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Tirunelveli Medical College

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Department of Anatomy

The Anatomy Of

Rectum

Presentation by

K Hari Krishnan

I Year MBBS (2008-’09)

Introduction

Distal part of the large gut

The pelvic part of the alimentary tract

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Rectum

Location

Posterior part of the lesser pelvis

In front of lower three pieces of sacrum and the coccyx

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Extent

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Begins at the rectosigmoid junction

at level of third sacral vertebra

Ends at the anorectal junction

2-3 cm in front of and a little below the coccyx

Dimensions

Length 13 cm (5 in.) Diameter 4 cm (in the upper part) Dilated (in the lower part)

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Dimensions

Course

Downwards and backwards Downwards Downwards and forwards

Flexures

Antero-posterior flexures (2 in number)

Sacral flexure

Follows the curve of the sacrum and coccyx

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Flexures

Antero-posterior flexures

Perineal flexure / Anorectal flexure

80° anorectal angle In the terminal part of the rectum At the anorectal junction Here the rectum perforates the pelvic diaphragm to become the anal canal

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Flexures

Lateral flexures (3 in number) – correspond to the transverse rectal folds

Superior

Convex to the right

Intermediate

Convex to the left Most prominent

Inferior

Convex to the right

Peritoneal Relations

Superior 1/3rd of the rectum

Covered by peritoneum on the anterior and lateral surfaces

Middle 1/3rd of the rectum

Covered by peritoneum on the anterior surface

Inferior 1/3rd of the rectum Subperitoneal – Devoid of peritoneum

Relations

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Visceral Relations Anterior

In males

Upper 2/3rd

Rectovesical pouch Coils of ileum Sigmoid colon

Lower 1/3rd

Fundus (base) of the urinary bladder Terminal parts of the ureters Seminal vesicles Ductus deferentes Prostate

Relations

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Visceral Relations Posterior

In females

Upper 2/3rd

Rectouterine pouch, which separates the rectum from the uterus and from the upper part of vagina

Coils of ileum Sigmoid colon

Lower 1/3rd

Lower part of vagina

Relations

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Posterior Relations

Bones

Lower three pieces of sacrum Coccyx

Ligaments

Anococcygeal ligament

Muscles

Piriformis

Coccygeus

Levator ani

Vessels

Median sacral Superior rectal Lower lateral sacral

Nerves

Sympathetic chain with ganglion impar Ventral primary rami of S3, S4, S5, Co1 Pelvic splanchnic nerves

Lymph nodes and lymphatics Fat

Relations

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Relations

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Arterial Supply

Superior rectal artery

Direct continuation of Inferior mesenteric artery

Enters the pelvis by descending in the root of the sigmoid mesocolon and divides into right and left branches, which pierce the muscular coat and supply the mucous membrane

They anastomose with one another and with the middle and inferior rectal arteries

Middle rectal artery

Small branch of anterior division of Internal iliac artery

Run in the lateral ligaments of the rectum

Supplies the muscular coat of the lower part of rectum

Inferior rectal artery

Branch of Internal pudental artery in the perineum Anastomoses with the middle rectal artery at the anorectal junction

Median sacral artery

Direct branch from the dorsal surface of Aorta near its inferior end Descends in the median plane Supplies the posterior wall of the anorectal junction

Arterial Supply

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Arterial Supply

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Venous Drainage

Venous Drainage

Venous Drainage

Submucosal rectal venous plexus

Surrounds rectum Communicates

2 Parts:

vesical venous plexus – males uterovaginal venous plexus – females

Internal rectal venous plexus Deep to the epithelium of rectum Drains into Superior rectal vein External rectal venous plexus External to the muscular wall of rectum Superior portion: drains into Superior rectal vein Middle portion: drains into Middle rectal vein Inferior portion: drains into Inferior rectal vein

Venous Drainage

Superior rectal vein

Formed from Internal rectal venous plexus Consists of 6 main tributary veins

Continues upwards as Inferior mesenteric vein

Middle rectal vein

Formed from the middle portion of External rectal venous plexus Pass alongside middle rectal artery

Drains into the anterior division of Internal iliac vein on the lateral wall of the pelvis

Inferior rectal vein

Formed from the inferior portion of the Inferior rectal vein Drains into the Internal pudental vein

Venous Drainage

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Lymphatic Drainage

Superior half of the rectum

Pararectal lymph nodes, located directly on the muscle layer of the rectum

Inferior mesenteric lymph nodes, via either the sacral lymph nodes or the nodes along the superior rectal vessels

