1887

The large intestine and perineum

image of The large intestine and perineum
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Abstract

Differentiation of large bowel disease from small intestinal disorders is based on history and clinical examination. The clinical signs are a result of disruption of the functions of the large bowel – namely, absorption of water and electrolytes from luminal contents, and storage and periodic expulsion of faecal material. This chapter addresses anatomy, diagnosis and treatment of many different conditions. Colotomy; Colectomy; Typhlectomy (caecal resection); Incision colopexy; Anal ‘pull-out’ procedure for lesions requiring full-thickness resection; Rectal ‘pull-through’ procedure; Dorsal rectal approach; Ventral approach to the rectum; Perineal herniorrhaphy in a male dog; Anal sacculectomy; Anoplasty.

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Figures

Image of 8.1
8.1 Anatomy and vascular supply of the large intestine. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.2 Vasa recti supplying the descending colon. The left colic artery anastomoses with the middle colic artery and supplies the descending colon by numerous vasa recti, and not the anastomosing arcades seen in the small intestines.
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8.4 (a) Caecal leiomyosarcoma in a cat. (b) Cross-section of removed tumour.
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8.5 Abdominal radiograph showing the caecum impacted with mineralized material, immediately caudal to rib 13.
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8.6 Abdominal radiographs of a 4-year-old Rottweiler bitch with caecal–colic volvulus. Note the dilated colon, ending abruptly cranial to the pelvic inlet (arrowed).
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8.9 Lateral radiograph of a cat with idiopathic megacolon.
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8.10 Contrast radiograph obtained using a barium enema. Arrows outline a filling defect in ventral colorectal wall.
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8.11 The perineal stand position. Note that the table should not be tilted more than 25–30 degrees. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 8.12
8.12 Anal ‘pull-out’ and local excision. For small lesions, full-thickness resection is not always required. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.13 Radiograph of Boxer puppy with Type III atresia ani.
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8.14 Imperforate anus (atresia ani).
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8.17 Radiograph showing an enlarged iliac lymph node. (Reproduced from the )
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8.18 Horizontal section through perineal area. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.19 Schematic drawing of perineal anatomy. (Reproduced from the )
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8.21 Perineal musculature. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.22 (a) Rectal sacculation. (b) Rectal diverticulum (rare; note the mucosa protruding through the muscularis and serosal layers of rectum). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.23 Pneumocystogram of a Cocker Spaniel bitch with perineal hernia and retroflexed bladder.
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8.26 (a) Large perineal swelling, suggestive of a perineal hernia. (b) Perineal hernia being confirmed by rectal examination; note the lack of lateral rectal wall support. (Reproduced from the )
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8.27 (a) Semitendinosus muscle being dissected prior to distal transection and used to repair a ventral perineal hernia. (b) Semitendinosus muscle being sutured in ventral portion of hernia.
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8.28 Rectocutaneous fistula.
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8.29 Omentalization of the perineal wound in Figure 8.28 .
Image of Colonic biopsy. A stay suture is placed through one side of the incision and a second incision is made with fine Metzenbaum scissors to form an ellipse around the stay suture.
Colonic biopsy. A stay suture is placed through one side of the incision and a second incision is made with fine Metzenbaum scissors to form an ellipse around the stay suture. Colonic biopsy. A stay suture is placed through one side of the incision and a second incision is made with fine Metzenbaum scissors to form an ellipse around the stay suture.
Image of Closure of a colostomy incision with a simple continuous suture pattern. Note: all sutures penetrate the submucosa.
Closure of a colostomy incision with a simple continuous suture pattern. Note: all sutures penetrate the submucosa. Closure of a colostomy incision with a simple continuous suture pattern. Note: all sutures penetrate the submucosa.
Image of Subtotal colectomy is performed after identifying the proximal (A or B) and distal (C) resection sites and ligating the appropriate blood vessels (blue crosses). If the ileocolic valve is to be removed, the ileocolic artery and vein need to be ligated (arrowed).
