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(BQ) Part 2 book “Anorectal surgery” has contents: Biofeedback, functional anorectal disorders, anorectal malformations, fissure in ano, hemorrhoids, anorectal abscess, hidradenitis suppurativa, pilonidal sinus, rectal prolapse, feca incontinence,… and other contents.
chapter Biofeedback 11 Dyssynergic defecation is one of the most common forms of functional constipation both in children and adults It is defined as incomplete evacuation of fecal material from the rectum due to paradoxical contraction or failure to relax pelvic floor muscles when straining to defecate Up to one half of patients with constipation suffer from the entity known as dyssynergic defecation This is an acquired behavioral problem and is caused by the inability to coordinate the abdominal and pelvic floor muscles to evacuate stools In the current scenario, it is possible to diagnose this problem through: • History • Prospective stool diaries • Anorectal physiologic tests Biofeedback also known as neuromuscular training is: • The use of electronic or electromechanical equipment to measure • Provide information about specific physiologic functions • That can then be controlled in therapeutic directions Neuromuscular training or biofeedback therapy is an instrumentbased learning process that is based on ‘‘operant conditioning’’ techniques The goal of neuromuscular training using biofeedback techniques is to restore a normal pattern of defecation A Standard Biofeedback Training Protocol The mainstay of behavior therapy is to first explain the anorectal dysfunction and discuss its relevance with the patient before approaching the treatment Biofeedback 233 The next step includes training the patients on a more effective use of the abdominal muscles to improve pushing effort Patients are next shown anal manometry or EMG recordings displaying their anal function and are taught through trial and error to relax the pelvic floor and anal muscles during straining This objective is first pursued with the help of visual feedback on pelvic floor muscle contraction, accompanied by continuous encouragement from the therapist When the patient has learned to relax the pelvic floor muscles during straining, the visual and auditory help are gradually withdrawn Biofeedback is often recommended for children who have constipation and encopresis Associated with specific: • Physical • Anatomic • Postsurgical complications Also recommended for children who exhibit: • Pelvic floor dyssynergia • Paradoxical contraction Biofeedback treatment of constipation and encopresis typically involves some combination of the following: • Training in discriminating the sensation of rectal distention • Strengthening or controlled relaxation of the external anal sphincter through electromyography (EMG) training • Training in the synchronization of internal and external anal sphincter responses • Training in the coordination of abdominal and pelvic floor musculature for elimination (For those who have pelvic floor dyssynergia or paradoxical contraction) Pelvic floor dyssynergia is the abnormal closure of the anal canal during straining for defecation During attempts to defecate, children who have dyssynergia squeeze the buttocks and hips but are unable to relax the external anal sphincter The child squeezes the anal canal during defecation: 234 Anorectal Surgery • To control the amount of stool being passed • To protect against pain These abnormal defecation dynamics are thought to develop in response to past painful bowel movements When any behavior is reinforced, may it be complex maneuver like eating or a simple task like muscle contraction, its likelihood of being repeated and perfected increases several fold In patients with dyssynergic defecation, the goal of neuromuscular training is two fold: • To correct the dyssynergia in coordination of the abdominal, rectal, and anal sphincter muscles to achieve a normal and complete evacuation • To enhance rectal sensory perception in patients with impaired rectal sensation In children, it is essential and prerequisite to decide which type of biofeedback be provided to a particular patient as the type of biofeedback used is a function of the physiologic mechanisms hypothesized to underlie the child’s soiling For example, training aimed at improving rectal sensation is indicated, if a child’s soiling is thought to be associated with poor sensation of the urge to stool Sphincter strengthening through EMG biofeedback would be a better option, if soiling is associated with poor control caused by a weak external anal sphincter Most available research apparently focuses on biofeedback treatment of constipation and encopresis associated with pelvic floor dyssynergia Most children who have encopresis contract the external anal sphincter during defecation, thereby impairing their ability to empty the rectum completely and which in turn compounds ongoing impaction To assess pelvic floor dyssynergia two electrodes are used: Surface EMG electrodes to monitor abdominal muscles An anal sensor (manometric sensor within anal canal or surface EMG electrodes just outside the anal opening) Biofeedback 235 To evaluate the ability of the child to maintain external anal sphincter relaxation while contracting abdominal muscle Biofeedback training is used to teach appropriate response Training varies in type and duration for each response Improve or correct dyssynergia: If