Exam 3: Lecture 19/20/21 - Surgery of the Perineum, Rectum, & Anus Flashcards
(163 cards)
1
Q
what does rectal resection mean
A
removal of a portion of the terminal large intestine
2
Q
what does rectal pull-through mean
A
resection of the terminal colon or midrectum (or both) using an anal approach with out without an abdominal approach
3
Q
what does anal saculectomy mean
A
removal of one or both anal sacs
4
Q
what are the possible indications (10) of rectal, anal, or perineal sx
A
- diagnostic biopsy
- anal sac disease
- colonic obstruction
- perineal hernia
- rectal perforation
- perianal fistulae
- rectal ischemia
- rectal prolapse
- neoplasia
- fecal incontinence
5
Q
what are the clinical signs of rectal, anal, and perineal disease
A
- anal biting or scooting
- anal licking
- tenesmus
- thickening or swelling
- constipation or obstipation
- diarrhea
- hemorrhage or hematochezia
- mass
6
Q
T/F: other clinical signs of rectal, anal, or perineal disease may be more associated with a specific condition or disease (like dermatits, self trauma, etc)
A
true
7
Q
what are some potential rectal exam findings (theres a lot… just list some)
A
- masses
- strictures
- perianal thickening
- anal sac enlargement
- pain
- reduced sphincter tone
- sublumbar lymph node enlargement
- prostatomegaly
8
Q
when is a myelographic eval, manometric eval, or electrodiagnostics required
A
if there is impaired anorectal innervation
9
Q
what are some lab abnormalities found with anal issues
A
cbc/chem are generally nonspecific
10
Q
what lab abnormalities do we find with paraneoplastic syndrome
A
- hypercalcemia
- anemia
- cachexia
- hypoglycemia
- alopecia
- gastric and intestinal ulcers
11
Q
what lab abnormalities do we see with bladder entrapment in perineal hernias
A
azotemia +/- hyperkalemia
12
Q
what PE findings can rads confirm for butt issues
A
- sublumbar lymphadenomegaly
- prostatomegaly
- abnormal bladder position with perineal hernia
- free gas in perineal, intrapelvic, or caudal retroperitoneal space with rectal perforation
13
Q
what are some pre-op management strategies for butt stuff (6 things)
A
- warm compress
- stool softener
- fistula and tumor mapping
- mechanical emptying and cleansing
- correct for hydration, acid-base, and electrolyte deficits
- blood transfusion if needed
14
Q
T/F: colon contains less bacteria than the rest of the GI tract
A
FALSE, it contains MORE
15
Q
T/F: pre-op colonic emptying and cleaning indicated to reduce bacterial load, unless perforation or obstruction is suspect
A
true!!
16
Q
what type of diet can help for pre-op patients
A
feeding an elemental diet or a low residue diet may decrease bacterial loads in colon prior to sx
17
Q
how long should we withhold food prior to butt sx
A
24 hours for adults
8 hours for pediatric patients
18
Q
what 3 things are given 24 hours prior to sx
A
- laxatives
- cathartics
- warm water enemas
19
Q
what duo is the best for cleaning the colon
A
electrolyte solution and enema
20
Q
10% povidone-iodine should be given ________ hours prior to sx
A
3 hours
21
Q
T/F: enemas given any closer than 3 hours prior to sx may liquefy intestinal content and add to the dissemination of the contaminated material during sx
A
TRUE! dont give enemas any closer than 3 hours prior
22
Q
what are 4 important things for pre-op enema management
A
- enemas can further deteriorate debilitated anorexic patients
- may cause colonic perforation
- never give hypertonic phosphate enemas to small or constipated patients
- patients with perianal disease may be too painful for pre-op enemas
23
Q
risk of ______ after colorectal sx is HIGH
A
infection
24
Q
what type of abx should be given prior to butt sx
A
systemic perioperative abx against anaerobes and gram neg aerobes
25
what are the sections of the large bowel
1. cecum
2. ascending colon
3. transverse colon
4. descending colon
5. rectum
26
what junction of intestines are hard to ID
colorectal junction
27
what are some landmarks you can use to estimate the location of the colorectal junction
pubic brim, pelvic inlet, 7th lumbar vertebra, seromuscular penetration point of the cranial rectal artery
28
when does fecal incontinence occur
1. more than 4cm of the terminal rectum is resected
2. the final 1.5cm of the terminal rectum is resected
3. the perineal nerves are damaged
4. more than half of the external anal sphincter is damaged
29
what are the primary indications to excise a segment of rectum
