51 CHAPTER
Colon and Rectum
Najjia N. Mahmoud, Joshua I.S. Bleier, Cary B. Aarons,
E. Carter Paulson, Skandan Shanmugan, Robert D. Fry
OUTLINE
Embryology of the Colon and Rectum Diverticular Disease
Anatomy of the Colon, Rectum, and Colonic Volvulus
Pelvic Floor Large Bowel Obstruction and
Physiology of the Colon Pseudo-obstruction
Preoperative Workup and Stoma Inflammatory Bowel Disease
Planning Infectious Colitis
EMBRYOLOGY OF THE COLON AND RECTUM
No comprehensive discussion of colorectal anatomy is complete
without a thorough understanding of the genesis of the gastroin-
testinal (GI) tract. Knowledge of the developmental anatomy
of the foregut, midgut, and hindgut establishes a context in
which to consider mature structural and functional anatomic
relationships.
The endodermal roof of the yolk sac gives rise to the primitive
gut tube. At the beginning of the third week of development, the
gut tube is divided into three regions; the midgut, which opens
ventrally, is positioned between the foregut in the head fold and
the hindgut in the tail fold. Development progresses through the
stages of physiologic herniation, return to the abdomen, and
fixation. The acquisition of length and the formation of dedicated
blood and lymphatic supplies take place during this time
(Fig. 51-1).
Foregut-derived structures end at the second portion of the
duodenum and rely on the celiac artery for blood supply. The
midgut, extending from the duodenal ampulla to the distal trans-
verse colon, is based on the superior mesenteric artery (SMA).
The distal third of the transverse colon, descending colon, and
rectum evolve from the hindgut fold and are supplied by the
inferior mesenteric artery (IMA). Venous and lymphatic channels
mirror their arterial counterparts and follow the same embryo-
logic divisions. At the dentate line, endoderm-derived tissues fuse
with the ectoderm-derived proctodeum, or ingrowth from the
anal pit.
Distal rectal development is complex. The cloaca is a special-
ized area of the primitive distal rectum composed of endoderm-
and ectoderm-derived tissues. This area is incorporated into the
anal transition zone, which surrounds the dentate line in the
adult. The cloaca exists in a continuum with the hindgut, but at
approximately the sixth week, it begins to divide and to differenti-
ate into anterior urogenital and posterior anal and sphincter ele-
ments. Simultaneously, the urogenital and GI tracts are separated
by caudal migration of the urogenital septum. During the tenth
1312
Ischemic Colitis
Neoplasia
Pelvic Floor Disorders and
Constipation
week of development, the external anal sphincter is formed from
the posterior cloaca as the descent of the urogenital septum
becomes complete. The internal anal sphincter is formed by the
twelfth week from enlarged circular muscle layers of the rectum.
ANATOMY OF THE COLON, RECTUM,
AND PELVIC FLOOR
The colon and rectum constitute a tube of variable diameter
approximately 150 cm in length. The terminal ileum empties into
the cecum through a thickened, nipple-shaped invagination, the
ileocecal valve. The cecum is a capacious sac-like segment of the
proximal colon, with an average diameter of 7.5 cm and length
of 10 cm. Although it is distensible, acute dilation of the cecum
to a diameter of more than 12 cm, which can be measured by a
plain abdominal radiograph, can result in ischemic necrosis and
perforation of the bowel wall. Surgical intervention may be
required when this degree of cecal distention is caused by obstruc-
tion or pseudo-obstruction (Fig. 51-2).
The appendix extends from the cecum approximately 3 cm
below the ileocecal valve as a blind-ending elongated tube, 8 to
10 cm in length. The proximal appendix is fairly constant in loca-
tion, whereas the end can be located in a wide variety of positions
relative to the cecum and terminal ileum. Most commonly, it is
retrocecal (65%), followed by pelvic (31%), subcecal (2.3%),
preileal (1.0%), and retroileal (0.4%). Clinically, the appendix is
found at the convergence of the taeniae coli. Another clinical aid
useful for detecting the location of the appendix through a small
abdominal incision is the identification of the fold of Treves, the
only antimesenteric epiploic appendage normally found on the
small intestine, marking the junction of the ileum and cecum.
The ascending colon, approximately 15 cm in length, runs
upward toward the liver on the right side; like the descending
colon, the posterior surface is fixed against the retroperitoneum,
whereas the lateral and anterior surfaces are true intraperitoneal
structures. The white line of Toldt represents the fusion of the
 CHAPTER 51 Colon and Rectum 1313