there is dyssynergia between the two muscle regions this training is used Along with manometric—guided pelvic floor relaxation, this training consists of improving the abdominal push effort (diaphragmatic muscle training) lastly followed by simulated defecation training Rectoanal coordination: The purpose of this training is to produce a coordinated defecatory movement consisting of an adequate abdominal push effort which in turn is reflected by a rise in intrarectal pressure on the manometric tracing that is synchronized with relaxation of the pelvic floor and anal canal as depicted by a decrease in anal sphincter pressure Ideally the subject should be seated on a commode with the manometry probe in situ, to facilitate this training Posture and sitting correction needs a special mention before any maneuver: • As against the regular posture of keeping the legs together correct the same by keeping the legs apart • Also correct the sitting angle at which the patient will attempt the defecation maneuver (i.e leaning forward) After this correction the patient is asked: • To take a good diaphragmatic breath • To push and bear down as if to defecate Encourage the patient to watch the monitor while performing this maneuver Throughout the maneuver keep a close watch and correct the patients posture and breathing techniques An instant feedback of their performance is provided to the patient from the visual display of the pressure changes in the rectum and anal canal on the monitor, this helps them to understand and learn quickly 236 Anorectal Surgery At least 10 to 15 maneuvers are performed To provide the subject with a sensation of rectal fullness or desire to defecate, the balloon in the rectum is distended with 60 ml of air While observing the pressure changes in the rectum and anal canal on the display monitor the patient is encouraged to push and attempt defecation, as soon as the he/she experiences this desire to defecate The breathing and postural techniques are corrected, once again The maneuvers are repeated approximately to 10 times Following instructions are passed to the patient during the attempted defecation, to titrate: • The degree of abdominal push • The anal relaxatory effort • Specifically not to push excessively Reason being this is often counterproductive and leads to voluntary withholding The balloon is deflated, after each attempt, and reinflated before the next attempt The balloon is fully deflated and the probe is removed, after completion of this maneuver In case an EMG device is used either of the following observation during the maneuver is essentially noted by the patient: • To reduce the amplitude of electrical wave forms on the monitor • To decrease the intensity of sound signals Simulated defecation training: The patient is trained and taught to expel artificial stool in the laboratory by using the correct technique Either a 50 ml water-filled balloon or an artificial stool is placed in the rectum to perform this maneuver The patient is asked to sit on a commode and to attempt defecation, after the balloon is placed in the rectum in the left lateral position During the attempt to pass the balloon assistance is provided to the patient and he/she is taught: • To relax the pelvic floor muscles • To correct the posture and breathing techniques Biofeedback 237 Apply gentle traction to the balloon, if the patient is not able to expel the balloon, just to add to the patient’s efforts Gradually and with repetition of the maneuver, the subject learns how to coordinate the defecation maneuver and to expel the balloon Sensory training: The main goal of this training is: • To improve the thresholds for rectal sensory perception • To promote better awareness for the process of passing stool Intermittent inflation of the balloon in the rectum, is the primary maneuver The primary objective is to teach the patient to perceive a particular volume of balloon distention but with the same intensity as they had previously experienced with a larger volume of balloon distention First and foremost the balloon is inflated progressively till the patient experiences an urge to defecate Note this threshold volume The balloon is reinflated to the same volume, after deflation and to educate the subject and to trigger appropriate rectal sensations, the maneuver is repeated two or three times The balloon volume is decreased in a stepwise manner by about 10% with each subsequent inflation, thereafter During each distention, the patient is encouraged: • To observe the monitor • To note the pressure changes in the rectum • Simultaneously pay close attention to the sensation they are experiencing in the rectum • To use the visual cues for volumes that are either not readily perceived or only faintly perceived In case if the patient fails to perceive: • A particular volume • Reports a significant change in the intensity of perception After a 5-second warning the balloon is inflated again either: • By using the same volume • By using the volume that was previously perceived (higher) By the end of each session, newer thresholds for rectal perception are established: 238 Anorectal Surgery • By repeated inflations and deflations • Through a process of trial and error Depending on their individual needs each training session should be customized for each patient in following aspects: • Duration and frequency of training • The number of neuromuscular training sessions • The length of each training