Advertisement

Anatomy and Embryology

  • José Marcio Neves Jorge
  • Angelita Habr-Gama
Chapter

Abstract

Although much of our fundamental understanding of the anatomy of the colon, rectum, and anus comes from the efforts of researchers of the nineteenth and early twentieth centuries, comprehensive observations of this region had been made as early as 1543 by Andreas Vesalius through anatomic dissections.1 However, anatomy of this region, especially that of the rectum and anal canal, is so intrinsically related to its physiology that much can be appreciated only in the living. Thus, it is a region in which the surgeon has an advantage over the anatomist through in vivo dissection, physiologic investigation, and endoscopic examination. However, anatomy of the pelvis is also challenging to the surgeon: the pelvis is a narrow space, packed with intestinal, urologic, gynecologic, vascular, and neural structures, all confined within a rigid and deep osseous–muscular cage.

Keywords

Anal Sphincter Anal Canal External Anal Sphincter Internal Anal Sphincter Inferior Mesenteric Artery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Vesalii Bruxellensis Andreae, de Humani corporis fabrica. De Recti intestini musculis. 1st ed. 1543:228.Google Scholar
  2. 2.
    Church JM, Raudkivi PJ, Hill GL. The surgical anatomy of the rectum – a review with particular relevance to the hazards of rectal mobilisation. Int J Colorectal Dis. 1987;2:158–66.PubMedGoogle Scholar
  3. 3.
    Shafik A. A concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. Dis Colon Rectum. 1987;30:970–82.PubMedGoogle Scholar
  4. 4.
    Klosterhalfen B, Vogel P, Rixen H, Mitterman C. Topography of the inferior rectal artery. A possible cause of chronic, primary anal fissure. Dis Colon Rectum. 1989;32:43–52.PubMedGoogle Scholar
  5. 5.
    Stoss F. Investigations of the muscular architecture of the rectosigmoid junction in humans. Dis Colon Rectum. 1990;33:378–83.PubMedGoogle Scholar
  6. 6.
    Levi AC, Borghi F, Garavoglia M. Development of the anal canal muscles. Dis Colon Rectum. 1991;34:262–6.PubMedGoogle Scholar
  7. 7.
    Lunniss PJ, Phillips RKS. Anatomy and function of the anal longitudinal muscle. Br J Surg. 1992;79:882–4.PubMedGoogle Scholar
  8. 8.
    Tjandra JJ, Milsom JW, Stolfi VM, et al. Endoluminal ultrasound defines anatomy of the anal canal and pelvic floor. Dis Colon Rectum. 1992;35:465–70.PubMedGoogle Scholar
  9. 9.
    Dobson HD, Pearl RK, Orsay CP, et al. Virtual reality: new method of teaching anorectal and pelvic floor anatomy. Dis Colon Rectum. 2003;46:349–52.PubMedGoogle Scholar
  10. 10.
    Milligan ETC, Morgan CN. Surgical anatomy of the anal canal: with special reference to anorectal fistulae. Lancet. 1934;2:1150–6.Google Scholar
  11. 11.
    Goligher JC, Leacock AG, Brossy JJ. The surgical anatomy of the anal canal. Br J Surg. 1955;43:51–61.PubMedGoogle Scholar
  12. 12.
    Garavoglia M, Borghi F, Levi AC. Arrangement of the anal striated musculature. Dis Colon Rectum. 1993;36:10–5.PubMedGoogle Scholar
  13. 13.
    Nivatvongs S, Gordon PH. Surgical anatomy. In: Gordon PH, Nivatvongs S, editors. Principle and practice of surgery for the colon, rectum and anus. St. Louis, MO: Quality Medical Publishing; 1992. p. 3–37.Google Scholar
  14. 14.
    Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. II. Anatomy of the levator ani muscle with special reference to puborectalis. Invest Urol. 1975;12:175–82.Google Scholar
  15. 15.
    Oh C, Kark AE. Anatomy of the external anal sphincter. Br J Surg. 1972;59:717–23.PubMedGoogle Scholar
  16. 16.
    Bollard RC, Gardiner A, Lindow S, Phillips K, Duthie GS. Normal female anal sphincter: difficulties in interpretation explained. Dis Colon Rectum. 2002;45:171–5.PubMedGoogle Scholar
  17. 17.
    Fritsch H, Brenner E, Lienemann A, Ludwikowski B. Anal sphincter complex: reinterpreted morphology and its clinical relevance. Dis Colon Rectum. 2002;45:188–94.PubMedGoogle Scholar
  18. 18.