Amniotic
cavity Proctodeum

Body stalk

M H
F

A Allantois
B C D

E F G
FIGURE 51-1 At the third week of development, the primitive tube can be divided into three regions
(A): the foregut (F) in the head fold, the hindgut (H) with its ventral allantoic outgrowth in the smaller tail
fold, and the midgut (M) between these two portions. Stages of development of the midgut are physiologic
herniation (B), return to the abdomen (C), and fixation (D). At the sixth week, the urogenital septum migrates
caudally (E) and separates the intestinal and urogenital tracts (F, G). (From Corman ML, editor: Colon and
rectal surgery, ed 4, Philadelphia, 1998, Lippincott-Raven, p 2.)

mesentery with the posterior peritoneum. This subtle peritoneal
landmark serves as a guide for the surgeon for mobilizing the
colon and mesentery from the retroperitoneum.
The transverse colon is approximately 45 cm in length.
Hanging between fixed positions at the hepatic and splenic flex-
ures, it is completely invested in visceral peritoneum. The neph-
rocolic ligament secures the hepatic flexure and directly overlies
the right kidney, duodenum, and porta hepatis. The phrenocolic
ligament lies ventral to the spleen and fixes the splenic flexure in
the left upper quadrant. The angle of the splenic flexure is higher,
more acute, and more deeply situated than that of the hepatic
flexure. The splenic flexure is typically approached by dissecting
the descending colon along the line of Toldt from below and then
entering the lesser sac by reflecting the omentum from the trans-
verse colon. This maneuver allows mobilization of the flexure to
be achieved, with minimal traction required for exposure. Attached
to the superior aspect of the transverse colon is the greater
omentum, a fused double layer of visceral and parietal peritoneum
(four total layers) that contains variable amounts of stored fat.
Clinically, it is useful in preventing adhesions between surgical
abdominal wounds and underlying bowel and is often used
to cover intraperitoneal contents as incisions are closed. The
omentum can be mobilized and placed between the rectum and
vagina after repair of a high rectovaginal fistula or used to fill the
pelvic and perineal space left after excision of the rectum. The
living tissue of the greater omentum makes a good patch in dif-
ficult situations, such as treatment of a perforated duodenum,
when closure of inflamed and friable tissues is impossible or
ill-advised.
The descending colon lies ventral to the left kidney and extends
downward from the splenic flexure for approximately 25 cm. It is
smaller in diameter than the ascending colon. At the level of the
pelvic brim, there is a transition between the relatively thin-
walled, fixed, descending colon and the thicker, mobile sigmoid
colon. The sigmoid colon varies in length from 15 to 50 cm
(average, 38 cm) and is very mobile. It is a small-diameter, mus-
cular tube on a long floppy mesentery that often forms an omega
loop in the pelvis. The mesosigmoid is frequently attached to the
left pelvic sidewall, producing a small recess in the mesentery
known as the intersigmoid fossa. This mesenteric fold is a surgical
landmark for the underlying left ureter.
The rectum, along with the sigmoid colon, serves as a fecal
reservoir. There is some controversy about the definition of the
proximal and distal extent of the rectum. Some consider the
1314 SECTION X Abdomen
FIGURE 51-2 Anatomy of the colon and rectum, coronal view. The
diameter of the right colon is larger than the diameter of the left side.
Note the higher location of the splenic flexure compared with the
hepatic flexure and the extraperitoneal location of the rectum.
rectosigmoid junction to be at the level of the sacral promontory;
others consider it to be the point at which the taeniae converge.
Anatomists consider the dentate line the distal extent of the
rectum, whereas surgeons typically view this union of columnar
and squamous epithelium as existing within the anal canal and
consider the end of the rectum to be the proximal border of the
anal sphincter complex. The rectum is 12 to 15 cm in length and
lacks taeniae coli or epiploic appendices. It occupies the curve of
the sacrum in the true pelvis, and the posterior surface is almost
completely extraperitoneal in that it is adherent to presacral soft
tissues and thus is outside the peritoneal cavity. The anterior
surface of the proximal third of the rectum is covered by visceral
peritoneum. The peritoneal reflection is 7 to 9 cm from the anal
verge in men and 5 to 7.5 cm in women. This anterior peritoneal-
ized space is called the pouch of Douglas, pelvic cul-de-sac, or
rectouterine pouch and may serve as the site of so-called drop
metastases from visceral tumors. These peritoneal metastases can
form a mass in the cul-de-sac (called Blumer’s shelf ) that can be
detected by a digital rectal examination.
The rectum possesses three involutions or curves known as the