session Each training session typically takes hour The visits to the motility lab are planned once in two weeks Four to six training sessions are required on an average Though it is not possible predict how many sessions a particular subject needs Periodic reinforcements at weeks, months, months, and 12 months after completion of neuromuscular training, may provide additional benefit These periodic reinforcements can improve the long-term outcome of these patients Devices and techniques for biofeedback: Several devices and methods are available, and newer techniques continue to evolve, the reason being neuromuscular training is an instrument-based learning technique Some of the devices being commonly used include: • Manometric-based biofeedback treatment with a solid-state manometry system • EMG biofeedback • Balloon defecation training • Home training devices Ideally suited and recommended for biofeedback therapy is, the solid-state manometry probe with microtransducers and a balloon A visual display of pressure activity throughout the anorectum is provided by the transducers that are located in the rectum and anal canal This visual display in turn provides visual feedback to the subject To provide both visual and auditory feedback, surface EMG electrodes can be incorporated on the probe The same probe can be used to provide sensory training All in all the system can serve as a comprehensive device for neuromuscular training Biofeedback 239 In place of manometric device, an EMG biofeedback system can be used This EMG biofeedback system consists of: • A surface EMG electrode that is mounted on a probe or • Affixed to the surface of the external anal sphincter muscle The EMG biofeedback system provides instant visual feedback, the EMG signals that are picked up from the surface of the anal sphincter muscle are in turn displayed on the monitor Instant feedback regarding the changes in electrical activity of the anal sphincter, can be generated from the pitch of the auditory signals Such feedback responses help the patient titrate the defecation effort and in turn can augment the learning process Home training devices largely use an EMG home trainer or silicon probe device attached to a hand-held monitor with an illuminated liquid crystal display The pressure or electrical activity of the patient’s sphincter responses can be displayed on a simple gauge, a strip chart recorder, or a color liquid crystal display and these are used to provide visual feedback for the subject Efficacy of Biofeedback Therapy The symptomatic improvement rate ranges between 44 and 100% in different uncontrolled clinical trials The results show that biofeedback therapy is superior to controlled treatment approaches, such as: • Diet • Exercise • Laxatives • Use of polyethylene glycol • Diazepam • Placebo • Balloon defecation therapy or • Sham feedback therapy Though offered in few centers only and without adverse effects, biofeedback therapy is a multidisciplinary approach and is laborintensive 240 Anorectal Surgery A home-based, self-training program is essential, to treat the vast number of constipated patients in the community Other Measures for Treating Dyssynergic Defecation Injection of botulinum toxin into the anal sphincter has been tried with mixed results Different surgical procedures like division of puborectalis muscle with varying degree of success have been described for managing dyssynergic defecation Biofeedback training seems to be a good treatment for lower gastrointestinal disturbances, especially for pelvic floor dyssynergia The effects of such training may not be limited to the anorectum and might also be useful in other conditions in which pelvic floor dyssynergia plays a role With biofeedback therapy the symptom improvement is caused by a change in underlying pathophysiology, it is not only efficacious but also superior to other modalities Use of home biofeedback programs along with development of user-friendly approaches to biofeedback therapy will significantly enhance the adoption of this treatment by gastroenterologists and colorectal surgeons In children who have pelvic floor dyssynergia and are not showing a positive response to standard medical management, recommended biofeedback protocol is a brief training program of around two to four sessions Biofeedback training to be more effective needs to be a complete comprehensive package of: • Biobehavioral treatment of encopresis • Cleanout • Medications • Sitting schedule • Dietary restrictions recommendations On the basis of cause, severity of incontinence, or initial manometry, a successful outcome could not be predicted In response to bearing down, most patients could be taught to relax their sphincter Functional Anorectal Disorders chapter 12 A functional anorectal disorder is defined as “a variable combination of chronic or recurrent anorectal symptoms not explained by structural or biochemical abnormalities”, or in simple terms, “Anorectal symptoms, the etiology of which is currently unknown or is related to the abnormal functioning of normally innervated and structurally intact muscles, or is attributed to psychological causes” Chronic anal or perianal pain without evident cause produces maximum mixed reactions among family, friends and physicians as compared to other disorders Usually the result of common and easily recognized disorders such as: • Anal fissure • Anal fistula • Intersphincteric abscess • Thrombosed hemorrhoids