Subtotal colectomy is performed after identifying the proximal (A or B) and distal (C) resection sites and ligating the appropriate blood vessels (blue crosses). If the ileocolic valve is to be removed, the ileocolic artery and vein need to be ligated (arrowed). Subtotal colectomy is performed after identifying the proximal (A or B) and distal (C) resection sites and ligating the appropriate blood vessels (blue crosses). If the ileocolic valve is to be removed, the ileocolic artery and vein need to be ligated (arrowed).
Image of The ileocaecal fold is dissected and branches of the ileocaecal artery supplying the caecum are ligated.
The ileocaecal fold is dissected and branches of the ileocaecal artery supplying the caecum are ligated. The ileocaecal fold is dissected and branches of the ileocaecal artery supplying the caecum are ligated.
Image of Two non-crushing intestinal clamps are placed across the base of the caecum and it is amputated between the two forceps.
Two non-crushing intestinal clamps are placed across the base of the caecum and it is amputated between the two forceps. Two non-crushing intestinal clamps are placed across the base of the caecum and it is amputated between the two forceps.
Image of The base of the caecum is then oversewn with synthetic absorbable suture material using a Parker–Kerr suture pattern.
The base of the caecum is then oversewn with synthetic absorbable suture material using a Parker–Kerr suture pattern. The base of the caecum is then oversewn with synthetic absorbable suture material using a Parker–Kerr suture pattern.
Image of TA stapling device being used to resect a perforated caecal mass in a 10-year-old Greyhound bitch. Histopathology revealed the mass to be a leiomyosarcoma.
TA stapling device being used to resect a perforated caecal mass in a 10-year-old Greyhound bitch. Histopathology revealed the mass to be a leiomyosarcoma. TA stapling device being used to resect a perforated caecal mass in a 10-year-old Greyhound bitch. Histopathology revealed the mass to be a leiomyosarcoma.
Image of Incisional colopexy. Gentle cranial traction is applied to the descending colon.
Incisional colopexy. Gentle cranial traction is applied to the descending colon. Incisional colopexy. Gentle cranial traction is applied to the descending colon.
Image of Incisions of similar length are made in the peritoneum of the left abdominal wall and through the seromuscular layer of the descending colon.
Incisions of similar length are made in the peritoneum of the left abdominal wall and through the seromuscular layer of the descending colon. Incisions of similar length are made in the peritoneum of the left abdominal wall and through the seromuscular layer of the descending colon.
Image of The colon is sutured to the abdominal wall using a simple continuous suture pattern, starting with the deepest side of the incision.
The colon is sutured to the abdominal wall using a simple continuous suture pattern, starting with the deepest side of the incision. The colon is sutured to the abdominal wall using a simple continuous suture pattern, starting with the deepest side of the incision.
Image of The superficial side of the incision is sutured similarly to complete the colopexy.
The superficial side of the incision is sutured similarly to complete the colopexy. The superficial side of the incision is sutured similarly to complete the colopexy.
Image of Anal ‘pull-out’ procedure for annular lesions.
Anal ‘pull-out’ procedure for annular lesions. Anal ‘pull-out’ procedure for annular lesions.
Image of The skin incision is made with care to avoid the anal sacs and their ducts.
The skin incision is made with care to avoid the anal sacs and their ducts. The skin incision is made with care to avoid the anal sacs and their ducts.
Image of A combination of sharp and blunt dissection is carried out to free the rectum from the external anal sphincter muscle.
A combination of sharp and blunt dissection is carried out to free the rectum from the external anal sphincter muscle. A combination of sharp and blunt dissection is carried out to free the rectum from the external anal sphincter muscle.
Image of The rectum is excised 1–2 cm proximal to the lesion.
The rectum is excised 1–2 cm proximal to the lesion. The rectum is excised 1–2 cm proximal to the lesion.
Image of The rectum is sutured to the skin using absorbable suture material in a simple interrupted pattern.