valves of Houston. The middle valve folds to the left, and the
proximal and distal valves fold to the right. These valves are more
properly called folds because they have no specific function as
impediments to flow. They are lost after full surgical mobilization
of the rectum, a maneuver that may provide approximately 5 cm
of additional length to the rectum, greatly facilitating the sur-
geon’s ability to fashion an anastomosis deep in the pelvis.
The posterior aspect of the rectum is invested with a thick,
closely applied mesorectum. A thin layer of investing fascia (fascia
propria) coats the mesorectum and represents a distinct layer from
the presacral fascia against which it lies. During proctectomy for
rectal cancer, mobilization and dissection of the rectum proceed
between the presacral fascia and fascia propria. Total mesorectal
excision is a well-described oncologic maneuver that makes good
use of the tissue planes investing the rectum to achieve a relatively
bloodless rectal and mesorectal dissection. The lymphatics are
contained within the mesorectum, and total mesorectal excision
adheres to the basic surgical oncologic principle of removal of the
cancer in continuity with its blood and lymphatic supplies. Resec-
tion of the rectum by this technique, and based on a thorough
understanding of anatomy, has been shown to reduce markedly
the incidence of subsequent local recurrence of rectal cancer.
Pararectal Fascia
The endopelvic fascia is a thick layer of parietal peritoneum that
lines the walls and floor of the pelvis. The portion that is closely
applied to the periosteum of the anterior sacrum is the presacral
fascia. The fascia propria of the rectum is a thin condensation of
the endopelvic fascia that forms an envelope around the mesorec-
tum and continues distally to help form the lateral rectal stalks.
The lateral rectal stalks or ligaments are actually anterolateral
structures containing the middle rectal artery. The stalks reside
close to the mixed autonomic nerves, containing sympathic and
parasympathetic nerves, and division of these structures close to
the pelvic sidewall may injure these nerves, resulting in impotence
and bladder dysfunction (Fig. 51-3).
The rectosacral fascia, or Waldeyer fascia, is a thick condensa-
tion of endopelvic fascia connecting the presacral fascia to the
fascia propria at the level of S4 that extends to the anorectal ring.
Waldeyer fascia is an important surgical landmark, and its division
during dissection from an abdominal approach provides entry to
the deep retrorectal pelvis. Dissection between the fascia propria
and presacral fascia follows the principles of surgical oncology and
minimizes the risk for vascular or neural injuries. Disruption of
the presacral fascia may lead to injury of the basivertebral venous
plexus, resulting in massive hemorrhage. Disruption of the fascia
propria during an operation for rectal cancer may significantly
increase the incidence of subsequent recurrence of cancer in the
pelvis if mesorectum is then left behind.
Pelvic Floor
The muscles of the pelvic floor, like those of the anal sphincter
mechanism, arise from the primitive cloaca. The pelvic floor, or
diaphragm, consists of the pubococcygeus, iliococcygeus, and
puborectalis, a group of muscles that together form the levator
ani. The pelvic diaphragm resides between the sacrum, obturator
fascia, ischial spines, and pubis. It forms a strong floor that sup-
ports the pelvic organs and, with the external anal sphincter, regu-
lates defecation. The levator hiatus is an opening between the
decussating fibers of the pubococcygeus that allows egress of the
anal canal, urethra, and dorsal vein in men and the anal canal,
urethra, and vagina in women. The puborectalis is a strong,
U-shaped sling of striated muscle coursing around the rectum just
above the level of the anal sphincters. Relaxation of the puborec-
talis straightens the anorectal angle and permits descent of feces;
contraction produces the opposite effect. The puborectalis is in a
state of continual contraction, a factor vital to the maintenance
of continence. Puborectalis dysfunction is an important cause of
defecation disorders. The pubococcygeus and iliococcygeus most
likely participate in continence by applying lateral pressure to
narrow the levator hiatus (Figs. 51-4 and 51-5).
Arterial Supply and Venous and Lymphatic Drainage
Knowledge of the embryologic development of the intestinal tract
provides an excellent foundation for understanding the anatomic
blood supply. The foregut is supplied by the celiac artery, the
 CHAPTER 51 Colon and Rectum 1315

Peritoneum

Investing fascia of rectum

Presacral fascia

Rectosacral fascia

Denonvilliers' fascia

FIGURE 51-3 Endopelvic fascia. (From Gordon PH, Nivatvongs S, editors: Principles and practice of surgery
for the colon, rectum and anus, ed 2, St. Louis, 1999, Quality Medical Publishing, p 10.)