or • Anorectal cancer Pain in the anal canal or perineum is easily manageable, but when no cause can be found management is difficult Often referred from one specialist to another, the patients are then offered a variety of different and yet ineffective treatments The functional anorectal disorders are defined primarily on the basis of the symptoms Men and women of all ages are affected by anorectal disorders Their management is not limited to the evaluation and treatment of hemorrhoids The spectrum of anorectal disorders ranges from benign and irritating (pruritus ani) to potentially life-threatening (anorectal cancer) disorders Patients usually present with ‘‘constipation’’, but the clinical picture of these disorders includes: 512 Anorectal Surgery In patients who not incur a complication, successful outcome is high and durable Future Perspectives Because management of incontinence requires an accurate multi modal diagnostic assessment The effectiveness of treatment of double fecal and urinary incontinence can be improvized by increased integration of knowledge and cooperation between: • Coloproctologists • Urologists • Gynecologists Treatment options may include rehabilitative procedures, surgery, or both What needs to be specified and defined precisely are the indications for: • The behavioral approach • Prosthetic/reconstructive surgery, or • Sacral nerve stimulation Index Page numbers followed by f refer to figure A Abdominal distention 150, 193 pain 177, 205, 206 procedures 462, 469 ultrasound 284 Abnormal anorectal anatomy 91 rectal compliance 485 sacrum 284 Abscess 55, 315, 342, 359 Acne vulgaris 384 Acquired immunodeficiency syndrome 376 Actinomycosis 372, 373, 396, 434 Activities of daily living 483 Acute abscess 405 anal fissure 314 appendicitis 150 bacterial colitis 137 cardiorespiratory compromise 121 colonic infection 91 diverticulitis 89, 91 fissure in ano 55, 121, 289, 293, 294f pain 314 peritonitis 128 pilonidal abscess 429, 432 severe diverticulitis 128 sigmoid diverticulitis 139 suppuration 432 Adenocarcinoma 22 of rectum 396 Adequate daily water intake 274 Advanced renal disease 167 Advantages of mucosal advancement flap 413 procedure 334 Alpha-1 receptor antagonists 300 Altemeier perineal rectosigmoidectomy 467f Alterations in bladder and sexual function 472 Altered bowel habits 52, 55 Ambiguous genitalia 283 Ambulatory anorectal surgery 153 Amebiasis 373 Amoebic colitis 137 Ampulla recti 480 Amyloidosis 167 Anal canal 21, 22, 22f, 55, 119 high pressure zone 475 stenosis 121 cancer 290 carcinoma 58 encirclement 466 endosonography 85, 87f, 459 fissure 128, 241, 242, 256, 315, 342, 354, 359 repair 478 fistula 241, 256, 434 plug 424, 426f incontinence 315, 354 manometry 100, 102, 158, 186, 403, 487 maximum pressure 106 portion 27 sonography 85 sphincter 165 weakness 475 stenosis 128, 167, 315, 359 stricture 354 tonometry 104, 242 device 106 tumor 315 wall 61 Anastomotic leak 470, 472 Anatomic disturbances of pelvic floor 476 Ancient Indian surgical instruments 3f Anemia 64 514 Anorectal Surgery Angiotensin converting enzyme inhibitors 300 Angulation of rectum 135f Annular carcinoma 55 Anococcygeal body 20, 37 ligament 36 triangle 44, 45f Anogenital warts 315 Anorectal abscess 314, 315, 368, 375f angle 475 biofeedback 205 cancer 241 Crohn’s disease 128, 137 disease 63 disorders 52, 84 dysfunction 68 fistula 315 function 487 group 27 lymphatics 27 malformations 275 malignancy 120 manometry 184, 458 membrane 13 muscle 31f ring 35 neoplasm 128, 137 pain 120, 270 physiologic tests 232 sensory and reflex mechanism 475 spaces 369f, 394f stenoses 13 stricture 139 surgery 5, trauma 484 ulcer 128 ultrasonography 158 Anorectum 100 Anoscopy 61, 119, 404 demonstrating normal mucosa and polyps 126f Anterior pull of puborectalis muscle 33f rectal wall support 217 resection 462 superior iliac spine 38f Anthraquinones 198 Antibiotic prophylaxis 145 Anticholinergics 168 Anticonvulsants 170 Antidepressants 170 Antihistamines 170 Antispasmodics 170 Anxiety 365 Appendicitis 396 Arterial supply 22, 310 of rectum and anal canal 26f Artificial anal sphincter 505f, 506f, 508f-510f around colostomy 509f sphincter 505 Ascorbic acid 76 Atomizer wand 362 Autonomic neuropathy 167 B Bacteremia 150 Bacterium minutissimum 258 Balloon defecation therapy 239 training 238 expulsion 184 test 186 Band ligator and slotted proctoscope 326f Barium enema 403, 458 Bartholin cyst 397 gland abscess in females 396 Bascom’s cleft closure procedure 450 flap 445, 446f Bhagandara yantra 3f Bilateral oopherectomy 155 tubal ligation 155 Bimanual examination 61 Biofeedback training 246 Biopsy forceps 69 Bladder 20 and sexual function alterations 470 augmentation 287 dysfunction 473 Bleeding 63, 65, 149, 162, 418, 470, 471 per rectum 52, 61, 315 Index 515 Botulinum A toxin injection 298 Bowel frequency 205 function 461 habits 483 injury 472 motility 48 preparation 143 Bowen’s disease 261 Brain tumor 484 Branch of superior hemorrhoidal artery 339f Bulbocavernosus 212 Bulk forming laxatives 190, 191 Bulky hemorrhoidal disease 365 C Cachexia 56, 57 Calcium channel blockers 298 containing antacids and supplements 168 dobesilate 320 Calibration port 507 Cancer 295, 396 therapies 376 Candida albicans 258 Carbon dioxide 94, 194 Carbuncle 434 Carcinoma ampulla of rectum 55 in pilonidal sinus 451 of anal canal 55 of rectum 57 Cardiac malformations 284 Cathartic colon 197 Caucasian race 430 Cauda equina lesions 485 