The rectum is sutured to the skin using absorbable suture material in a simple interrupted pattern. The rectum is sutured to the skin using absorbable suture material in a simple interrupted pattern.
Image of A horseshoe-shaped incision is made dorsal to the anus.
A horseshoe-shaped incision is made dorsal to the anus. A horseshoe-shaped incision is made dorsal to the anus.
Image of Muscles exposed via the dorsal approach.
Muscles exposed via the dorsal approach. Muscles exposed via the dorsal approach.
Image of The rectum and lesion are identified and the area to be excised planned.
The rectum and lesion are identified and the area to be excised planned. The rectum and lesion are identified and the area to be excised planned.
Image of Stay sutures are used to reduce the risk of retraction of the severed ends of the rectum.
Stay sutures are used to reduce the risk of retraction of the severed ends of the rectum. Stay sutures are used to reduce the risk of retraction of the severed ends of the rectum.
Image of The rectum is anastomosed using monofilament absorbable suture material.
The rectum is anastomosed using monofilament absorbable suture material. The rectum is anastomosed using monofilament absorbable suture material.
Image of Pelvic symphysiotomy. Symphysiotomy/osteotomy sites.
Pelvic symphysiotomy. Symphysiotomy/osteotomy sites. Pelvic symphysiotomy. Symphysiotomy/osteotomy sites.
Image of Use of a rib retractor, such as a Finochietto retractor, helps to improve exposure.
Use of a rib retractor, such as a Finochietto retractor, helps to improve exposure. Use of a rib retractor, such as a Finochietto retractor, helps to improve exposure.
Image of Following resection of the rectal lesion, a routine anastomosis is carried out.
Following resection of the rectal lesion, a routine anastomosis is carried out. Following resection of the rectal lesion, a routine anastomosis is carried out.
Image of The symphysis or osteotomy is repaired with orthopaedic wire passed through pre-drilled holes.
The symphysis or osteotomy is repaired with orthopaedic wire passed through pre-drilled holes. The symphysis or osteotomy is repaired with orthopaedic wire passed through pre-drilled holes.
Image of Incision from the base of the tail to the ischial tuberosity.
Incision from the base of the tail to the ischial tuberosity. Incision from the base of the tail to the ischial tuberosity.
Image of Ultrasound scan of a perineal prostatic cyst.
Ultrasound scan of a perineal prostatic cyst. Ultrasound scan of a perineal prostatic cyst.
Image of Perineal prostatic cyst at surgery.
Perineal prostatic cyst at surgery. Perineal prostatic cyst at surgery.
Image of Perineal anatomy in a dog without a perineal hernia. (Courtesy of M McLoughlin)
Perineal anatomy in a dog without a perineal hernia. (Courtesy of M McLoughlin) Perineal anatomy in a dog without a perineal hernia. (Courtesy of M McLoughlin)
Image of Elevation of the internal obturator muscle (IOM). EASM = external anal sphincter muscle.
Elevation of the internal obturator muscle (IOM). EASM = external anal sphincter muscle. Elevation of the internal obturator muscle (IOM). EASM = external anal sphincter muscle.
Image of Elevation of internal obturator muscle using a periosteal elevator. (Courtesy of M McLoughlin)
Elevation of internal obturator muscle using a periosteal elevator. (Courtesy of M McLoughlin) Elevation of internal obturator muscle using a periosteal elevator. (Courtesy of M McLoughlin)
Image of The internal obturator muscle has been elevated. Note that the internal obturator tendon has been transected (arrowed). (Courtesy of M McLoughlin)
The internal obturator muscle has been elevated. Note that the internal obturator tendon has been transected (arrowed). (Courtesy of M McLoughlin) The internal obturator muscle has been elevated. Note that the internal obturator tendon has been transected (arrowed). (Courtesy of M McLoughlin)
Image of Surgical anatomy of a perineal hernia; note suture placement. EASM = external anal sphincter muscle; IOM = internal obturator muscle.