Dorsal vein of penis

Urethra
Anorectal junction
Levator hiatus
Pubococcygeus

Obturator internus

Iliococcygeus

Coccygeus
Anococcygeal raphe

Piriformis

FIGURE 51-4 Levator muscles. (From Gordon PH, Nivatvongs S, editors: Principles and practice of surgery
for the colon, rectum and anus, ed 2, St. Louis, 1999, Quality Medical Publishing, p 18.)
1316 SECTION X Abdomen
Puborectalis
Hiatal ligament
FIGURE 51-5 Hiatal ligament. (From Gordon PH, Nivatvongs S, editors: Principles and practice of surgery
for the colon, rectum and anus, ed 2, St. Louis, 1999, Quality Medical Publishing, p 18.)
midgut by the SMA, and the hindgut by the IMA (Figs. 51-6 and
51-7). Anatomic redundancy confers survival advantages, and in
the intestinal tract, this feature is provided by extensive commu-
nication between the major arteries and collateral blood supply
(Fig. 51-8). The territory of the SMA ends at the distal portion
of the transverse colon, and that of the IMA begins in the region
of the splenic flexure. A large collateral vessel, the marginal artery,
connects these two circulations and forms a continuous arcade
along the mesenteric border of the colon. Vasa recta from this
artery branch off at short intervals and supply the bowel wall
directly (Fig. 51-9). The SMA supplies the entire small bowel,
giving off 12 to 20 jejunal and ileal branches to the left and up
to three main colonic branches to the right. The ileocolic artery
is the most constant of these branches; it supplies the terminal
ileum, cecum, and appendix. The right colic artery is absent in
2% to 18% of specimens; when present, it may arise directly from
the SMA or as a branch of the ileocolic or middle colic artery. It
supplies the ascending colon and hepatic flexure and communi-
cates with the middle colic artery through collateral marginal
artery arcades. The middle colic artery is a proximal branch of the
SMA. It generally divides into right and left branches, which
supply the proximal and distal transverse colon, respectively. Ana-
tomic variations of the middle colic artery include complete
absence in 4% to 20% and the presence of an accessory middle
colic artery in 10% of specimens. The left branch of the middle
colic artery may supply territory also supplied by the left colic
artery through the collateral channel of the marginal artery. This
collateral circulation in the area of the splenic flexure is the most
inconsistent of the entire colon and has been referred to as a
watershed area, vulnerable to ischemia in the presence of hypo-
tension. In some studies, up to 50% of specimens were found to
lack clearly identified arteries in a small segment of colon at the
confluence of the blood supplies of the midgut and hindgut.
These individuals rely on adjacent vasa recta in this area for
Pubococcygeus
Anorectal junction
arterial supply to the bowel wall. In practice, surgeons avoid
making anastomoses in the region of the splenic flexure, fearing
that the blood supply will not be sufficient to permit healing of
the anastomosis, a situation that could lead to anastomotic leak
and sepsis.
The IMA originates from the aorta at the level of L2 to L3,
approximately 3 cm above the aortic bifurcation. The left colic
artery is the most proximal branch, supplying the distal transverse
colon, splenic flexure, and descending colon. Two to six sigmoid
branches collateralize with the left colic artery and form arcades
that supply the sigmoid colon and contribute to the marginal
artery.
The arc of Riolan is a collateral artery, first described by Jean
Riolan (1580-1657), that directly connects the proximal SMA
with the proximal IMA and may serve as a vital conduit when
one or the other of these arteries is occluded. It is also known as
the meandering mesenteric artery and is highly variable in size.
Flow can be forward (IMA stenosis) or retrograde (SMA stenosis),
depending on the site of obstruction. Such obstruction results in
increased size and tortuosity of this meandering artery, which may
be detected by arteriography; the presence of a large arc of Riolan
thus suggests occlusion of one of the major mesenteric arteries
(Fig. 51-10).
The IMA terminates in the superior rectal (superior hemor-
rhoidal) artery, which courses behind the rectum in the mesorec-
tum, branching and then entering the rectal submucosa. Here,
the capillaries form a submucosal plexus in the distal rectum at
the level of the anal columns. The anal canal also receives arterial
blood from the middle rectal (hemorrhoidal) and inferior rectal
(hemorrhoidal) arteries. The middle rectal artery is a branch of
the internal iliac artery. It is variable in size and enters the rectum
anterolaterally, passing alongside and slightly anterior to the
lateral rectal stalks. It has been reported to be absent in 40% to
80% of specimens studied. The inferior rectal artery is a branch