1. neoplasia
2. necrosis
3. trauma (prolapse, fistula, diverticulum)
4. stricture
30
what are other reasons for rectal resection
congenital anomalies, perforations, lacerations
31
what are the 5 surgical approaches to the rectum
1. ventral
2. dorsal
3. lateral
4. anal
5. rectal-pull through
32
what do ventral approaches to the rectum require
a pubic osteotomy for better exposure
or pubic symphysiotomy for more limited exposure
33
how do we do a pubic symphysiotomy
1. incise the entire length of the adductor aponeurosis
2. divide the pubis and the ischium on the midline with an osteotome and mallet or an oscillating saw
3. separate the pubis and the ischium with a self retaining retractor
34
when do you use a dorsal approach to the rectum
if the lesion involves the caudal or middle rectum and not the anal canal
35
what is limiting of a lateral approach to the rectum and when is it used
limits exposure to one side of the rectum and used for repairing lacerations and resecting a diverticulum
36
what type of approach is shown in this image
pubic symphysiotomy
37
what type of approach is this
dorsal approach
38
what type of approach is this
lateral approach
39
when is an anal approach used to resect part of the rectum
1. small non-invasive pedunculated polyps
2. broad based rectal masses
3. lesions involving the caudal rectum or anal canal
40
what is a common result if the mucocutaneous junction and skin are resected because they are diseased
fecal incontinence
41
when is a rectal pull-through primarily indicated
to resect a distal colonic or mid-rectal lesion that is not approachable through the abdomen and too large or cranial for an anal approach
42
when are post-op rectal pull-through strictures a major concern
when circumferential or near-circumferential lesions are resected
43
what procedure is shown here
rectal pull-through
44
when in a swensons pull-through indicated
when disease extends all the way into the colon
45
what is the swensons pull-through
a combination of a ventral abdomen and anal approach
46
anal saculitis = _____
inflammation
47
anal sac abscess = ____
infection
48
anal sac impaction = ______
obstruction of the duct
49
what is the anal sac anatomy
1. paired (2)
2. located 4-5 o'clock and 7-8 o'clock
3. between the internal and external anal sphincter muscles
4. lined by squamous epithelium with modified sebaceous and apocrine glands
50
when is anal sac excretions normally expelled
during normal defecation or extreme excitement
51
forceful contractions of the _____ are necessary for anal sac emptying
sphincter
52
anal saculitis usually affects about _____% of dogs
10%
53
what is anal saculitis usually caused by
1. infection
2. obstruction
3. ductal obstruction leads to infection and inflammation leading to fistulation
54
T/F: anal saculitis occurs without duct obstruction
true! It can
55
what are some of the big factors that can cause chronic hyper-secretion of anal sacs
1. infectious mechanisms
2. endocrine
3. allergic
4. behavioral
5. idiopathic
6. malfunction of the anal sphincter
56
T/F: anal saculitis may occur in animals of any age, breed, or gender but is MOST common in small and toy breed dogs
very true
57
is anal saculitis rare or common in cats
rare
58
what is the usual history of an animal with anal saculitis
1. recent diarrhea of 1-3 weeks or soft stool
2. scooting, licking, biting at tail or anus
3. tail chasing
4. malodorous perianal discharge
5. pain or behavioral changes
6. tenesmus, dyschezia, constipation
59
what are the usual PE findings for anal saculitis
1. anal sac region may be swollen or inflamed
2. anal sac may rupture and drain
3. +/- fever
4. palpation of enlarged, firm, and sometimes painful anal sacs
5. may be impossible to express
60
what does normal anal sac secretions look like
serous, slightly viscid, granular, pale-yellow liquid
61
what do abnormal anal sac secretions look like
whitish gray, brown, yellow, green, bloody, purulent, gritty, turbid, or opaque
62
T/F: routine palpation and expression of the anal sacs during PE may allow early detection of anal sac disease
TRUE
63
why does early detection of untreated anal sac abscesses matter
1. may become debilitated
2. may have other perianal or rectal abscesses
3. may develop anal stricture
4. occasionally develop perineal fistulae
64
T/F: survey rads, CT, or MRI are recommended if there is neoplasia suspected for anal sacs
true!!