    Morren GL, Beets-Tan RGH, van Engelshoven JMA. Anatomy of the anal canal and perianal structures as defined by phased-array magnetic resonance imaging. Br J Surg. 2001;88:1506–12.PubMedGoogle Scholar
  19. 19.
    Williams AB, Bartram CI, Halligan S, Marshall MM, Nicholls RJ, Kmiot WA. Endosonographic anatomy of the normal anal compared with endocoil magnetic resonance imaging. Dis Colon Rectum. 2002;45:176–83.PubMedGoogle Scholar
  20. 20.
    Jorge JMN, Habr-Gama A. The value of sphincter asymmetry index in anal incontinence. Int J Colorectal Dis. 2000;15:303–10.PubMedGoogle Scholar
  21. 21.
    Swash M. Histopathology of pelvic floor muscles in pelvic floor disorders. In: Henry MM, Swash M, editors. Coloproctology and the pelvic floor. London: Butterworth-Heinemann; 1992. p. 173–83.Google Scholar
  22. 22.
    Courtney H. Anatomy of the pelvic diaphragm and anorectal musculature as related to sphincter preservation in anorectal surgery. Am J Surg. 1950;79:155–73.PubMedGoogle Scholar
  23. 23.
    Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. III. The longitudinal anal muscle: anatomy and role in sphincter mechanism. Invest Urol. 1976;13:271–7.PubMedGoogle Scholar
  24. 24.
    Lawson JON. Pelvic anatomy. II. Anal canal and associated sphincters. Ann R Coll Surg Engl. 1974;54:288–300.PubMedGoogle Scholar
  25. 25.
    Roux C. Contribution to the knowledge of the anal muscles in man. Arch Mikr Anat. 1881;19:721–3.Google Scholar
  26. 26.
    Haas PA, Fox TA. The importance of the perianal connective tissue in the surgical anatomy and function of the anus. Dis Colon Rectum. 1977;20:303–13.PubMedGoogle Scholar
  27. 27.
    Gordon PH. Anorectal anatomy and physiology. Gastroenterol Clin North Am. 2001;30:1–13.PubMedGoogle Scholar
  28. 28.
    Lilius HG. Investigation of human fetal anal ducts and intramuscular glands and a clinical study of 150 patients. Acta Chir Scand Suppl. 1968;383:1–88.Google Scholar
  29. 29.
    Chiari H. Über die Nalen Divertik Fel der Rectum-schleimhaut und Ihre Beziehung zu den anal fisteln. Wien Med Press. 1878;19:1482.Google Scholar
  30. 30.
    Parks AG. Pathogenesis and treatment of fistula-in-ano. BMJ. 1961;1:463–9.PubMedGoogle Scholar
  31. 31.
    Abel AL. The pecten band: pectenosis and pectenectomy. Lancet. 1932;1:714–8.Google Scholar
  32. 32.
    Goligher J. Surgery of the anus, rectum and colon. London: Bailliére Tindall; 1984. p. 1–47.Google Scholar
  33. 33.
    Abramson DJ. The valves of Houston in adults. Am J Surg. 1978;136:334–6.PubMedGoogle Scholar
  34. 34.
    Cawthorn SJ, Parums DV, Gibbs NM, et al. Extent of mesorectal spread and involvement of lateral resection margin as prognostic factors after surgery for rectal cancer. Lancet. 1990;335:1055–9.PubMedGoogle Scholar
  35. 35.
    Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery – the clue to pelvic recurrence? Br J Surg. 1982;69:613–6.PubMedGoogle Scholar
  36. 36.
    Boxall TA, Smart PJG, Griffiths JD. The blood-supply of the distal segment of the rectum in anterior resection. Br J Surg. 1963;50:399–404.PubMedGoogle Scholar
  37. 37.
    Nano M, Dal Corso HM, Lanfranco G, Ferronato M, Hornung JP. Contribution to the surgical anatomy of the ligaments of the rectum. Dis Colon Rectum. 2000;43:1592–8.PubMedGoogle Scholar
  38. 38.
    Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet. 1986;1:996–8.Google Scholar
  39. 39.
    Jorge JMN, Habr-Gama A, Souza Jr AS, Kiss DR, Nahas P, Pinotti HW. Rectal surgery complicated by massive presacral hemorrhage. Arq Bras Circ Dig. 1990;5:92–5.Google Scholar
  40. 40.
    Wang Q, Shi W, Zhao Y, Zhou W, He Z. New concepts in severe presacral hemorrhage during proctectomy. Arch Surg. 1985;120:1013–20.PubMedGoogle Scholar
  41. 41.