Middle colic artery
Superior
mesenteric artery
Right colic artery
Ileocolic artery
Ileal branch
Anterior cecal branch
Median sacral artery
Posterior cecal branch
Appendicular artery
Internal iliac artery
Accessory middle rectal artery
Middle rectal artery
Inferior rectal artery
FIGURE 51-6 Arterial supply of the colon. (From Gordon PH, Nivatvongs S, editors: Principles and practice
of surgery for the colon, rectum and anus, ed 2, St. Louis, 1999, Quality Medical Publishing, p 23.)
of the pudendal artery, which itself is a more distal branch of the
internal iliac. From the obturator canal, it traverses the obturator
fascia, ischiorectal fossa, and external anal sphincter to reach the
anal canal. This vessel is encountered during the perineal dissec-
tion of an abdominoperineal resection.
The venous drainage of the colon and rectum mirrors the arte-
rial blood supply. Venous drainage from the right and proximal
transverse colon empties into the superior mesenteric vein, which
coalesces with the splenic vein to become the portal vein. The
distal transverse colon, descending colon, sigmoid, and most of
the rectum drain into the inferior mesenteric vein, which empties
into the splenic vein to the left of the aorta. The anal canal is
drained by the middle and inferior rectal veins into the internal
iliac vein and subsequently the inferior vena cava. The bidirec-
tional venous drainage of the anal canal accounts for differences
in patterns of metastasis from tumors arising in this region
(Fig. 51-11).
Lymphatic drainage also follows the arterial anatomy. The wall
of the large bowel is supplied with a rich network of lymphatic
capillaries that drain to extramural channels paralleling the arterial
supply. Lymphatics from the colon and proximal two thirds of the
CHAPTER 51 Colon and Rectum 1317
Ascending branch
of left colic artery
Marginal artery
Inferior
mesenteric artery
Left colic
artery
Sigmoid arteries
Left common iliac
artery
Bifurcation of superior
rectal artery
rectum ultimately drain into the para-aortic nodal chain, which
empties into the cisterna chyli. Lymphatics draining the distal
rectum and anal canal may drain to the para-aortic nodes or later-
ally, through the internal iliac system, to the superficial inguinal
nodal basin. Although the dentate line roughly marks the level
where lymphatic drainage diverges, classic studies by Block and
Enquist using dye injection demonstrated that spread through
lymphatic channels occurs to adjacent pelvic organs, such as the
vagina and broad ligament, when injections are administered
as high as 10 cm proximal to the dentate line (Figs. 51-12
and 51-13).
Lymph nodes are commonly grouped into levels according to
their location. Epicolic nodes are located along the bowel wall and
in the epiploic appendices. Nodes adjacent to the marginal artery
are paracolic. Intermediate nodes are located along the main
branches of the large blood vessels; primary nodes are located on
the SMA or IMA. Lymph node invasion by metastatic cancer is
an important prognostic factor for patients with colorectal cancer.
Accurate pathologic assessment of lymph nodes is essential for
accurate staging, which serves as a determinant for treatment of
patients with colorectal cancer.
1318 SECTION X Abdomen

Inferior mesenteric artery

Marginal arteries

Median sacral artery

Superior rectal artery

Right common iliac artery

Right external iliac artery

Right internal iliac artery

Right superior gluteal artery

Right inferior epigastric artery

Right obturator artery

Right inferior gluteal artery

Accessory middle rectal artery

Right internal pudendal artery

Right middle rectal artery

Right inferior rectal artery

FIGURE 51-7 Arterial supply of the rectum. (From Gordon PH, Nivatvongs S, editors: Principles and practice
of surgery for the colon, rectum and anus, ed 2, St. Louis, 1999, Quality Medical Publishing, p 24.)