65
what does impaction of anal sacs looks like
sac is distended and mildly painful and account be readily expressed
66
what does anal saculitis of anal sacs looks like
moderate or severe pain is elicited on palpation and secretions are liquids, yellowish, blood tinged, or purulent
67
what do anal sac abscesses look like
marked distention of the sac with a purulent exudate, cellulitis of surrounding tissues, erythema of overlying skin, pain, and fever
68
what does anal sac rupture look like
draining tract associated with the anal sac
69
what are the 3 normal bacterial floras in the butt
1. e coli
2. streptococcus faecalis
3. staphylococcus spp
70
what are the diseased anal sac bacterial floras
1. e coli
2. steptococcus faecalis
3. staphylococcus spp
4. clostridium perfringens
5. proteus spp
6. micrococci
7. diphtheroids
71
what are the ways to manage most anal sac problems
manual expression, lavage, topical antibiotics, and dietary changes
72
T/F: chemical cauterization is recommended for the treatment of anal sacculitis
FALSE!! not recommended
73
when is an anal saculectomy indicated
1. chronically infected or impacted anal glands
2. anal sac fistulae
3. anal sac neoplasia
74
Meticulous dissection to preserve the anal sphincter muscle and nerves is required to prevent what
fecal incontinence
75
what are 4 tips Dr. T recommends for anal saculectomies
1. always warn owners risk of incontinence
2. lining of the anal sac is grayish and glistening so its easy to distinguish from surrounding tissues
3. anal sacs can be packed with iodoform umbilical take to facilitate dissection
4. always perform histopathological exam of removed tissue to R/O tumors
76
why is closed technique for anal saculectomy preferred
1. external anal sphincter muscle is not transected
2. lumen of the anal sac remains closed
77
what type of anal saculectomy is this
closed
78
what type of anal saculectomy is this
open technique
79
when do perineal hernias occur
when the perineal muscles separate allowing rectum, pelvic, and/or abdominal contents to displace perineal skin
80
what is a caudal hernia
between the levator ani, external anal sphincter, and internal obturator muscles
81
what is a sciatic hernia
between the sacrotuberous ligament and coccygeus muslce
82
what is a dorsal hernia
between the levator ani and coccygeus muscle
83
what is a ventral hernia
between the ischiourethralis, bulbocavernosus, and ischiocavernosus muscles
84
T/F: the cause of pelvic diaphragm weakening is poorly understood but believed to be associated with male hormones, straining, and congenital/acquired muscle weakness
TRUEEEE
85
the pelvic diaphragm is stronger in ____1_____ dogs than ____2_____ dogs
1. female dogs
2. male dogs
86
T/F: only specific causes of straining may stress the pelvic diaphragm
false, ANY condition that causes straining can stress it
87
what are the 9 conditions that cause straining and may predispose to perineal hernias
1. urinary tract obstruction
2. colorectal obstruction
3. rectal deviation or dilatation
4. perianal inflammation
5. prostatitis
6. cystitis
7. anal sacculitis
8. diarrhea
9. constipation
88
what does the hernial sac contain
pelvic or retroperitoneal fat, serous fluid, deviated/dilated rectum, a rectal diverticulum, prostate, urinary bladder, or small intestine
89
T/F: In cats, the hernial sac only contains the rectum
true
90
why are perineal hernias potentially life threatening
1. organs displaced into hernia may become strangulated
2. visceral obstruction or strangulation is associated with rapid deterioration unless the obstruction or entrapment is corrected
91
postrenal uremia is associated with _____ entrapment
bladder
92
____ is associated with intestinal strangulation
SHOCK!!
93
what is the signalment of perineal hernias
common in dogs, rare in cats, males, short tails, over 5 years old
94
______% of perineal hernias occur almost exclusively in intact male dogs
93%
95
what usually happens to a female to get a perineal hernia
usually related with trauma
96
what 10 breeds are most commonly affected by perineal hernias
1. boston terriers
2. poodles
3. boxers
4. collies
5. kelpies
6. dachshunds
7. old english sheep dogs
8. mongrels
9. welsh corgi
10. pekingese
97
what is this a picture of
perineal hernia in a dog
98
what are the findings on PE with a perineal hernia
1. diagnosis based on finding a weakened pelvic diaphragm during rectal palpation
2. +/- perineal swelling lateral to anus (not always there)
3. rectal deviation containing feces
4. sometimes a right-sided predominance
99
what should we do if we think there is bladder entrapment in a perineal hernia
prompt therapy may be needed to relieve urinary obstruction
100
if you think there is liquid present and the animal is dysuric with a perineal hernia, what should we aboslutely do
ultrasound or perineal centesis to determine if fluid (urine) is present
101
what do patients with bladder retroflexion often have
1. azotemia
2. hyperkalemia
3. hyperphosphatemia
4. neutrophilic leukocytosis
102
what procedure should ALWAYS be recommended for hernias
herniorrhaphy
103
T/F: retroflexion of the urinary bladder and visceral entrapment require emergency surgery
true!!