    Zama N, Fazio VW, Jagelman DG, Lavery IC, Weakley FL, Church JM. Efficacy of pelvic packing in maintaining hemostasis after rectal excision for cancer. Dis Colon Rectum. 1988;31:923–8.PubMedGoogle Scholar
  42. 42.
    Crapp AR, Cuthbertson AM. William Waldeyer and the rectosacral fascia. Surg Gynecol Obstet. 1974;138:252–6.PubMedGoogle Scholar
  43. 43.
    Tobin CE, Benjamin JA. Anatomical and surgical restudy of Denonvilliers’ fascia. Surg Gynecol Obstet. 1945;80:373–88.Google Scholar
  44. 44.
    Lindsey I, Guy RJ, Warren BF, Mortensen NJ. Anatomy of Denonvilliers’ fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br J Surg. 2000;87:1288–99.PubMedGoogle Scholar
  45. 45.
    Michels NA, Siddharth P, Kornblith PL, Park WW. The variant blood supply to the small and large intestines: its importance in regional resections. A new anatomic study based on four hundred dissections with a complete review of the literature. J Int Coll Surg. 1963;39:127–70.Google Scholar
  46. 46.
    Ayoub SF. Arterial supply of the human rectum. Acta Anat. 1978;100:317–27.PubMedGoogle Scholar
  47. 47.
    Didio LJA, Diaz-Franco C, Schemainda R, Bezerra AJC. Morphology of the middle rectal arteries: a study of 30 cadaveric dissections. Surg Radiol Anat. 1986;8:229–36.PubMedGoogle Scholar
  48. 48.
    Bernstein WC. What are hemorrhoids and what is their relationship to the portal venous system? Dis Colon Rectum. 1983;26:829–34.PubMedGoogle Scholar
  49. 49.
    Miscusi G, Masoni L, Dell’Anna A, Montori A. Normal lymphatic drainage of the rectum and the anal canal revealed by lymphoscintigraphy. Coloproctology. 1987;9:171–4.Google Scholar
  50. 50.
    Block IR, Enquist IF. Studies pertaining to local spread of carcinoma of the rectum in females. Surg Gynecol Obstet. 1961;112:41–6.Google Scholar
  51. 51.
    Gerstenberg TC, Nielsen ML, Clausen S, Blaabgerg J, Lindenberg J. Bladder function after abdominoperineal resection of the rectum for anorectal cancer. Am J Surg. 1980;91:81–6.Google Scholar
  52. 52.
    Orkin BA. Rectal carcinoma: treatment. In: Beck DE, Wexner SD, editors. Fundamentals of anorectal surgery. New York: McGraw-Hill; 1992. p. 260–369.Google Scholar
  53. 53.
    Balslev I, Harling H. Sexual dysfunction following operation for carcinoma of the rectum. Dis Colon Rectum. 1983;26:785.PubMedGoogle Scholar
  54. 54.
    Danzi M, Ferulano GP, Abate S, Califano G. Male sexual function after abdominoperineal resection for rectal cancer. Dis Colon Rectum. 1983;26:665–8.PubMedGoogle Scholar
  55. 55.
    Weinstein M, Roberts M. Sexual potency following surgery for rectal carcinoma. A follow-up of 44 patients. Ann Surg. 1977;185:295–300.PubMedGoogle Scholar
  56. 56.
    Bauer JJ, Gerlent IM, Salky B, Kreel I. Sexual dysfunction following proctectomy for benign disease of the colon and rectum. Ann Surg. 1983;197:363–7.PubMedGoogle Scholar
  57. 57.
    Walsh PC, Schlegel PN. Radical pelvic surgery with preservation of sexual function. Ann Surg. 1988;208:391–400.PubMedGoogle Scholar
  58. 58.
    Lee ECG, Dowling BL. Perimuscular excision of the rectum for Crohn’s disease and ulcerative colitis. A conservative technique. Br J Surg. 1972;59:29–32.PubMedGoogle Scholar
  59. 59.
    Metcalf AM, Dozois RR, Kelly KA. Sexual function in women after proctocolectomy. Ann Surg. 1986;204:624–7.PubMedGoogle Scholar
  60. 60.
    Duthie HL, Gairns FW. Sensory nerve endings and sensation in the anal region in man. Br J Surg. 1960;47:585–95.PubMedGoogle Scholar
  61. 61.
    Kaiser AM, Ortega AE. Anorectal anatomy. Surg Clin North Am. 2002;82:1125–38.PubMedGoogle Scholar
  62. 62.
    Wendell-Smith CP. Studies on the morphology of the pelvic floor [Ph.D. thesis]. University of London; 1967.Google Scholar
  63. 63.