Nerves prostatic urethra. Failure to preserve at least one of the hypogastric

Preganglionic sympathetic nerves from T6 to T12 synapse in
preaortic ganglia. Postsympathetic fibers then course along blood
vessels to reach the right and transverse colon. The right and
transverse colon parasympathetic supply comes from the right
vagus nerve. Parasympathetic fibers follow branches of the SMA
to synapse in the wall of the bowel. The left colon and rectum
receive sympathetic supply from the preganglionic lumbar
splanchnics of L1 to L3. These synapse in the preaortic plexus
located above the aortic bifurcation, and the postganglionic ele-
ments follow the branches of the IMA and superior rectal artery
to the left colon, sigmoid, and rectum. The lower rectum, pelvic
floor, and anal canal receive postganglionic sympathetics from the
pelvic plexus. The pelvic plexus is adherent to the pelvic sidewalls
and is adjacent to the lateral stalks. It receives sympathetic branches
from the presacral plexus that condense at the sacral promontory
into the left and right hypogastric nerves. These sympathetic
nerves, which descend into the pelvis dorsal to the superior rectal
artery, are responsible for delivery of semen to the posterior
nerves during rectal dissection results in ejaculatory dysfunction
in men.
The pelvic parasympathetic nerves, or nervi erigentes, arise
from S2 to S4. Preganglionic parasympathetic nerves merge with
postganglionic sympathetics after the latter emerge from the
sacral foramina. These nerve fibers, through the pelvic plexus,
surround and innervate the prostate, urethra, seminal vesicles,
urinary bladder, and muscles of the pelvic floor. Rectal dissection
may disrupt the pelvic plexus and its subdivisions, resulting in
neurogenic bladder and sexual dysfunction. Rates of bladder and
erectile dysfunction after rectal surgery are as high as 45%. The
degree and type of dysfunction are affected by the level of the
neurologic injury. A high IMA ligation severing the hypogastric
nerves near the sacral promontory results in sympathetic dys-
function characterized by retrograde ejaculation and bladder
dysfunction. Injury to the mixed parasympathetic and sympa-
thetic periprostatic plexus results in impotence and an atonic
bladder.
 CHAPTER 51 Colon and Rectum 1319

SMA SMA

IMA
IMA

A B

Meandering mesenteric artery

IMA
1

C
FIGURE 51-8 Pathologic anatomy and occlusion of the superior mesenteric artery (SMA) and inferior mes-
enteric artery (IMA). A, Occlusion of the SMA. B, Occlusion of the IMA. C, Ligating the IMA: 1, correct
location of ligation (inset); 2, incorrect location of ligation. (From Gordon PH, Nivatvongs S, editors: Principles
and practice of surgery for the colon, rectum and anus, ed 2, St. Louis, 1999, Quality Medical Publishing,
p 28.)

PHYSIOLOGY OF THE COLON
Generally speaking, the function of the colon is the recycling of
nutrients, whereas the function of the rectum is the elimination
of stool. The recycling of nutrients depends on the metabolic
activity of the colonic flora, colonic motility, and mucosal absorp-
tion and secretion. Stool elimination involves dehydration of
colonic contents and defecation.
Recycling of Nutrients
During the digestive process, ingested nutrients are diluted within
the intestinal lumen by biliopancreatic and GI secretions. The
small intestine absorbs most ingested nutrients and some of the
fluid and bile salts secreted into the lumen. However, the ileal
effluent is still rich in water, electrolytes, and nutrients that resist
digestion. The colon has the functional ability to recover these
substances to avoid unnecessary losses of fluids, electrolytes, nitro-
gen, and energy. To accomplish this, the colon depends highly on
its bacterial flora.
Colonic Flora
Nutrients are digested within the intestinal lumen with the aid of
biliopancreatic and GI secretions. By the time the chyme reaches
the terminal ileum, most of the nutrients have been absorbed,
1320 SECTION X Abdomen

Visceral peritoneum

Taenia (longitudinal muscle)

Circular muscle

Submucosa

Circular muscle
Mucosa
Taenia omentalis Peritoneum
Taenia libera

Lumen Submucosa

Appendix
epiploica

Lumen Vasa recta longa

Vasa recta brevia Mucosa
Taenia mesocolica

Vasa recta

Marginal artery

FIGURE 51-9 Cross-sectional anatomy of the colon, with vasa brevia and vasa recta. (From Gordon PH,
Nivatvongs S, editors: Principles and practice of surgery for the colon, rectum and anus, ed 2, St. Louis,
1999, Quality Medical Publishing, p 26.)

