Rectum and Anal Canal General Anatomy

The rectal wall consists of mucosa, submucosa, and two complete muscular layers: inner circular and outer longitudinal (Fig. 26-3). The rectum is approximately 12 to 15 cm in length and extends from the sigmoid colon to the anal canal following the curve of the sacrum (Fig. 26-4). The anterior peritoneal reflection is about 5 to 7.5 cm above the anus in females and 7 to 9cm above the anus in males. The posterior peritoneal reflection is usually 12 to 15 cm above the anus. The upper third of the rectum is covered by peritoneum on its anterior and lateral surfaces. The middle third of the rectum is covered by peritoneum only on its anterior surface, and the lower third of the rectum is below the peritoneal reflection. The proximal rectum is identified as the level at which the teniae coli of the colon coalesce to form a complete layer of longitudinal muscle at approximately the level of the sacral promontory. The rectum contains three distinct curves: The proximal and distal curves are convex to the right, whereas the middle curve is convex to the left. These folds project into the lumen as the valves of Houston. These mucosal infoldings present some difficulty for proctoscopic examination, but they are excellent targets for mucosal biopsy because they do not contain all layers of the muscular rectal wall and the risk of perforation is therefore diminished. The middle valve of Houston roughly correlates with the level of the anterior peritoneal reflection. Waldeyer's fascia is a dense rectosacral fascia that begins at the level of the fourth sacral body and extends anteriorly to the rectum, covering the sacrum and overlying the vessels and nerves (see Fig. 26-86 E). Anterior to the extraperitoneal rectum is Denonvilliers' fascia, which is the rectovesical septum in men and the rectovaginal septum in women. The lateral ligaments of endopelvic fascia support the lower rectum but do not usually contain major blood vessels, as previously believed. Division of the lateral ligaments is thus possible without impairing the blood supply to the rectum or encountering a significant bleeding. Accessory middle hemorrhoidal arteries can be located in the lateral ligaments but are not critical to the blood supply of the rectum. The pelvic floor is a musculotendinous sheet formed by the levator ani muscle and is innervated by the fourth sacral nerve (Fig. 26-5). The pubococcygeus, iliococcygeus, and puborectalis muscles make up the levator ani muscle. These are paired muscles that intertwine and act as a single unit. The line of decussation is called the anococcygeal raphe. The rectum, vagina, urethra, and the dorsal vein of the penis pass through the

levator hiatus in the pubococcygeal portion of the levator ani. During defecation, the puborectalis relaxes and the levator ani contracts, widening the levator hiatus. The anal canal starts at the pelvic diaphragm and ends at the anal verge (see Fig. 26-4). It is approximately 4 cm long and normally exists as a collapsed anteroposterior slit. The anatomic anal canal extends from the anal verge to the dentate line. For practical purposes, however, surgeons usually define the surgical anal canal as extending from the anal verge to the anorectal ring, which is the circular lower (see Fig. 26-3) border of the puborectalis that is palpable by digital rectal examination. The anorectal ring is 1 to 1.5 cm above the dentate line. The anal verge is the junction between anoderm and perianal skin. The anoderm is a specialized epithelium rich in nerves but devoid of secondary skin appendages (hair follicles, sebaceous glands, or sweat glands). The dentate line is a true mucocutaneous junction located 1 to 1.5 cm above the anal verge (see Fig. 26-3). A 6- to 12-mm transitional zone exists above the dentate line over which the squamous epithelium of the anoderm becomes cuboidal and then columnar epithelium. The anal canal is surrounded by an internal and external sphincter, which together constitute the anal sphincter mechanism (see Fig. 26-5). The internal sphincter is a specialized continuation of the inner circular smooth muscle of the rectum. It is an involuntary muscle and is normally contracted at rest. The intersphincteric plane represents the fibrous continuation of the longitudinal smooth muscle layer of the rectum. The external sphincter is a voluntary, striated muscle divided into three Ushaped loops (subcutaneous, superficial, and deep) acting as a single functional unit. It is a specialized continuation of the levator muscles of the pelvic floor, specifically of the puborectalis muscle. The puborectalis originates at the pubis and joins posterior to the rectum. It is normally contracted, causing an 80 angulation of the anorectal junction. The columns of Morgagni consist of 8 to 14 longitudinal mucosal folds located just above the dentate line and forming the anal crypts at their distal end (see Fig. 26-3). Small rudimentary glands open into some of these crypts. The ducts of these glands penetrate the internal sphincter, and the body of the gland resides in the intersphincteric plane.

