Surgical Anatomy of

ANAL CANAL

Dr.Syed Nazeeb Ulla

M.S.,2nd Year
Shalya
Green batch
 INTRODUCTION
Definition

Anal canal is the terminal part of large intestine

commences at the level
where rectum
passes into pelvic diaphragm
ends at the anal verge
(distal boundary of the anal canal).
 anal triangle

right and left

ischiorectal fossa

allows expansion
during passage
of the faeces.
ANAL TRIANGLE
 Length,Extent,Direction

• its length is 2.5 – 4.5cm

• directed downwards and
backwards.
• The Ano rectal is marked by
Perineal flexure of the rectum.
• lies 2-3cm in front and slightly below
the tip of coccyx.
• anal canal from the tip of the coccyx
is about 4cm.
• In males it
corresponds to the
level of the apex of
the prostate.
 RELATIONS OF ANAL CANAL
• Anteriorly :
a)in both sexes perineal
body
b) in males – membranous
uretra and bulb of penis.
c)in females – lower end of
the vagina
• Posteriorly:
a) anococcygeal ligament
and tip of the coccyx.
• Laterally :
ischiorectal fossae
• All round :
surrounded by the
sphincter muscles.
 INTERIOR OF ANAL CANAL

• can be divided into 3 parts

• Upper about 15mm long
• Middle part about 15mm
long
• Lower part about 8mm
long
 2 cm

1 ½ cm

½ cm
 UPPER MUCOUS PART
• It is about 15mm long. It is
lined by columnar/mucous
membrane and is of
endodermal origin.
• The mucous membrane
shows
• Anal columns
• Valves
• Glands
• Sinus
• Papillae
• Dentate line
 Anal columns

• a)6to10 vertical folds of

mucous membrane-called
the anal columns of
“MORGAGNI’’.
• b)each column contains a
terminal radicle of the
superior rectal artery and
vein.
• c)these radicles being
largest in the 3,7,11’O
clock
 Anal valves

a)the lower ends of the

anal column are united to
each other by short
transverse folds of mucous
membrane these folds are
called the anal valves.
b)it may torn by hard
faeces produce an anal
fissure.
 Anal sinus
• above each valve there is a
depression in the mucosa
which is called the anal
sinus.
• the sinuses deepest on the
posterior wall of the anal
canal, may retain faecal
matter and become
infected, leading to
abscess formation in the
wall of the anal canal.
Dentate line
• the anal valves together
form a transverse line
that runs all round the
anal canal. This is also
called “Pectinate line”.
• it is situated opposite the
middle of internal anal
sphincter the junction of
ectodermal and
endodermal parts.
• Dentate line separates:
above
1.cubical epithelium
2.autonomic nerves
3.portal venous system
below
1.from squamous epithelium
2.from spinal nerves
3.systemic venous system
• From surgical point of view it is one of
the most important landmark.
• According to Perminton85% of all
Proctological diseases occur in this
area.
papillae
• occasionally the anal valves show
epithelial projections called anal
papillae.
• These papillae are remnants of the
embryonic anal membrane.
Anal glands

• These are 6-12 number,extend upwards or

downwards into the submucosa and
occasionally even penetrate deeply into the
internal sphincter.
• vary widely in number and depth of
penetration and they extend in the
submucosa above the anorectal junction.
• That is secretary in nature and contain
mucin.
• The duct of each gland
which is lined by stratified
columnar epithelium opens
into anal crypt.
• The glands are surrounded
by lymphocytes-form
resembling lymphatic
follicles
• occasionally the terminal
part of a duct is not
canalized and the secretion
may distend the gland to
form a cyst.
• may become infected with
the result that an abscess
or a fistula may be
produced.
The crypts of morgagni
• Also called anal crypts
• are small pockets between the inferior extremities
of the column of morgagni.
• these are opens into one anal gland by a narrow
duct.
• this duct bifurcates-branches internal sphincter
muscle in 60% individuals.
• sub branches extend into the intermuscular
connective tissue, where they blindly.
• as the lining of anal glands is cubical mucous
secreting property is extremely low.
• infection leads abscess fistula…..
MIDDLE OR TRANSITIONAL
ZONE OR PECTEN
• The next 15mm or so of the anal canal is
also lined by mucous membrane, but
anal columns are not present here.
• The mucosa has a bluish appearance
because of a dense venous plexus that
lies between it and muscle coat.
• Mucosa is less mobile than in the upper
part of the anal canal.
• This region is reffered as pecten or
transitional zone.
• The lower limit of the
Pecten often has a
whitish appearance
because of which it is
referred to as the “White
line of Hilton”.
• It is situated at the level
of the interval between
the subcutaneous part of
external anal sphincter
and the lower border of
internal anal sphincter.
• It marks the lower limit of
Pecten or stratified
squamous epithelium
which is thin , pale and
glossy and is devoid of
sweat glands.
• Anal fascia and lunate fascia extends
upto this line

