docSurgery of the anorectum and the perianal region in small animals
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Surgery of the anorectum and the perianal region in small animals
Surgical anatomy (Anorectum Anorectum)) Surgery of the anorectum and the perianal region in small animals Dr. T. Németh, DVM, PhD, DipECVS Associate Professor and Head of Surgery Surgical anatomy (Anorectum Anorectum)) Surgical anatomy (Perineum) Zona cutanea – Circumanal glands – Anal sacs Zona intermedia Zona columnaris Linea anorectalis General diagnostic considerations of the anorectal and perianal diseases I. Anamnesis m. coccygeus m. levator ani m. sphincter ani ext. m. sphincter ani int. m. obturatorius int. a., v. pudenda int. n. pudendus General diagnostic considerations of the anorectal and perianal diseases II. Physical examination – generally chronic history – tenesmus in defecation – fecal deviation – inspection – palpation – local signs (pruritus, formal deviation…) superficial – General signs (alimentary, septicus…) rectal (RDP) 1 General diagnostic considerations of the anorectal and perianal diseases III. Suppl Suppl.. General considerations of anorectal and perianal surgery I. examinations – Bloodwork, Bloodwork, urinalysis (gen gen.. state state)) – Fine needle aspirate/ aspirate/cytology (tumours tumours)) – X-ray / pos pos.. contrast rectogr., rectogr., cystogr cystogr.. – evacuation of rectum (enema) – antimicrobial prophylaxis (rectal fistulation fistulation,, perineal hernia hernia)) – Rectoscopy (rectal tumours tumours)) – US (perineal hernia hernia//prostate prostate,, perineal tumour tumour//lnn lnn.) .) – CT / MRI General considerations of anorectal and perianal surgery II. Surgery Preoperative duties enteral parenteral General considerations of anorectal and perianal surgery III. Postoperative duties – atraumatic handling – Parenteral / enteral feeding / diet – preservation of ext. anal sphincter ani – analgesia – monophil suture materials – cont cont.. of antibacterial therapy – protection of operation site (collar (collar,, cleaning cleaning)) Most important diseases of the region Anal/rectal prolaps Anal sacculitis Perianalis fistula Anal and rectal tumours Anal/rectal prolaps Incidence – result of diseases with defecation tenesmus of frequent defecation – commonly in combination with intussusception 2 Anal/rectal prolaps Diagnosis Anal/rectal prolaps Therapy – assesment of vitality of the prolapsed gut – Treatment of primary disease – reponability (?) – 1. reposition purse string suture – diagnosis of the primary disease (enteritis) – 2. reposition colopexy – 3. resection Anal/rectal prolaps Therapy Anal/rectal prolaps Therapy – Treatment of primary disease – Treatment of primary disease – 1. reposition purse string suture – 1. reposition purse string suture – 2. reposition colopexy – 2. reposition colopexy – 3. resection – 3. resection Anal/rectal prolaps Therapy – Treatment of primary disease – 1. reposition purse string suture – 2. reposition colopexy – 3. resection Anal/rectal prolaps Therapy – Treatment of primary disease – 1. reposition purse string suture – 2. reposition colopexy – 3. resection 3 Anal/rectal prolaps Anal/rectal prolaps Therapy – Treatment of primary disease – 1. reposition purse string suture – 2. reposition colopexy Therapy – Treatment of primary disease – 1. reposition purse string suture – 2 reposition colopexy – 3. resection („’pull through”) – 3. resection Rectal resection Rectal resection „Pull Pull--through” „Pull Pull--through” Indication – Partial rectal resection between pubic bone and anorectal line – necrosis, tumour, stricture, injury Surgery – – – – – preparation (see general considerations) prolapsing of rectum circumferential transection rectal resection interrupted monofilament absorbable stitches Rectal resection Rectal resection „Pull Pull--through” „Pull Pull--through” 4 Rectal resection Rectal resection „Pull Pull--through” „Pull Pull--through” A vastagbél sebészete „Pull Pull--through” Anal sacculitis / Paraproctitis VIDEO Incidence – mainly in dogs – primary or secondary – combined with allergodermatitis Anal sacculitis / Paraproctitis Anal sacculitis / Paraproctitis Diagnosis – Local signs Increased amount of content Local irritation abscess / phlegmone / cyst Therapy – conservative – surgical – Systemic signs pruritus septic signs allergic reactions 5 Anal sacculitis / Paraproctitis Anal sacculitis / Paraproctitis Surgery (anal sacculectomy sacculectomy)) Conservative therapy – precise evacuation of the sac (rectally!!!) – parenteral antibiotics – analgesia/NSAIDs „closed” „open” Anal sacculitis / Paraproctitis Surgery (anal sac removal) Perianal fistula / furunculosis Incidence / Aetiology – in German shepherd and its mongrels – Irish setter setter,, Labrador, Collie – uncertain aetiology aetiology:: Anal sacculitis / Paraproctitis immune-mediated (autoimmune immuneautoimmune)) Decreased activity of mucosal and circulating IgA hyperaktív local immuniy (IgA IgA,, IgG IgG,, B-and T-lymphocytes lymphocytes,, CD3+, macrophages macrophages,, plasma cells cells,, ILIL-2, INFINF- ) Surgery (anal sac removal) Perianal fistula / furunculosis Diagnosis – breed – typical chronic, nonnonhealing, recurring analis fistulous tract – concurrent colitis – concurrent chronic colitis – Analogy with human Crohn’s Crohn’s--disease (?) 6 Perianal fistula / furunculosis Diagnosis Perianal fistula / furunculosis – breed Therapy – Currently no effective causative treatment !!! – typical chronic, nonnonhealing, recurring analis fistulous tract – concurrent colitis Perianal fistula / furunculosis Perianal fistula / furunculosis Conservative therapy (!!!) – Protocol #1 (Michigan State University) Therapy – conservative (!!!) – surgical (!?) diet Prednisolone Azathioprine – Protocol #2 (Ontario Veterinary College) diet Cyclosporine – Protocol #3 Perianal fistula / furunculosis #1 or #2 + Tacrolimus ointment topically Anal / Rectal tumours Surgery • Previous failed techniques cryo-surgery (UK) soft laser tail amputation (USA) castration (???) • Current surgical recommendation „Anoplasty” fistulectomy paraproctectomy cryptectomy (zona columnaris) Incidence – hepatoid circumanal gland tumours (hyperplasia, adenoma, anapl. carcinoma) in male dogs – anal sac tumours (adenocarcinoma) in female dogs – rectal adenoma / adenocarcinoma 7 Anal /Rectal tumours Anal /Rectal tumours Hepatoid circumanal tumours Hepatoid circumanal tumours Diagnosis – in male dogs – testosterone dependency – multilocal perianal lumps (anus anus,, base of tail)) tail – common ulceration – RDP – fine needle aspirates / cytology – in male dogs – testosterone dependency – multilocal perianal lumps (anus, base of tail) – common ulceration – RDP – fine needle aspirates / cytology Anal /Rectal tumours Anal /Rectal tumours Hepatoid circumanal tumours Hepatoid circumanal tumours Diagnosis – in male dogs – testosterone dependency – multilocal perianal lumps (anus, base of tail) – common ulceration – RDP – fine needle aspirates / cytology Therapy – – – – – – castration (!) (oestrogen inj.) excision of tumour histopath (!) postop. antibiotics local cleansing Anal /Rectal tumours Anal /Rectal tumours Hepatoid circumanal tumours Rectal tumours Therapy – – – – – – Diagnosis castration (!) (oestrogen inj.) excision of tumour histopath (!) postop. antibiotics local cleansing Diagnosis – – – – – – bloody feces tenesmus RDP (pelvic lymphonodes) rectoscopy (US) cytology 8 Anal /Rectal tumours „Pull Pull--open open”” – anorectalis stricture Rectal tumours Therapy – „pull„pull-open” – excision of tumour (electrocautery) – histopath. – antibiotics – diet „Pull Pull--open open”” – anorectalis stricture „Pull Pull--open open”” – anorectalis stricture „Pull Pull--open open”” – anorectalis stricture „Pull Pull--open open”” – anorectalis stricture 9 „Pull Pull--open open”” – anorectalis stricture „Pull Pull--open open”” – anorectalis stricture „Pull Pull--open open”” – anorectalis stricture „Pull Pull--open open”” – anorectalis stricture Rectal tumours Therapy – Dorsally positioned intrapelvic localisation localisation:: – „dorsal rectal approach” approach ” Rectal tumours Therapy – Laterally positioned intrapelvic localisation localisation:: – „lateral rectal approach”” approach 10 Rectal tumours Therapy – Caudal intrapelvic localisation:: localisation – „pull pull--through through” ” rectum resection Rectal tumours Therapy – Cranial intrapelvic localisation:: localisation – „ventral rectal approach with pubic osteotomy”” osteotomy 11