Causes of anal incontinence 475 chronic constipation 168 Cellulitis 342 Central nervous system 484 disorders 167 Chagas’ disease 167 Chest wall 428 Childbirth injury 484 Cholecystectomy 480 Chronic constipation 55, 160, 215, 271 cough 215 discharge 56 fissure in ano 289, 294 illness 168 ischiorectal abscess 55 medical immunosuppression 376 obstructive pulmonary disease 215, 456 pain 354, 315 pilonidal sinus 432 proctalgia 244 straining 476 Cinedefecography 274 Classification of fistula in ano 398f Cloacal anomalies 281 exstrophy 282 Clostridium botulinum 204, 298 difficile colitis 137 Coccygeal sinus 434 Coccygeus 21 Coccyx 20 Colchicine 261 Colectomy 206 Collagen disorders 215 Collitis 54 Colloid carcinoma of rectum 56 Colon cancer 64, 167 Colonic distention 93 necrosis 128 transit study 459 Colonoscopic tattooing 151 Colonoscopy 141, 405, 458 Colorectal and anal disease 260 cancer 163 Colpocystodefecography 226 Common course of track of fistula 398, 399 Complete blood count 154 excision of internal opening 414 mechanical colonic obstruction 91 516 Anorectal Surgery Complex AIDS 412 flap reconstruction 438 matrix 424 Complicated pilonidal sinuses 434 Composed of skin 447 tomographic 89 Computerized tomography scan 157 Concomitant diarrhea 480 Concurrent systemic illness 437 Condyloma acuminata 315 of rectum 55 Condylomata 58 Congenital abnormalities of anorectum 484 aganglionic megacolon 169 anomalies 476 anorectal malformation 169 megacolon 14, 15f Congestive heart failure 92 tissue and smooth muscle 310 laxity 366 Conservative sphincterotomy 303 Constipation 102, 159, 241, 366 in children 168 in elderly 168 in pregnancy 177 Construction of stoma 206, 207 Continent diversion 287 Contracts bowel 18 smooth muscle 18 Contrast enema 274 Copious mucous discharge 270 Corpus cavernosum recti 480 Corrugator cutis ani muscle 32 Crohn’s disease 54, 56, 89, 144, 290, 295, 372, 396, 400, 410, 415, 420, 476, 484 affecting anal canal 315 and hemorrhoids 366 fistulae 420 fistulae 412, 420, 421 Cryotherapy 328 Cryptococcal infection 373 CT colonography 89 scan 403 Curves of rectum 17f Curvilinear incision 498f Cutting seton 411 Cyclobenzaprine 246 Cyst 58 Cystic fibrosis 169, 456 Cystocele 216, 218 Cystodefecography 81 D Darbhakrti khala mukha sala 3f Deep postanal space 368 Defecation reflex 50 Defecatory dysfunction 168 Defecography 81, 186 Degenerative disease 168 Degree of abdominal push 236 Dehydration 168 Delayed wound healing 418 Delorme mucosal sleeve resection 468, 468f procedure 224 for rectal prolapse 219 Dementia 168, 476, 484 Dennonviller’s fascia 20 Depression 182 Dermal island advancement flap 416 Dermatitis 486 Dermatological causes of pruritus ani 257 conditions and neoplasia 260 Dermatomyositis 167 Dermoid cysts 386 Descending perineum syndrome 476 Development of gastrointestinal tract 11f Diabetes 477 insipidus 169 mellitus 167, 262, 485 Diabetic neuropathy 476 Diarrhea 309, 395 Diarrheal states 476 Diazepam 246 Index 517 Dietary modifications 188 Digital rectal examination 60, 70, 73f, 316, 404 Diphenylmethane derivatives 199 Disadvantages of intravenous contrast 95 Distal anorectal masses 119 Distention 206 Diuretics 170 Diverticular abscess 128 Diverticulitis 395, 396 Docusate sodium 200 Doppler guided hemorrhoidal artery ligation 335 Drainage of abscess 378f horseshoe abscess 380f supralevator abscess 379f Draining seton 411, 412 Dull ache 244 Duration of incontinence 497 Dvitala yantra 3f Dynamic graciloplasty 501 MRI defecography 97 Dyssynergic defecation 174 Dysuria 373 E Echo sounder 336 Echocardiogram 284 Eczema 56, 315 Edema of dermis 262 Electrocardiogram 155 Electrocoagulation 329 Electrogalvanic stimulation 246 Electromyography 114, 117, 459, 489 Electrophysiology tests 489 Elements of anorectal manometry 101 Embryology 10 Endoanal ultrasound 490 Endocrine disorders 167 Endorectal ultrasonography 157 Endoscopic and surgical significance of rectum 18 Endoscopy 119 Enlarging gravid uterus 177 Enterocele 82, 210, 218, 225 Eradicating fistula 405 Eradication of perianal sepsis 406 Erosions 264 Erythrocyte sedimentation rate 61, 183 Esophageal atresia 284 Evacuatory difficulty 223, 225 Evaluate sphincter tone 317 Exact position of swelling 55 Exaggerated skin folds 264 Examination of perineum 404 under anesthesia 74, 404 Excessive perineal descent 175 Exstrophy of cloacal membrane 14 Extension of pilonidal abscess 372 Extensive soft tissue cellulitis 379 Extent of procedure 461 prolapse 461 External anal sphincter 86, 299 and internal sphincters 275 hemorrhoidal thrombosis 354 hemorrhoids 316, 486 opening 395 skin tags 58 sphincter 30 muscles 370 Extrarectal group 27 Extrasphincteric fistulae 422 Extrinsic compression 167 F Failed colonoscopy 90 Fascia 20 Fecal contamination of perineum 256 continence 475 diversion 504 impaction 418, 476, 485 incontinence 102, 225, 242, 359, 361, 474, 482, 484 occult blood test 75 Feeling of incomplete emptying 223 obstruction 242 518 Anorectal Surgery Ferguson’s hemorrhoidectomy 355, 363 procedure 358 technique 355 Fever 56 Fibrin glue 422, 423f Fibromuscular obliteration 271 First degree hemorrhoids 311 Fissure 57, 264 in ano 59, 66, 289, 290f, 302, 315, 316 Fistula 315, 342, 359, 476, 484 in ano 56, 58, 66, 391 evaluation 119 Fistulectomy 409 Fistulography 79, 402 Fistulotomy 408, 418, 476, 486 Flexible sigmoidoscopy 137 Flexiprobe new modified proctoscope for rectoanal repair 344f Fluid intake 170, 187 overload 359 Foley’s catheter 