• Ischiorectal abscess-communicates
with anal canal usually opens at or
below Hilton’s line
LOWER CUTANEOUS
PART
• It is about 8mm long and is lined by
true skin containing sweat and
sebaceous glands
ANAL SPHINCTERS & MUSCLES
• Internal anal
sphincter which is
the continuation of
circular muscle of
rectum
• Longitudinal
muscle of the
rectum
• External sphincter
• Levator ani muscle
 The internal sphincter:
• it is the continuation of the
circular muscle coat of the
rectum.
• this involuntary muscle
commences where the
rectum passes through the
pelvic diaphragm and ends
at the White line of hilton.
• it surrounds the upper
three fourths
• it is 2.5cm long and 2-5mm
thick , pearly white in
colour.
• spasm and contracture of
this muscle play a major
part in fissure and other
anal affections.
• The fibres of internal
sphincter are unstriated and
are under the involuntary
control. They help in the
expulsion of the faeces.
• Under anesthesia or when
anus is stretched, the lower
end of the internal sphincter
lies lower than the external
sphincter.
• This sphincter is the muscle,
which is divided in
sphincterotomy for anal
fissure and is also exposed
during a haemorrhoidectomy.
 Longitudinal muscle
• it is the continuation of the
longitudinal muscle coat of the
rectum intermingled with fibres from
the Puborectalis.
• its fibres fan out through the lowest
part of the external sphincter to be
inserted into the true anal and
perianal skin.
• This fibres that are attached to the
epithelium provide pathways for
spread of perianal infections and
mark out tight compartments that are
responsible for intense pressure and
pain that accompany many localised
perianal lesions.
• beneath the anal skin lie the scanty
fibres of the corrugator cutis ani
muscle.
External sphincter
• it is made up of striated muscle and
formerly divided in to
Deep,Superficial,Subcutaneous portions
is now considered as one muscle.
• Subcutaneous part lies below the level of
the internal sphincter and surrounds the
lower part of the anal canal.
• it is in the form of a flat band about
15mm broad. It has no bony
attachement.
2 1
• The superficial part is elliptical in shape
and arises from the posterior surface of
the terminal segment of the coccyx and
the anococcygeal ligament or raphe.
• The fibres surround the lower part of the
internal sphincter and are inserted into
the perineal body.
• The deep part surrounds the upper
part of the internal sphincter and is
fused with the puborectalis.
• It has also no bony attachements
• its fibres posteriorly attached to coccyx
while anteriorly they are inserted into the
mid perineal point in the male and in the
female fuse with the sphincter vaginae.
• it is pink in
colour,homogenous,volountary.
• it is supplied by the inferior rectal
nerve and the perineal branch of the
fourth sacral nerve.
• The intersphincteric plane: between both
external and internal sphincter a
potential space.
• It is important as it contains 8 to 10
apocrine glands which can infection and
also route for spread of pus.
• Puborectalis: plays a key role in
maintaining the angle between rectum
and anal canal, hence essential for
maintaining for continance
Conjoint longitudinal coat
• It is formed by fusion of the puborectalis with
the longitudinal muscle coat of the rectum at
the anorectal junction
• It lies between the external and internal
sphincters.
• When traced downwards it becomes
fibroelastic and at the level of the white line it
breaks up into a number of fibroelastic septa
which spread out fanwise, pierce the
subcutaneous part of the external sphincter
and are attached to the skin around the anus.
• The most lateral
of these septa
forms perianal
fascia.
• The most medial
septum forms the
anal
intermuscular
septum which is
attached to the
white line.
ANORECTAL RING
• marks the junction between the
rectum and anal canal.
• Formed by 1.puborectalis 2.deep
external sphincter 3.conjoined
longitudinal muscle 4. highest part of
internal sphincter.
• Can be felt digitally especially on its
posteriorly and lateral aspects.
Puborectalis muscle
Puborectalis muscle
• Division of the ARR results in
permanent incontinence of faeces.
• The position and length of the anal
canal as well as the angle of the
anorectal junction, depends to a major
extent on the integrity and strength of
the PB muscle.
• It is less marked anteriorly where
the fibres of the PR are absent.
SURGICAL SPACES RELATED
TO THE ANAL CANAL
• Perianal space
• Ischiorectal space
-suprategmental
-tegmental
• Submucous space
• Inter sphincteric space
• Pelvirectal space
Perianal space:
• surrounds the anal canal below the white