Arterial Supply
The terminal branch of the inferior mesenteric artery becomes the superior rectal artery as it crosses the left common iliac artery (Fig. 26-6 A). It

descends in the sigmoid mesocolon and bifurcates at the level of the third sacral body. The left and right branches of the superior rectal artery supply the upper and middle rectum. The middle and inferior rectal arteries supply the lower third of the rectum. The middle rectal arteries arise from the internal iliac arteries, run through Denonvilliers' fascia, and enter the anterolateral aspect of the rectal wall at the level of the anorectal ring. Collaterals exist between the middle and superior rectal arteries. Preservation of the middle rectal arteries is necessary to maintain viability of the remaining rectum after proximal ligation of the inferior mesenteric artery. The inferior rectal arteries are branches of the internal pudendal arteries. They traverse Alcock's canal and enter the posterolateral aspect of the ischiorectal fossa. They supply the internal and external sphincters and the lining of the anal canal and do not form collaterals with the other rectal arteries. The middle sacral artery arises just proximal to the aortic bifurcation and provides very little blood supply to the rectum.

Venous Drainage
The venous drainage of the rectum parallels the arterial supply and empties into both the portal and the systemic (caval) systems. The upper and middle rectum are drained by the superior rectal vein, which enters the portal system via the inferior mesenteric vein (see Fig. 26-6 B). The lower rectum and upper anal canal are drained by the middle rectal veins, which empty into the internal iliac veins and then into the caval system. The inferior rectal veins drain the lower anal canal and empty into the pudendal veins, which drain into the caval system via the internal iliac veins. Low rectal tumors can thus metastasize through venous channels into both the portal and systemic venous systems. There are three submucosal internal hemorrhoidal complexes located above the dentate line (see Fig. 26-3). The left lateral, right posterolateral, and right anterolateral internal hemorrhoidal veins drain into the superior rectal vein. Below the dentate line the external hemorrhoidal veins drain into the pudendal veins. There is communication between the internal and external plexi.

Lymphatic Drainage
The rectal lymphatic flow is segmental and circumferential and follows the same distribution as the arterial blood supply (Fig. 26-7). Lymph from the upper and middle rectum drains into the inferior mesenteric nodes. The lower rectum is drained primarily by lymphatics that follow the superior rectal artery and enter the inferior mesenteric nodes. Lymph from the lower

rectum also can flow laterally along the middle and inferior rectal arteries, posteriorly along the middle sacral artery, or anteriorly through channels in the rectovesical or rectovaginal septum. These channels drain to the iliac nodes and subsequently to periaortic lymph nodes. Lymphatics from the anal canal above the dentate line drain via the superior rectal lymphatics to the inferior mesenteric lymph nodes or laterally to the internal iliac lymph nodes. Below the dentate line, the lymphatics drain primarily to the inguinal nodes but can drain to the inferior or superior rectal lymph nodes as well.

Nerve Supply
The innervation of the rectum is shared with the urogenital organs of the pelvis and consists of both sympathetic and parasympathetic nerves (Fig. 26-8). Sympathetic nerves from thoracolumnar segments unite below the inferior mesenteric artery to form the inferior mesenteric plexus. These purely sympathetic nerves descend to the superior hypogastric plexus located below the aortic bifurcation. They then bifurcate and descend in the pelvis as the hypogastric nerves. The lower rectum, bladder, and sexual organs in both men and women receive sympathetic innervation via the hypogastric nerve. Injury to the inferior mesenteric plexus can result during ligation of the inferior mesenteric artery at its origin. Parasympathetic fibers from the second, third, and fourth sacral roots (the nervi erigentes) unite with the hypogastric nerves anterior and lateral to the rectum forming the pelvic plexus, which runs laterally in the pelvis. The periprostatic plexus arises from the pelvic plexus. Mixed fibers from these plexi innervate the rectum, internal anal sphincter, prostate, bladder, and penis. The pudendal nerve (S2, S3, S4) mediates sensory stimuli from the penis and clitoris via the dorsal nerve. Both sympathetic and parasympathetic fibers are essential for penile erection. The parasympathetic fibers cause vasodilation and increased blood flow in the corpus cavernosum, resulting in an erection. The sympathetic fibers cause vasoconstriction of the penile veins and thus sustain the erection. Sympathetic nerves cause contraction of the ejaculatory ducts, seminal vesicles, and prostate and are necessary for ejaculation. Damage to the periprostatic plexus might occur during surgical dissection of the rectum. Injury to the pelvic autonomic nerves may result in bladder dysfunction, impotence, or both. The internal anal sphincter is innervated by both sympathetic and parasympathetic nerves, and both are inhibitory to the sphincter. The internal sphincter has a continuous tone that decreases as rectal pressure