Inferior half of the rectum

Sacral group of lymph nodes or Internal iliac lymph nodes

Lymphatic Drainage

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Nerve Supply

Sympathetic nerve supply

L1, L2 fibres Through Superior rectal and Inferior hypogastric plexuses Vasoconstrictor Inhibitory to musculature of rectum Motor to internal sphincter Carry sensations of pain

Parasympathetic nerve supply

S2, S3, S4 fibres

Passes via pelvic splanchnic nerves and inferior hypogastric plexuses to rectal (pelvic) plexus

Motor to musculature of the rectum Inhibitory to internal sphincter Carry sensations of pain and distension

Nerve Supply

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Nerve Supply

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Interior

Interior

Interior

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Longitudinal folds

Present in lower part of the empty rectum

Effaced during distension

Interior

Transverse folds (Houston’s valves or plicae transversae recti)

Marked in rectal distension

Superior fold

At beginning of rectum Projects from the right or the left wall

Middle fold

Above the rectal ampulla Projects from the anterior and right walls Largest and most constant

Inferior fold

About 2.5 cm below the middle fold Projects from the left wall Variable

Occasional fourth fold

About 2.5 cm above the middle fold Projects from the left wall

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Interior

Histology

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Supports

Pelvic Floor

Levator ani muscles

Fascia of Waldeyer

Condensation of pelvic fascia behind rectum Lower part of ampulla to Sacrum Encloses Superior rectal vessels and lymphatics

Lateral ligaments of Rectum Denonvilliers fascia Pelvic peritoneum Perineal body

Supports

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Supports

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Clinical

Aspects

Digital Rectal Examination

Examination to check for abnormalities of organs or other structures in the pelvis and lower abdomen

To check for

growths in or enlargement of the prostate gland in males. A tumor in the prostate can often be felt as a hard lump

problems in female reproductive organs (uterus and ovaries)

rectal bleeding or tumors in the rectum

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Proctoscopy

Proctoscopy - Visual examination of the rectum and anus

Visualizing the interior of the rectum and anal canal

Helps in revealing ulcers, abnormal growths and diverticula

Sigmoidoscopy

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Sigmoidoscope

An endoscope for viewing the lumen of the sigmoid colon

Sigmoidoscopes

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Rectal Prolapse

Rectocoele

Protrusion of the mucous membrane and submucosa of the rectum outside the anus for approximately 1–4 cm

Common in

Children: 1 – 3 years Elderly people Middle-aged women

Rectal Prolapse Rectocoele Protrusion of the mucous membrane and submucosa of the rectum outside the anus

Partial Rectal Prolapse

Rectal mucous membrane and submucous coat protrude for a short distance outside the anus

Common in children

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Complete Rectal Prolapse

Procidentia

Whole thickness of the rectal wall protrudes through the anus

A sliding hernia through the pelvic diaphragm

Common in adults Associated with rectal incontinence

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Rectal Prolapse

Causes

In infants

Undeveloped sacral curve

Reduced resting anal tone – diminished support to the mucosal lining of anal canal

In children

Diminution of fat in ischiorectal fossae

Diarrhoea Severe whooping cough Sudden loss of weight

Fibrocystic disease

Neurological causes

Mal-development of pelvis

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Rectal Prolapse

Causes

In adults Haemorrhoids Torn perineum Straining from urethral obstruction Following operation for fistula in ano In the elderly Atony of sphincter mechanism

Rectal Prolapse

Treatment

Submucous injections Excision of the prolapsed mucosa Surgery

Rectal Carcinoma

Found mainly in

Rectosigmoid junction Ampulla

Rectal Carcinoma Found mainly in Rectosigmoid junction Ampulla Click to edit Master text styles Second level

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Bleeding per rectum

Initial finding – Lymphatics around the bowel

Later – lymph nodes along superior rectal and middle rectal arteries

Venous spread – Superior rectal vein to portal vein

Liver – secondary deposits

Rectal Carcinoma

Treatment

Rectal excision and total mesorectal excision

Abdomino-perineal excision with a permanent colostomy

Adjuvant preoperative radiotherapy

Liver resection for liver metastases

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Sources

Gray’s Anatomy: The Anatomical Basis of Clinical Medicine Gray’s Anatomy for Students Richard S. Snell – Clinical Anatomy by Regions Keith L. Moore – Essential Clinical Anatomy Last’s Anatomy - Regional and Applied Frank H. Netter – Atlas of Human Anatomy Bailey and Love’s Short Practice of Surgery

Thank You!

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