497 Forceps 336 Foreign bodies 119 Formation of skin tags 359 Fourth degree hemorrhoids 312 Frei’s test in lymphogranuloma inguinale 62 Fulminant colitis 128 Function of external anal sphincter 49 internal anal sphincter 48 Functional anatomy of pelvic floor 165f anorectal disorders 241 pain 102 fecal retention 176 Fungal infection 257, 315 Furuncle 386, 434 G Gastrointestinal transit 177 Genupectoral position 252f Giant cells 385 Gluteal fascia 447 Gluten enteropathy 169 Gluteus maximus musculocutaneous flap 449, 449f myocutaneous flap 450 Glyceryl trinitrate 259, 297 Golligher’s Classification 310 Goodsall’s rule 58, 58f, 59f, 401f Granuloma inguinale 386 Greater patient satisfaction 348 Guar gum 193 H Harmonic scalpel and ligasure 361 Heavy metal poisoning 167 Hematologic malignancy 412 Hemorrhage 354 Hemorrhoid 306, 366 evaluation 119 injection syringe and needle 324f Hemorrhoidal artery ligation 341 Hemorrhoidectomy 356, 396, 476, 478, 486 Hepatitis 420 Hidradenitis suppurativa 372, 383, 396, 397, 434 High definition colonoscopy 152 fiber diet 169 imperforate anus on radiography 14f ligation of hemorrhoidal pedicle 359 suspicion of cancer 141 trans-sphincteric fistulotomy with seton 410f Hirschsprung’s disease 102, 113, 169 History of artificial bowel sphincter 505 fistula in ano 391 surgery HIV infection 395 Home training devices 238 Hormonal therapy 387 Horseshoe abscess 377 Human immunodeficiency virus infection 295 Hydrogen 194 Hydrops of epidermis 262 Index 519 Hyperbaric oxygen 300 Hypercalcemia 167 Hyperthyroidism 167, 262 Hypertrophied anal papilla 289 Hypoechoic anococcygeal ligament 86 Hypokalemia 167 Hypothyroidism 167, 169, 182, 485 I Idiopathic inflammation 264 Iliococcygeus 36 muscle 38 Immunodeficient patients with neutropenia 412 Imperforate anus 14, 91, 121, 276, 283 before and after surgery 13f in females 278f in males 279f Important steps of anoscopy 124f Incision with marsupialization 438 Incomplete rectal evacuation 506 Incontinence 228 Increased estrogen 177 progesterone 177 Infected inclusion cysts 396 Infection 315, 342, 372, 470, 471 Infectious enteritis 476 proctitis 128 Inferior rectal artery 22, 25 Inflammatory bowel disease 315, 395, 396, 476, 489 cells 385 Infrared coagulation 329 Injury of vagina 508 Integrity of perineal body 217 Intermediate anomalies 13 Intermuscular sulcus 35f Internal anal sphincter 86, 289, 292 and external hemorrhoids 311f hemorrhoids 119, 315, 321 iliac 25 procidentia 222 sphincter 33 sphincterotomy 476 Intersphincteric abscess 241, 374 groove 299 space 368 Intertrigo 257 Intestinal injury 470 pseudo-obstruction 167 Intra-abdominal hemorrhage 150 Intramural fistulization and abscess formation 354 Iron deficiency anemia 262 supplements 177 Irregular proliferation of stratum mucosum 262 Irritable bowel syndrome 176, 477, 485, 488 Ischemia 488 Ischioanal fatty spaces 86 fossa 21 space 368 Ischiococcygeus 36 muscle 38 Ischiorectal abscess 374, 375 fossae 41, 42f Island flap anoplasty 416 Itching 63, 68 J Jackknife position 131 Jeep riders disease 428 K Kanka mukha svastika 3f Karna sodnana 3f Karydakis flap 444, 444f procedure 444f Kazumasa morinaga 335 Knee-elbow position 57 Knot pusher 336, 337f L Lactulose 194 520 Anorectal Surgery Laparoscopic rectocele repair technique 221 rectopexy 465 Laser surgery for hemorrhoids 361 Lateral incision and excision of midline pits 439 internal sphincterotomy 301, 302, 302f, 303, 304, 486 ligaments of rectum 21 Laxative abuse 477 Less postoperative pain 348 Leukemia 262 Leukocytosis 150 Leukopenia 420 Levator ani 21, 370 muscle 36 syndrome 242, 243 plate integrity 217 spasm 244 Lichen planus 257 sclerosus 261 Ligation of intersphincteric fistula tract 426 Limberg flap 445 Linen and disposable gloves 130 Lithotomy position 57 Liver disease 262 Local irradiation 400 Localize pain 317 Longitudinal muscle 34 Long-term constipation 456 diarrhea 456 straining during defecation 456 Low anomalies 13 anterior colorectal resection 476 lesions 277 Lower abdominal and back pain 225 border of gluteus maximus 370 sacrum 37 Lubiprostone 204 Lubricant jelly 130 Lymphatic drainage 22 of rectum and anal canal 28f Lymphogranuloma venereum 373, 396 Lymphoma 262, 396 M Magnetic resonance imaging 402, 403 Malignancy 22, 315 Management of constipation 186 pruritus ani 266 Mantoux test in tuberculosis 62 Manual dilatation of anus 300 Marlex rectopexy 464f Maximal tolerable rectal volume 116 Measurement of hemoglobin level 183 Median sacral and rectal vessels 20 artery 25 Medical causes of secondary constipation 167 Menopause 155 Mental retardation 484 Metabolic disorders 163 Methocarbamol 246 Methylcellulose 193 Microballoon devices 103 Microtransducer arrays 103 Middle rectal artery 25 Milligan septum 34 Morgan hemorrhoidectomy 357 Minor’s triangle 46f Modified Ferguson hemorrhoidectomy 355f proctoscope for rectoanal repair 345f Motility and evacuability of rectum 475 of anal canal 475 Motor fibers 29f Mucosal advancement flap 413, 414f, 418 prolapse 316 Mucus and pus discharge 52, 54 Multiple fistulae 410 sclerosis 48, 167, 456, 476, 485 Index 521 Muscular dystrophy 485 Myasthenia gravis 485 N Narcotics and anticholinergic drugs 359 Natural phlebotonic 319 Nature of bleeding 53 Necrotizing anorectal infection 381 Needle holder 337f Neoplasia 264 Nerve supply of rectum and anal canal 29f Neurologic disease 456, 482 Neuromuscular disorders 167 Neuropathy stretch injury 476 Nodes 21 Nonanatomic repair 220 