    Paramore RH. The Hunterian lectures on the evolution of the pelvic floor in non-mammalian vertebrates and pronograde mammals. Lancet. 1910;1(1393–1399):1459–67.Google Scholar
  64. 64.
    Percy JP, Swash M, Neill ME, Parks AG. Electrophysiological study of motor nerve supply of pelvic floor. Lancet. 1981;1:16–7.PubMedGoogle Scholar
  65. 65.
    Russell KP. Anatomy of the pelvic floor, rectum and anal canal. In: Smith LE, editor. Practical Guide to anorectal testing. New York: Igaku-Shoin; 1991. p. 744–7.Google Scholar
  66. 66.
    Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. Proc R Soc Med. 1966;59:477–82.PubMedGoogle Scholar
  67. 67.
    Bannister JJ, Gibbons C, Read NW. Preservation of faecal continence during rises in intra-abdominal pressure: is there a role for the flap valve? Gut. 1987;28:1242–5.PubMedGoogle Scholar
  68. 68.
    Bartolo DCC, Roe AM, Locke-Edmunds JC, Virjee J, Mortensen NJ. Flap-valve theory of anorectal continence. Br J Surg. 1986;73:1012–4.PubMedGoogle Scholar
  69. 69.
    Fraser ID, Condon RE, Schulte WJ, Decosse JJ, Cowles VE. Longitudinal muscle of muscularis externa in human and non-human primate colon. Arch Surg. 1981;116:61–3.PubMedGoogle Scholar
  70. 70.
    Guyton AC, editor. Textbook of medical physiology. Philadelphia: WB Saunders; 1986. p. 754–69.Google Scholar
  71. 71.
    Kumar D, Phillips SF. The contribution of external ligamentous attachments to function of the ileocecal junction. Dis Colon Rectum. 1987;30:410–6.PubMedGoogle Scholar
  72. 72.
    Wakeley CPG. The position of the vermiform appendix as ascertained by an analysis of 10, 000 cases. J Anat. 1983;67:277–83.Google Scholar
  73. 73.
    Skandalakis JE, Gray SW, Ricketts R. The colon and rectum. In: Skandalakis JE, Gray SW, editors. Embryology for surgeons. The embryological basis for the treatment of congenital anomalies. Baltimore: Williams & Wilkins; 1994. p. 242–81.Google Scholar
  74. 74.
    O’Beirne J, editor. New views of the process of defecation and their application to the pathology and treatment of diseases of the stomach, bowels and other organs. Dublin: Hodges and Smith; 1833.Google Scholar
  75. 75.
    Hyrtl J. Handbuch der topographischen anatomie und ihrer praktisch medicinisch-chirurgischen anwendungen. II. Band, 4. Aufl. Wien: Braumüller; 1860.Google Scholar
  76. 76.
    Mayo WJ. A study of the rectosigmoid. Surg Gynecol Obstet. 1917;25:616–21.Google Scholar
  77. 77.
    Cantlie J. The sigmoid flexure in health and disease. J Trop Med Hyg. 1915;18:1–7.Google Scholar
  78. 78.
    Otis WJ. Some observations on the structure of the rectum. J Anat Physiol. 1898;32:59–63.Google Scholar
  79. 79.
    Balli R. The sphincters of the colon. Radiology. 1939;33:372–6.Google Scholar
  80. 80.
    Ewing MR. The significance of the level of the peritoneal reflection in the surgery of rectal cancer. Br J Surg. 1952;39:495–500.PubMedGoogle Scholar
  81. 81.
    Stelzner F. Die Verschlubsysteme am Magen-Darm-Kanal und ihre chirurgische Bedeutung. Acta Chir Austriaca. 1987;19:565–9.Google Scholar
  82. 82.
    Sonneland J, Anson BJ, Beaton LE. Surgical anatomy of the arterial supply to the colon from the superior mesenteric artery based upon a study of 600 specimens. Surg Gynecol Obstet. 1958;106:385–98.PubMedGoogle Scholar
  83. 83.
    Steward JA, Rankin FW. Blood supply of the large intestine. Its surgical considerations. Arch Surg. 1933;26:843–91.Google Scholar
  84. 84.
    Griffiths JD. Surgical anatomy of the blood supply of the distal colon. Ann R Coll Surg Engl. 1956;19:241–56.PubMedGoogle Scholar
  85. 85.
    Haller A. The large intestine. In: Cullen W, editor. First Lines of physiology. A reprint of the 1786 edition (Sources of Science 32). New York: Johnson; 1966. p. 139–40.Google Scholar
  86. 86.