104
what is controversial but recommended during a herniorrhaphy
castration
105
what is a herniorrhaphy
surgical repair of a hernia
106
what are the 2 most common surgical treatments for hernias
1. traditional/anatomic reapposition
2. internal obturator roll-up or transposition technique
107
with which surgical technique is it more difficult to close the ventral aspect of the hernia
traditional technique
108
bilateral herniorrhaphy is possible but post-op __1____ and ____2____ may be greater compared to unilateral procedures
1. post op discomfort
2. tenesmus
109
what should we do if the prostate is enlarged during a hernia repair
biopsy!!!
110
what types of castration can be performed during a hernia repair
caudal or pre-scrotal
111
T/F: colopexy may help prevent recurrent rectal prolapse after herniorrhaphy
TRUE!!!
112
what is some pre-op management before hernia repair
1. stool softeners 2-3 days prior to sx
2. large intestines should be evacuated with laxatives, cathartics, enemas, and manual extraction
3. prophylactic abx effective against gram-neg and anaerobic organisms should be given IV
4. if bladder is retroflexed into hernia, a urinary catheter should be placed or cystocentesis via perineum to relieve distress
113
what are 3 important things about surgical anatomy for hernia repairs
1. perineal vessels and nerves may be displaced from their normal anatomic location
2. careful observation and dissection is required to preserve these structures
3. do not mistake the prostate for a mass and attempt to excise it
114
what technique of hernia repair is shown here
traditional technique
115
what technique of hernia repair is shown here
internal obturator transposition
116
what are the post op complications of a hernia repair
1. castration is believed to reduce hernia recurrence
2. recurrence is related to expertise of surgeon
3. infection and dehiscence
4. sciatic nerve entrapment
117
most post-op complications can be prevented by what
meticulous surgical technique
118
when is prognosis of perineal hernia repair fair to good
when an experienced surgeon performs sx
119
when is perineal hernia repair prognosis poor
with bladder retroflexion
120
T/F: preexisting neuro abnormalities (ex: anal sphincter incompetence or compromised urinary bladder innervation) are corrected by the herniorrhaphy
FALSE, they are NOT corrected
121
what are some of the listed complications of herniorrhaphy
1. hemorrhage
2. anorexia
3. tenesmus
4. hematochezia
5. rectal prolapse
6. anal sacculitis
7. fecal incontinence
8. bladder necrosis
122
what is rectal prolapse
protrusion or eversion of the rectal mucosa from the anus
123
what is the signalment for rectal prolapse
seen in dogs and cats
no breed disposition
any age but more common in YOUNG animals
124
what is the usual history for a rectal prolapse
1. straining
2. recent perineal sx
3. any age but usually younger animas
4. tenesmus
5. perineal or perianal irritation from trauma or sx
6. parasites and acute enteritis
125
what are some of the conditions listed that are associated with rectal prolapse
1. endoparasitism
2. enteritis
3. FB
4. dystocia
5. constipation
6. perineal sx
126
what do we see on PE of a rectal prolapse
protrusion of anorectal mucoas
127
what must rectal prolapse be differentiated from
ileocolic intussusception that is protruding from the rectum
128
how do we differentiate between a rectal prolapse and ileocolic intussusception
insertion of a finger or probe alongside the prolapsed mass is possible with an intussusception but NOT with a rectal prolapse
129
T/F: acute and chronic rectal prolapse are easily treatable
false, acute is easily treated whereas chronic disease may require resection
130
what are the factors to consider when thinking about medical management of rectal prolapse
1. cause
2. severity or degree of prolapse
3. chronicity
4. recurrent or not
131
how do we medically manage acute prolapse with minimal tissue damage
manual reduction and placement of a purse-string suture around the anus
132
what should we do prior to manual reduction of a rectal prolapse
1. warm saline lavages
2. massage
3. lubrication
133
what should we do after manual reduction of rectal prolapse
1. retention enema of several mL of kaopectate to decrease straining