Nonobstetric anorectal injury 480 Nonobstetrical causes of anal incontinence 478 Nonpharmacologic therapy 435 Nonspecific pelvic pain 271 proctitis 127, 137 Nonsteroidal anti-inflammatory drugs 76 Normal endoanal ultrasound 491 transit constipation 170 vaginal caliber and length 217 O Obesity 215, 431 Obstetric trauma 476 Obstructed defecation 223, 228 syndrome 209 Obstructing rectoceles 175 Obstructive defecation 214 Obturator internus 21 Occasional contrast reactions 95 Operations for defecatory disorders 208 Operative trauma 359 Opioids 170 Oral medication 319 Organ transplant 412 Osmotic laxatives 191, 193 Osteomyelitis 434 Overlapping sphincteroplasty 499f repair 496, 496f Overt rectal prolapse 210, 228 P Paget’s disease 261 Pain 52, 53, 54, 63, 66, 314, 359, 394 after defecation 66 Painful hemorrhoids 177 Painless bleeding 312, 313 Pancreatitis 420 Panhypopituitarism 167 Papillomas 256 Papillomata 58 Para-aortic lymph nodes 22 Paradoxic contraction of pelvic floor muscles 272 Paradoxical contraction 233 Paralysis 456 Paraplegia 456 Pararectal spaces 42f Parasympathetic fibers 29f Parkinson disease 476 Partial thromboplastin time 154 Pediculosis pubis 257 Pelvic dyssynergy 210 floor dysfunction 165, 166 dyssynergia 102, 174, 233, 242 floor muscles 481 inflammatory disease 396 neuromuscular function 216 organ prolapse 210 pain and pressure 223, 228 pressure 225 and congestion 367 splanchnic nerves 20 tension myalgia 244 triangles 39 Peppermint oil 261 Perfused catheters 103 Perianal abscess 55, 56, 66, 374, 437 condyloma 120 Crohn’s disease 386 cryptoglandular fistulas 386 hematoma 55 522 Anorectal Surgery itching 52 plaques 260 rashes 316 region 61 space 40, 368 thrombosis 342 viral infections 258 Perineal descent 485, 486 syndrome 253 fecal contamination 256 groove 13 group 27 procedures 466, 470 rectosigmoidectomy 466 skin 217 Perineopelvic spaces 39 Peripheral nervous system 485 Peripherally acting opioid antagonists 204 Peritoneal signs 150 Peritoneum 21 Persistent anal membrane 13 Pheochromocytoma 167 Phosphate enemas 201 Piles 57, 306 Pilonidal abscess 429 cyst 429, 386 disease 396, 397, 429, 432 sinus 428 with midline pits 430f, 433f with pits 433f tract 429f Piriformis 20 Pitfalls of CT colonography 96 Polyethylene glycol 195, 196 Polyneuropathies 485 Polyposis 57 Polyps 315 Poor preoperative sphincter pressures 410 Porphyria 167 Position for sigmoidoscopy 131f Positive fecal occult blood test 141 Posterior colporrhaphy 478 fornix 20 pull of superficialis muscle 33f vaginal wall 217 Postmenopausal status 215 Postoperative pain 361 Postpartum pudendal neuropathy 485 Postpolypectomy coagulation syndrome 149 Postradiation stenosis 89 Potential morbidity 461 Pre-existing incontinence 400 Pregnancy 167 and hemorrhoids 366 and stresses of childbirth 456 Premenstrual flare-ups 384 Presacral cyst 397 Presence of multiple tracts 400 Preserving anal sphincter 405 Pressure sensation high in rectum 244 Previous fistulotomy 410 pelvic surgery 89 surgery 456 Principles of disease 307 Proctalgia fugax 242, 246 Proctitis 315, 485 Proctoscope 68 Proctosigmoidoscopy 405 Profundus muscle 32 Progressive systemic sclerosis 167 Prolapse rectum 55 Prolapsed hemorrhoids 315, 316 internal hemorrhoids 53 rectal polyp 55 thrombosed piles 55 Prolapsing hemorrhoids 256 Promote wound healing 320 Prospective stool diaries 232 Prostate 20 Prosthetic devices 379 valves 379 Prucalopride 203 Pruritus ani 52, 56, 65, 242, 255, 315 Pseudo-obstruction 169 Index 523 Pseudopolyps 359 Psoriasis 257, 260 Psychosocial stress 177 Psyllium husk 192 Pubococcygeus 36 muscle 36 Puborectalis 36 muscle 36, 37 syndrome 244 Pudendal nerve motor latency test 30 terminal motor latency 118, 489 neuropathy 497 terminal motor nerve latency 242 Purified flavonoid fraction 319 Purpose of performing anal tonometry 105 Purse string suture 350f Pyriformis syndrome 244 Q Quality of bleeding 53 pain 54 perianal skin 257 stool 257 Quinidine 261 R Radiation enteritis 476 proctitis 127, 137, 489 therapy 396 Radiofrequency coagulation and excision 333 equipment 333f Radiotherapy and ergotamine suppositories 272 Rash in perianal skin 56 Recent colonic surgery 128 Rectal atresia 281, 283 balloon manometry 112, 488 bleeding 120, 223, 270 contents 61 intussusception 175, 210, 222, 228 ischemia 485 pain and bleeding 242 polyp 53, 316 portion 27 prolapse 53, 57, 82, 120, 256, 315, 316, 453, 454f, 476, 484 procidentia 454f schistosomiasis 373 sensation 116 trauma 315 tumor 315 ulcer 137 ulceration 227, 270 valves 134f wall 61 Rectoanal coordination 235 inhibitory reflex 116, 488 repair 343, 346f Rectocele 167, 210, 211, 213f Rectoperineal fistula 280, 281 Rectosigmoid junction 55 Rectourethral fistula in boys 276 Rectouterine pouch of Douglas 20 Rectovaginal fistula 478 septum 212f space 44 Rectovesical pouch 20 Rectovestibular fistula in female 12f girls 276 Rectum 16 Recurrence rate 461 Recurrent fistula 400, 410 pilonidal disease 434, 450 prolapse 469 Regional lymph nodes 61 Relations of rectum 19f Relationship of anterior limit of pubis 38f Relaxes bowel 18 smooth muscle 18 Removal of primary and secondary tracts 414 Renal failure 262 524 Anorectal Surgery Repair of rectocele 219f Retrograde ejaculation 473 Retroperitoneal abscess 150 Retrorectal space 43, 43f, 368 Retrovesicular fistulas 280 Rhomboid flap 445f Right lateral position 57 Rigid sigmoidoscope 68, 129f, 130f, 133f Ringworm 257 Ripstein procedure 463 Role of antibiotics 