increases. Once the rectum empties, the internal sphincter tone rises again. The external anal sphincter and levator ani muscles are innervated by the inferior rectal branch of the internal pudendal nerve (S2, S3, S4) and the perineal branch of the fourth sacral nerve. Any distention of the rectum results in relaxation of the internal sphincter. The external sphincter can be contracted voluntarily and kept in that state for approximately 1 minute. Below the dentate line, cutaneous sensations of heat, cold, pain, and touch are conveyed by afferent fibers of the inferior rectal and perineal branches of the pudendal nerve. Above the dentate line, a poorly defined dull sensation, experienced when the mucosa is pinched or when internal hemorrhoids are ligated, is probably mediated by parasympathetic fibers. Resection of the sacrum with sacrifice of sacral nerves occasionally may be required for total resection of pelvic tumors. Sacrifice of the lower sacral nerves will lead to saddle anesthesia and possible motor weakness in the lower extremities. Preservation of at least one of the third sacral nerves is required to maintain acceptable anal continence. Near-normal continence will be maintained if the upper three sacral roots on one side are preserved along with the upper two sacral roots on the contralateral side. If all the sacral roots are destroyed unilaterally but the contralateral nerves are preserved, the patient should maintain continence. If both S3 roots are destroyed, the patient will be incontinent. The upper half of S1 is needed for stability of the spine and pelvis.

Normal Function of Anorectum

The rectum functions mostly as a storage capacitance vessel. The rectum has very little peristaltic function of its own and relies on external pressure to empty. The outer longitudinal muscle is thick and has some contractility but has lost the organization of the teniae found on the colon. The rectum has a normal manometric resting pressure of approximately 10 mmHg, mostly due to intraperitoneal pressure and resting muscle tone. Conditions such as Crohn's disease or radiation injury cause the rectum to lose its natural compliance. This loss of compliance and capacitance is occasionally incapacitating to the patient. The normal rectum can hold 650 to 1200 mL of liquid. A rectum that holds more than 1500 mL can be classified as a megarectum. The normal daily volume of stool eliminated by the rectum ranges from 250 to 750 mL of formed feces. The anal sphincter mechanism is the other component of defecation and continence. Its anatomy and innervation have been described previously

(see Fig. 26-5). The external sphincter fibers are responsible for 20 percent of the resting pressure and 100 percent of generated squeeze pressure. The internal sphincter provides 80 percent of anal resting pressure. Both the internal and external sphincter muscles are contracted at rest. Defecation and continence are coordinated mechanisms. Continence can be described as controlled elimination of the rectal contents at a socially acceptable time and place. The coordination of rectal emptying and sphincter contraction and relaxation is very complex, and there are numerous abnormalities that occur. Defecation can be divided into four components. The first is movement of feces into the rectal vault or capacitance organ. A mass peristaltic wave in the proximal colon and sigmoid colon occurs two or three times per day to pass solid substance into the rectum. The gastrocolic reflex is a well-known phenomenon that results in colonic mass peristaltic movement after distention of the stomach, probably hormonally mediated. The second component of defecation is the rectal-anal inhibitory reflex or sampling reflex. Distention of the rectum results in involuntary relaxation of the internal anal sphincter and allows sensation of the rectal contents at the transitional zone. The sampling reflex has been shown by ambulatory manometry to occur frequently throughout the day and night. The third component of defecation is voluntary relaxation of the external sphincter mechanism. Voluntary relaxation of the pelvic floor, puborectalis muscle, and external sphincter allows the rectal contents to be pushed farther into the anal canal and expelled. The relaxation of the sphincter mechanism is actually a failure to contract rather than an active relaxation, because the mechanism is paradoxically contracted when the rest of the individual is relaxed, yet continent (Fig. 26-21). The fourth component of defecation is the voluntary increase of intraabdominal pressure, using the diaphragm and abdominal wall muscles. This increase in pressure serves to propel the rectal contents through the anal canal and accomplish defecation. The passage of flatus also requires coordination of multiple factors. The sensation of gas at the transitional zone and in the anoderm informs the individual that gas is present to be eliminated. If the situation is such that full evacuation of the rectum is not possible but elimination of gas is desired, a voluntary contraction of the pelvic floor including the puborectalis and external sphincter muscles occurs to prevent loss of solid

rectal contents. With an increase in abdominal pressure and a coordinated relaxation of some of the external sphincter, selective passage of flatus may be accomplished. During defecation, the gaseous contents of the rectum will be expelled with the solid contents without discrimination. This mechanism of discrimination appears to be learned. Patients eventually can pass flatus selectively even after the rectum has been removed and replaced by a reservoir of ileum for diseases such as ulcerative colitis and familial adenomatous polyposis. Continence, or the control of rectal contents, requires an adequate rectal capacity and normal compliance. It may be difficult to retain rectal contents in conditions such as Crohn's disease, in which the rectum becomes a rigid tube rather than a soft distensible bag, even if the external and internal sphincter mechanisms work properly. Adequate sensation at the transitional cell zone is required to coordinate pelvic pressure and sphincter tone during the sampling reflex. The external sphincter is most responsible for the fine control of solid, liquid, and gas. The puborectalis muscle has been proposed as the mainstay of the sphincter mechanism and is probably responsible for the control of solid stool. The internal sphincter may be responsible for fine control of gas on the basis of the sampling reflex and constantly provides resting pressure to prevent release of flatus. The pudendal nerves provide both the sensory afferents of the anal canal and the motor efferents to the voluntary muscles of the anal canal.