2. purse string suture should be tight enough to maintain reduction of prolapse but loose enough to allow passage of soft stool
3. epidural anesthesia
4. treat/resolve the CAUSE
134
when should we use surgical treatment for rectal prolapse
1. reducible prolapses
2. severely traumatized prolapse
135
T/F: we should perform a colopexy if rectal prolapse repeatedly recurs after manual reduction or amputation
TRUEEEE
136
what should we do for pre-op management for rectal prolapse
same as rectal and perineal sx :)
137
how should we position a patient for rectal prolapse sx
1. patient should be in ventral recumbency with the hind legs over the end of the table
2. pelvis should be elevated with padding and the tail secured over the back
3. end of the table should be padded to prevent pressure on femoral nerve
138
how should we place sutures for a surgical rectal prolapse
aprox 2mm apart and 2mm from cut edge
139
what does post-op management look like for rectal prolapses
1. cause of prolapse MUST be treated
2. retention enemas
3. opioid epidurals
4. systemic analgesia PRN
5. low fiber diet while purse string is in place
140
T/F: rectal prolapses are a primary problem, not secondary
FALSE!!! they are a SECONDARY problem!!!!
141
when do we remove the purse string after manual reduction of rectal prolapse
3-5 days after
142
when do we remove the purse string after surgical resection of rectal prolapse
1-2 days after
143
how long should we use stool softeners after rectal prolapse resection
2-3 weeks
144
what are 4 complications of manual reduction of rectal prolapse
1. tenesmus
2. dyschezia
3. hematochezia
4. recurrence
145
what are some additional complications of rectal prolapse resection
1. hemorrhage
2. leakage
3. anal stenosis
4. infection
5. dehiscence
6. fecal incontinence
146
when is prognosis poor for rectal prolapses
chronic without surgical intervention
147
when is prognosis good for rectal prolapses
with sx and treatment of primary cause
148
what is this a picture of (ew)
perianal fistulae
149
what is the definition of a perianal fistula
chronically relapsing suppurative, progressive, deep ulcerating tracts in the perianal tissues
150
Although the etiology of perianal fistula is unknown, what do we think may play a role
multifactorial immune mediated disease process and conformation
151
how do we diagnose perianal fistulae
exam of the perineal area establishes tentative diagnosis BUT histological exam is required to R/O squamous cell carcinoma, pythiosis, and other erosive conditions
152
what is the common signalment for perianal fistula
GSD and irish setters are more prone, more liekly to be male than female, intact males
153
T/F: pain from perianal fistula may cause dogs to become vicious when the tail or perineum is examined or manipulated
very very true!!
154
what are some clinical signs of perianal fistulae
1. tenesmus
2. dyschezia
3. constipation or obstipation
4. ribbon like stool
5. increased defecation
6. perianal licking or pain
155
what are some differential diagnoses for perianal fistulae symptoms
1. squamous cell carcinoma
2. perianal tumors
3. anal sac or rectal tumors
4. atypical bacterial infection
5. pythiosis
156
what does medical management of perianal fistulae look like
1. immunosuppression, hygiene, dietary therapy
2. stool softeners
3. perianal cleaning and abx
157
T/F: managing perianal fistulae requires a LOT of work and can be very frustrating for owners
TRUE!!
158
T/F: initial treatment for perianal fistulae is needed for several months but doesn't require lifelong treatment
false, initial treatment is required for several months but you may need to do lifelong treatment!
159
__1___ and __2___ can effectively treat perianal fistulae but is not cheap
1. immunosuppressive drugs
2. abx
160
how often should we re-eval perianal fistulae
every 3-5 weeks
161
what are the 2 goals of medically managing perianal fistulae
1. alleviate signs of tenesmus, dyschezia, hematochezia, constipation, diarrhea, pain, and reduce defecation frequency
2. reduce diameter, depth, extent, and recurrence of fistulae
162
T/F: surgery is often used to treat perianal fistulae
FALSEEEE!!!!! FALSEEE!!! it is SELDOM indicated
163
what are 8 complications of wide resection of perianal fistulae
1. fecal incontinence
2. flatulence
3. diarrhea
4. tenesmus
5. dyschezia
6. constipation
7. anal stenosis
8. recurrence