    Drummond H. Some points relating to the surgical anatomy of the arterial supply of the large intestine. Proc R Soc Med Proctol. 1913;7:185–93.Google Scholar
  87. 87.
    Drummond H. The arterial supply of the rectum and pelvic colon. Br J Surg. 1914;1:677–85.Google Scholar
  88. 88.
    Meyers CB. Griffiths’ point: critical anastomosis at the splenic flexure. Am J Roentgenol. 1976;126:77.Google Scholar
  89. 89.
    Landreneau RJ, Fry WJ. The right colon as a target organ of non-occlusive mesenteric ischemia. Arch Surg. 1990;125:591–4.PubMedGoogle Scholar
  90. 90.
    Longo WE, Ballantyne GH, Gursberg RJ. Ischemic colitis: patterns and prognosis. Dis Colon Rectum. 1992;35:726–30.PubMedGoogle Scholar
  91. 91.
    Sudeck P. Über die Gefassversorgung des Mastdarmes in Hinsicht auf die Operative Gangran. Münch Med Wochenschr. 1907;54:1314.Google Scholar
  92. 92.
    Griffiths JD. Extramural and intramural blood supply of the colon. BMJ. 1961;1:322–6.Google Scholar
  93. 93.
    Lindstrom BL. The value of the collateral circulation from the inferior mesenteric artery in obliteration of the lower abdominal aorta. Acta Chir Scand. 1950;1:677–85.Google Scholar
  94. 94.
    Fisher DF, Fry WI. Collateral mesenteric circulation. Surg Gynecol Obstet. 1987;164:487–92.PubMedGoogle Scholar
  95. 95.
    Moskowitz M, Zimmerman H, Felson H. The meandering mesenteric artery of the colon. Am J Roentgenol. 1964;92:1088–99.Google Scholar
  96. 96.
    Jameson JK, Dobson JF. The lymphatics of the colon. Proc R Soc Med. 1909;2:149–72.Google Scholar
  97. 97.
    Nobles VP. The development of the human anal canal. J Anat. 1984;138:575.Google Scholar
  98. 98.
    Duhamel B. From the mermaid to anal imperforation: the syndrome of caudal regression. Arch Dis Child. 1961;36:152–5.PubMedGoogle Scholar
  99. 99.
    Moore TC, Lawrence EA. Congenital malformations of rectum and anus. II. Associated anomalies encountered in a series of 120 cases. Surg Gynecol Obstet. 1952;95:281.PubMedGoogle Scholar
  100. 100.
    Anderson RC, Reed SC. The likelihood of congenital ­malformations. J Lancet. 1954;74:175–9.PubMedGoogle Scholar
  101. 101.
    Gough MH. Congenital abnormalities of the anus and rectum. Arch Dis Child. 1961;36:146–51.PubMedGoogle Scholar
  102. 102.
    Santulli TV, Schullinger JN, Amoury RA. Malformations of the anus and rectum. Surg Clin North Am. 1965;45:1253–71.PubMedGoogle Scholar
  103. 103.
    Brown SS, Schoen AH. Congenital anorectal stricture. J Pediatr. 1950;36:746–50.PubMedGoogle Scholar
  104. 104.
    Romolo JL. Congenital lesions: intussusception and volvulus. In: Zuidema GD, editor. Shackelford’s surgery of the alimentary tract. Philadelphia: WB Saunders; 1991. p. 45–51.Google Scholar
  105. 105.
    McPherson AG, Trapnell JE, Airth GR. Duplication of the colon. Br J Surg. 1969;56:138.PubMedGoogle Scholar
  106. 106.
    Benson CD. Surgical implications of Meckel’s diverticulum. In: Ravitch MM, Welch KJ, Benson CD, et al., editors. Pediatric surgery. 3rd ed. Chicago: Year Book; 1979. p. 955.Google Scholar
  107. 107.
    Louw JH. Investigations into the etiology and congenital atresia of the colon. Dis Colon Rectum. 1964;7:471.PubMedGoogle Scholar
  108. 108.
    Hirschsprung H. Fälle von angeborener Pylorusstenose beobachtet bei Säulingen. Jahrb Kinderh. 1888;27:61–9.Google Scholar
  109. 109.
    Finney JMT. Congenital idiopathic dilatation of the colon. Surg Gynecol Obstet. 1908:624–643.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • José Marcio Neves Jorge
    • 1
  • Angelita Habr-Gama
    • 2
    • 3
  1. 1.Department of Gastroenterology, Colorectal DivisionUniversity of Sao PaoloSao PaoloBrazil
  2. 2.University of São PauloSao PaoloBrazil
  3. 3.University of São PauloSao PaoloBrazil

Personalised recommendations