line.
• It contains the subcutaneous external
sphincter, the external rectal venous
plexus, and the terminal branches of the
inferior rectal vessels and nerves.
• Pus in this space tends to spread to the
anal canal at the white line or to the
surface of the perineal skin rather than to
the ischiorectal space.
Submucous space:
• lies above the white line between the
mucous membrane and internal
sphincter.
• It contains the internal rectal venous
plexus and lymphatics.
Ischiorectal space:
• Is a wedge shaped space situated one
on each side of the anal canal below
the pelvic diaphragm.
• Its base is directed downwards towards
the surface, apex is directed upwards.
• Length (anteroposteriorly) 5cm,
width(side to side) 2.5cm and depth
(vertically) 5to6.2cm.
Boundaries :
• Base is formed by the skin
• Apex is formed by the line where the
obturator fascia meets the inferior
fascia of the pelvic diaphragm or anal
fascia.
• Anteriorly the fossa is limited by the
posterior border of the perineal
membrane but for the anterior recess
of the fossa.
• Posteriorly the fossa reaches
• a)the lower border of the gluteus
maximus and b)sacro tuberous
ligament.
• Lateral wall is vertical and is formed by
a)the obturator internus with the
obturator fascia.
b)the medial surface of the ischial
tuberosity, below the attachment of the
obturator fasica.
• The medial wall slopes upwards and
laterally and is formed by
a) the external anal sphincter with the
fascia covering it in the lower part.
b)the levator ani with the anal fascia
in the upper part.
Pelvirectal space
• This space is a potential space which
lies between the pelvic peritoneal floor
and levator ani muscle
Inter sphincteric space
• Interval between the internal and
external anal sphincters is known as the
inter sphincter space.
• The anal intramuscular glands, which
open into the anal crypts, pass through
this space before penetrating the internal
sphincter.
• No essential nerves or blood vessels
cross the space and a plane of
dissection is fairly easily developed.
RECESSES:
• these are narrow extensions of the fossa beyond
its boundaries.
• 1) the anterior recess extends forwards above
the urogenital diaphragm, reaching almost up to
the posterior surface of the body of the pubis.
• It is closely related to the prostate or the vagina.
• 2)the posterior recess is smaller than the
anterior, it extends deep to sacrotuberous
ligament.
• 3)the horseshoe recess connects the two
ischiorectal fossae behind the anal canal.
BLOOD SUPPLY
• Arterial supply: branches from the superior
middle and inferior haemorrhoidal arteries.
• The most imp is the superior haemorrhoidal
whose left branch supplies left half of anal
canal by a single terminal branch , while its
right has two two terminal branches.
• All of the arteries contribute to a rich
submucous and intramural plexus so that
interruption of the arterial supply from above
by the division of the superior and middle
rectal arteries does not deprive the anus of
its blood suply.
ARTERIAL SUPPLY
VENOUS DRAINAGE
• they are distributed in a similar manner of
arteries.
• The sup and middle haemorrhoidal veins
drain via the inferior mesenteric vein into the
portal system, having become the superior
rectal vein en route.
• The superior haemorrhoidal vein drains the
upper half of the anal canal.
• Inferior haemorrhoidal veins drain the lower
half of anal canal and the subcutaneous
perianal plexus of veins they eventually join
the external iliac vein on each side.
VENOUS DRAINAGE
LYMPHATIC DRAINAGE:
• from upper half of anal canal flows
upwards to drain in to the post rectal
lymph nodes and from there goes to
the para aortic nodes via the inferior
mesenteric chain.
• Lymph from lower half drains on each
side 1st into the superficial and then
into deep inguinal group of lymph
glands.
LYMPHATIC DRAINAGE
NERVE SUPPLY
• Above the Pectinate line, the anal canal
is supplied by autonomic nerves both
sympathetic (inferior hypogastric plexus
L1,L2) and parasympathetic (pelvic
splanchnic S2,S3,S4) .
• Below the Pectinate line, it is supplied by
somatic (inferior rectal S2,S3,S4)
nerves.
• The internal sphincter is caused to
contract by sympathetic nerves and is
relaxed by parasympathetic nerves.
• The external sphincter is supplied by
the inferior rectal nerve and by the
perineal branch of the fourth sacral
nerve.
EMBROYOLOGY
• upper 15mm develops from the
primitive anorectal canal.
• Lower part below the pectinate line
(lower 15+8mm) is formed from
ectodermal invagination i.e.
proctodeum.
• Non continuity of the two parts results
in imperforate anus.
THANK YOU