castration (!)–– (oestrogen inj.)(oestrogen inj.)–– excision of tumourexcision of tumour–– histopath (!)histopath (!)–– postop. antibioticspostop. antibiotics–– local cleansinglocal cleansing


TherapyTherapy–– castration (!)castration (!)–– (oestrogen inj.)(oestrogen inj.)–– excision of tumourexcision of tumour–– histopath (!)histopath (!)–– postop. antibioticspostop. antibiotics–– local cleansinglocal cleansing

Anal /Rectal tumoursAnal /Rectal tumoursRectalRectal tumourstumours

DiagnosisDiagnosis–– bloody fecesbloody feces–– tenesmustenesmus–– RDP RDP (pelvic lymphonodes)(pelvic lymphonodes)

–– rectoscopyrectoscopy–– (US)(US)–– cytologycytology

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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

„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture „„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture„„PullPull--openopen” ” –– anorectalisanorectalis stricturestricture


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RectalRectal tumourstumours

TherapyTherapy–– DorsallyDorsally positionedpositioned

intrapelvicintrapelvic localisationlocalisation::–– „„dorsaldorsal rectalrectal

approachapproach””


TherapyTherapy–– LaterallyLaterally positionedpositioned

intrapelvicintrapelvic localisationlocalisation::–– „„laterallateral rectalrectal

approachapproach””

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TherapyTherapy–– CaudalCaudal intrapelvicintrapelvic

localisationlocalisation::–– „„pullpull--throughthrough””rectumrectum resectionresection


TherapyTherapy–– CranialCranial intrapelvicintrapelvic

localisationlocalisation::–– „„ventralventral rectalrectal

approachapproach withwith pubicpubicosteotomyosteotomy””

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Surgery of the anorectum and the perianal region in small ... · Surgery of the anorectum and the perianal region in small animals Dr. T. Németh, ... –evacuation of rectum