9e. New: Anorectal Landmarks

Anorectal Landmarks
(Bullard Dunn KM, Rothenberger DA. Chapter 29. Colon, Rectum,

and Anus. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter
JG, Matthews JB, Pollock RE. eds. Schwartz's Principles of Surgery,
9e.
New
York,
NY:
McGraw-Hill;
2010.
http://accessmedicine.mhmedical.com/content.aspx?
bookid=352&Sectionid=40039771. Accessed April 27, 2014.)
The surgical anal canal measures 2 to 4 cm in length and generally
is longer in men than in women. It begins at the anorectal junction
and terminates at the anal verge. The dentate or pectinate line
marks the transition point between columnar rectal mucosa and
squamous anoderm. The 1 to 2 cm of mucosa just proximal to the
dentate line shares histologic characteristics of columnar, cuboidal,
and squamous epithelium and is referred to as the anal transition
zone. The dentate line is surrounded by longitudinal mucosal folds,
known as the columns of Morgagni, into which the anal crypts
empty. These crypts are the source of cryptoglandular abscesses
(Fig. 29-3).
FIG. 29-3.
In the distal rectum, the inner smooth muscle is thickened and

comprises the internal anal sphincter that is surrounded by the
subcutaneous, superficial, and deep external sphincter. The deep
external anal sphincter is an extension of the puborectalis muscle.
The puborectalis, iliococcygeus, and pubococcygeusmuscles form
the levator ani muscle of the pelvic floor (Fig. 29-4).
FIG. 29-4.
Anorectal Vascular Supply

The superior rectal artery arises from the terminal branch of the
inferior mesenteric artery and supplies the upper rectum. The
middle rectal artery arises from the internal iliac; the presence and
size of these arteries are highly variable. The inferior rectal artery
arises from the internal pudendal artery, which is a branch of the
internal iliac artery. A rich network of collaterals connects the
terminal arterioles of each of these arteries, thus making the rectum
relatively resistant to ischemia (Fig. 29-5).
FIG. 29-5.
The venous drainage of the rectum parallels the arterial supply. The
superior rectal vein drains into the portal system via the inferior
mesenteric vein. The middle rectal vein drains into the internal iliac
vein. The inferior rectal vein drains into the internal pudendal vein,
and subsequently into the internal iliac vein. A submucosal plexus
deep to the columns of Morgagni forms the hemorrhoidal plexus and
drains into all three veins.
Anorectal Lymphatic Drainage

Lymphatic drainage of the rectum parallels the vascular supply.
Lymphatic channels in the upper and middle rectum drain superiorly
into the inferior mesenteric lymph nodes. Lymphatic channels in the
lower rectum drain both superiorly into the inferior mesenteric
lymph nodes and laterally into the internal iliac lymph nodes. The
anal canal has a more complex pattern of lymphatic drainage.
Proximal to the dentate line, lymph drains into both the inferior
mesenteric lymph nodes and the internal iliac lymph nodes. Distal to
the dentate line, lymph primarily drains into the inguinal lymph
nodes, but also can drain into the inferior mesenteric lymph nodes
and internal iliac lymph nodes.
Anorectal Nerve Supply
Both sympathetic and parasympathetic nerves innervate the
anorectum. Sympathetic nerve fibers are derived from L1L3 and
join the preaortic plexus. The preaortic nerve fibers then extend
below the aorta to form the hypogastric plexus, which subsequently
joins the parasympathetic fibers to form the pelvic plexus.
Parasympathetic nerve fibers are known as the nervi erigentes and
originate from S2S4. These fibers join the sympathetic fibers to
form the pelvic plexus. Sympathetic and parasympathetic fibers
then supply the anorectum and adjacent urogenital organs.
The internal anal sphincter is innervated by sympathetic and
parasympathetic nerve fibers; both types of fibers inhibit sphincter
contraction. The external anal sphincter and puborectalis muscles
are innervated by the inferior rectal branch of the internal pudendal
nerve. The levator ani receives innervation from both the internal
pudendal nerve and direct branches of S3 to S5. Sensory
innervation to the anal canal is provided by the inferior rectal
branch of the pudendal nerve. Although the rectum is relatively
insensate, the anal canal below the dentate line is sensate.
Motility, Defecation, and Continence
Motility
Unlike the small intestine, the large intestine does not demonstrate
cyclic motor activity characteristic of the migratory motor complex.
Instead, the colon displays intermittent contractions of either low or
high amplitude. Low-amplitude, short-duration contractions occur in
bursts and appear to move the colonic contents both antegrade and
retrograde. It is thought that these bursts of motor activity delay
colonic transit and thus increase the time available for absorption of
water and exchange of electrolytes. High-amplitude contractions
occur in a more coordinated fashion and create mass movements.
Bursts of rectal motor complexes also have been described. In
general, cholinergic activation increases colonic motility.
Defecation
Defecation is a complex, coordinated mechanism involving colonic
mass movement, increased intra-abdominal and rectal pressure,
and relaxation of the pelvic floor. Distention of the rectum causes a
reflex relaxation of the internal anal sphincter (the rectoanal
inhibitory reflex) that allows the contents to make contact with the
anal canal. This sampling reflex allows the sensory epithelium to
distinguish solid stool from liquid stool and gas. If defecation does
not occur, the rectum relaxes and the urge to defecate passes (the
accommodation response). Defecation proceeds by coordination of
increasing intra-abdominal pressure via the Valsalva maneuver,
increased rectal contraction, relaxation of the puborectalis muscle,
and opening of the anal canal.
Continence
The maintenance of fecal continence is at least as complex as the
mechanism of defecation. Continence requires adequate rectal wall
compliance to accommodate the fecal bolus, appropriate neurogenic
control of the pelvic floor and sphincter mechanism, and functional
internal and external sphincter muscles. At rest, the puborectalis
muscle creates a sling around the distal rectum, forming a
relatively acute angle that distributes intra-abdominal forces onto
the pelvic floor. With defecation, this angle straightens, allowing
downward force to be applied along the axis of the rectum and anal
canal. The internal and external sphincters are tonically active at
rest. The internal sphincter is responsible for most of the resting,
involuntary sphincter tone (resting pressure). The external sphincter
is responsible for most of the voluntary sphincter tone (squeeze
pressure). Branches of the pudendal nerve innervate both the
internal and external sphincter. Finally, the hemorrhoidal cushions
may contribute to continence by mechanically blocking the anal
canal. Thus, impaired continence may result from poor rectal
compliance, injury to the internal and/or external sphincter or
puborectalis, or nerve damage or neuropathy.

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Anorectal Landmarks

(Bullard Dunn KM, Rothenberger DA. Chapter 29. Colon, Rectum,

In the distal rectum, the inner smooth muscle is thickened and

Anorectal Vascular Supply

Anorectal Lymphatic Drainage

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