Surgical anatomy of a perineal hernia; note suture placement. EASM = external anal sphincter muscle; IOM = internal obturator muscle. Surgical anatomy of a perineal hernia; note suture placement. EASM = external anal sphincter muscle; IOM = internal obturator muscle.
Image of Polypropylene sutures have been pre-placed between: the levator ani/coccygeus and the external anal sphincter muscles; the levator ani/coccygeus and the internal obturator muscles; and the internal obturator and external anal sphincter muscles. (Courtesy of M McLoughlin)
Polypropylene sutures have been pre-placed between: the levator ani/coccygeus and the external anal sphincter muscles; the levator ani/coccygeus and the internal obturator muscles; and the internal obturator and external anal sphincter muscles. (Courtesy of M McLoughlin) Polypropylene sutures have been pre-placed between: the levator ani/coccygeus and the external anal sphincter muscles; the levator ani/coccygeus and the internal obturator muscles; and the internal obturator and external anal sphincter muscles. (Courtesy of M McLoughlin)
Image of Fine mosquito forceps or a sterile probe is placed within the duct of the anal sac.
Fine mosquito forceps or a sterile probe is placed within the duct of the anal sac. Fine mosquito forceps or a sterile probe is placed within the duct of the anal sac.
Image of Incise on to the probe with a No. 15 scalpel blade; the incision is extended into the anal sac.
Incise on to the probe with a No. 15 scalpel blade; the incision is extended into the anal sac. Incise on to the probe with a No. 15 scalpel blade; the incision is extended into the anal sac.
Image of The anal sac is dissected free and amputated at the level of the duct opening.
The anal sac is dissected free and amputated at the level of the duct opening. The anal sac is dissected free and amputated at the level of the duct opening.
Image of The defect is closed routinely with absorbable sutures subcutaneously and monofilament nylon in the skin.
The defect is closed routinely with absorbable sutures subcutaneously and monofilament nylon in the skin. The defect is closed routinely with absorbable sutures subcutaneously and monofilament nylon in the skin.
Image of A 9-year-old male crossbreed dog with mild perianal fistulae.
A 9-year-old male crossbreed dog with mild perianal fistulae. A 9-year-old male crossbreed dog with mild perianal fistulae.
Image of A 360-degree incision is made around the anus, incorporating all fistulous tracts.
A 360-degree incision is made around the anus, incorporating all fistulous tracts. A 360-degree incision is made around the anus, incorporating all fistulous tracts.
Image of Anal sacculectomy being performed owing to secondary involvement of the anal sacs in a German Shepherd Dog with severe perianal fistulae. Note that a surgical probe has been placed into the anal sac.
Anal sacculectomy being performed owing to secondary involvement of the anal sacs in a German Shepherd Dog with severe perianal fistulae. Note that a surgical probe has been placed into the anal sac. Anal sacculectomy being performed owing to secondary involvement of the anal sacs in a German Shepherd Dog with severe perianal fistulae. Note that a surgical probe has been placed into the anal sac.
Image of The diseased tissue (including the anus) is dissected free. The external anal sphincter muscle (EASM) should be preserved if possible.
The diseased tissue (including the anus) is dissected free. The external anal sphincter muscle (EASM) should be preserved if possible. The diseased tissue (including the anus) is dissected free. The external anal sphincter muscle (EASM) should be preserved if possible.
Image of The rectum and anus are amputated.
The rectum and anus are amputated. The rectum and anus are amputated.
Image of The rectum is sutured to the skin with absorbable monofilament suture material.
The rectum is sutured to the skin with absorbable monofilament suture material. The rectum is sutured to the skin with absorbable monofilament suture material.
Image of Following excision of all diseased tissue the anus has been reconstructed by closing the skin defect and suturing the rectal mucosa to the skin.
Following excision of all diseased tissue the anus has been reconstructed by closing the skin defect and suturing the rectal mucosa to the skin. Following excision of all diseased tissue the anus has been reconstructed by closing the skin defect and suturing the rectal mucosa to the skin.

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