436 intravenous contrast 95 spasmolytics 94 Rubber band ligation 325 Ruptured thrombosed hemorrhoids 315 S Sacral and coccygeal roots 20 nerve stimulation 502 Sacrococcygeal regions 316 Sacrotuberous ligament 370 Sacrum 20 Saline 201 Scabies 257 Scalp 428 Scars in perianal skin 60 Scissors 336 Scleroderma 485 Sclerotherapy 322 Secca procedure 503 Second degree hemorrhoids 312 Secondary hemorrhage 359, 360 Seminal vesicle 20 Sensoric innervation of anal canal and rectal ampulla 480 Sensory fibers 29f function 486 training 237 Sentinel pile 58, 289 Septicemia 342 Sequelae of anorectal infections 484 Serum calcium 183 cortisol 183 glucose 183 parathyroid hormone 183 protein electrophoresis 183 Seton placement 409 Severe anal pain from anal diseases 139 coagulopathy 128 colonic pseudo-obstruction 91 diarrhea 485 infectious colitis 91 neutropenia 128 pain 354 with hypersensitivity 365 rectal pain 121, 373 secondary hemorrhage 342 thrombocytopenia 128 Sexual function 228 Sexually transmitted diseases 315 infections 264 Shy-Drager syndrome 167 Side opening scope 119 Sigmoid colon 55 Sigmoidocele 82, 167 Sigmoidoscope 138f Significant abdominal pain 162 Sim’s position 57, 130 Simhamukha swastika 3f Simulated defecation 186 Sinus excision 447 Sitz baths 246, 364 Skeletal muscle diseases 485 problems 482 Skin carbuncle 386 excoriation 395 furuncles 434 lesions 316 tags 256, 316 tuberculosis 386 Slow transit constipation 171 Small bowel 20 series 403 transit 475 Smooth muscle dysfunction 482, 485 Soiling 68, 314 Index 525 Solitary rectal ulcer syndrome 242, 270, 271 Sorbitol 195 Space contains 40 Sphincter 30 function 486 Spinal cord abnormality 169 injury 167, 476 lesions 485 Spine radiographs 284 Splenic rupture 150 Spurious diarrhea in morning 55 Squamous cell carcinoma 22 of anus 396 portion of anal canal 316 Staging of cancers 90 Staphylococcus aureus 258, 385 Stapled hemorrhoidectomy 348 Status of estrogenation 216 fecal continence 461 Stenosing tumors 89 Steps of hemorrhoidal artery ligation 346f Milligan-Morgan open hemorrhoidectomy 358f Steroid therapy 395 Stimulant laxatives 191, 197 Stool softeners 190, 200, 274 Strenuous defecation 271 Stroke 167, 476, 484 Strong insertions of glutei muscles 36 Structures around rectal wall 61 Subcutaneous abscesses 385 emphysema 150 muscle 30 Submucous space 40 Superficial external sphincter muscles 275 part of external anal sphincter 212 postanal space 368 transverse perinei muscles 212 Superficialis and subcutaneous muscles 37f fibers 36 muscle 32 Superior hemorrhoidal artery ligation 341f Supralevator abscess 374, 375 anomalies 12 space 42, 368 Surgical hemorrhoidectomy 354 therapy 460 Sushruta performing surgery 8f Suture dehiscence 354 Swelling 52, 55, 65, 394 Sympathetic trunk 20 Synthetic phlebotonic 320 Syphilis 290, 295 Syphilitic granulomas 434 Systemic sclerosis 476 T Tabes dorsalis 485 Tenesmus 52, 55, 56 Thiersch procedure 466 Third degree hemorrhoids 312 sacral vertebra 18 Threadworm 257 infestation 56 Throbbing pain 66 Thrombosed external hemorrhoids 364 hemorrhoid 241, 315, 316, 418 internal hemorrhoids 364 Thrombosis 316 Thyroid function 183 Tight anal stricture 91 Timed toilet training 188 Toilet paper dye 259 Total colectomy 206 fistulectomy 414 hysterectomy 155 pelvic organ prolapse 228 Toxic colitis 91, 139 megacolon 91, 128 neuropathy 485 Traditional sphincterotomy 303 526 Anorectal Surgery Transanal rectal advancement flap 415 repair 222 Transperineal repair 221 Transrectal repair 218 Transverse perineal muscles 370 Trauma 272, 396, 484 Traumatic neuropathy 485 Trendelenburg’s position 465 Tuberculosis 56, 295, 372, 373, 395, 396 Tuberculous granulomas 434 Tumors 316 Types of abscesses 374 hemorrhoids 311f U Ulceration of vaginal mucosa 226 Ulcerative carcinoma of rectum 55 colitis 56, 89, 372, 476 infective carcinoma of rectum 54 Umbilicus 428 Unexplained weight loss 141 Urethra 87 Urinary defects 284 problems 354 retention 359, 360, 418 Urine 62 porphyrins 183 Use of anorectal manometry 102 birth control pills 384 clonidine for proctalgia fugax 253 polyethylene glycol 239 U-shaped pubirectalis muscle 86, 87f Uterus 20 V Vaginal mucosa 217 mucosal thickness 216 reconstruction 287 tears 486 ulceration 227 vault prolapse 216, 227 Valsalva maneuvers 456 Valve malfunction 505 Valvular heart disease 379 Vascular supply of rectum and anal canal 23, 24f Venous drainage 22 drainage of rectum 25 and anal canal 26f plexus 310 radicals 40 Vertebral anomalies 284 Very recent colonic surgery 91 Video assisted anal fistula treatment 427 colonoscope 142f defecography 102, 458 sigmoidoscope 138f Vitamin C 76 V-Y advancement flap 447, 447f W Warts 58 Weight loss 162 Wells’ posterior ivalon rectopexy 464 Wet wipes 259 Whooping cough 456 Wireless capsule endoscopy 152 X Xylocaine jelly 336 Z Z limbs 447 Z-plasty 447, 450 incision 448f steps 448f ... biofeedback therapy is a multidisciplinary approach and is laborintensive 24 0 Anorectal Surgery A home-based, self-training program is essential, to treat the vast number of constipated patients... usually been attributed to: • Pelvic floor weakness resulting from 25 4 Anorectal Surgery – Neuropathy – Trauma during: - Pregnancy or - Childbirth – Abnormal defecation behaviors However, the claims... usually present with ‘‘constipation’’, but the clinical picture of these disorders includes: 24 2 Anorectal Surgery • Rectal pain and bleeding • Digitalization • Incomplete evacuation • A feeling of