Arc of Riolan leaving a succus entericus composed of electrolyte-rich fluid, bile

salts, and some proteins and starches that have resisted digestion.
An enormous quantity of autochthonous flora, consisting of more
than 400 bacterial species, resides in the large intestine. Large
bowel contents may contain as many as 1011 to 1012 bacterial cells
per gram, contributing approximately 50% of fecal mass. Most
Middle of these colonic species are anaerobes. These bacteria feed on
colic artery proteins sloughed from the bowel wall and undigested complex
carbohydrates.
Superior Colonic microflora provide several important functions to the
mesenteric
artery host, including barrier functions that help maintain epithelial
integrity, nutritive functions that use plant polysaccharides, devel-
opmental functions that stimulate epithelial cell differentiation
and angiogenesis, and, finally, immune functions through the gut.
Gut-associated lymphoid tissue contributes to both innate and
adaptive immunity.1 Short-chain fatty acids (SCFAs) are produced
by microbial breakdown and fermentation of dietary starches.
These fatty acids are the principal source of nutrition for the
colonocyte. Bacteroides species predominate throughout the colon,
composing two thirds of the total counts of the proximal colon
and almost 70% of the bacteria in the rectum. Escherichia, Kleb-
siella, Proteus, Lactobacillus, and enterococci are the predominant
species of facultative anaerobes.

Prebiotics and Probiotics

FIGURE 51-10 Arc of Riolan. (From Gordon PH, Nivatvongs S, editors: Probiotics can be defined as dietary supplements that contain live
Principles and practice of surgery for the colon, rectum and anus, ed 2, cultures of bacteria and yeast that are beneficial to colonic and
St. Louis, 1999, Quality Medical Publishing, p 27.)
 CHAPTER 51 Colon and Rectum 1321

Superior pancreaticoduodenal vein

Portal vein Splenic vein

Superior mesenteric vein

Inferior
Right colic vein mesenteric vein

Left colic vein

Ileocolic vein
Testicular/ovarian
Superior veins
mesenteric vein

Inferior vena cava Sigmoid veins

Right common
iliac vein
Right internal Middle
iliac vein sacral vein

Right external Superior

iliac vein rectal vein
Middle rectal vein

Internal pudendal vein

Internal hemorrhoidal plexus

Inferior rectal vein External hemorrhoidal plexus
FIGURE 51-11 Venous drainage of the colon and rectum. (From Gordon PH, Nivatvongs S, editors: Prin-
ciples and practice of surgery for the colon, rectum and anus, ed 2, St. Louis, 1999, Quality Medical Publish-
ing, p 30.)

host function. The two most widely used agents are Lactobacillus
and Bifidobacterium. Studies have indicated that probiotics may
have widespread health benefits, including stimulation of immune
function, anti-inflammatory effects, and suppression of entero-
pathogenic colonization.2 In addition, they may increase the
digestibility of dietary proteins, enhance absorption of amino
acids, and play a protective or therapeutic role against Clostridium
difficile–associated diarrhea.3 The ultimate role of probiotics has
not yet been determined. There are conflicting data in regard to
whether they work more effectively as primary therapy or as pro-
phylaxis against recurrent C. difficile–associated diarrhea. Indica-
tions for their use are evolving but may include necrotizing
enterocolitis in neonates, patients with HIV-AIDS, and neutro-
penic patients undergoing chemotherapy. Further research is
needed, but the evidence for probiotic use in various settings is
encouraging.
Prebiotics are nondigestible oligosaccharides (e.g., inulin) that
help the host by stimulating the growth of certain species of
beneficial intestinal bacteria. There is a growing body of data
suggesting health benefits; however, there is currently little evi-
dence to guide recommendations for their use.
Fermentation
Unlike most of the mucosal lining of the proximal GI tract,
colonic mucosa does not receive its primary nutrition from the
bloodstream. Instead, nutrient requirements are fulfilled from the
colonic luminal contents. The primary energy source for the colo-
nocyte is the SCFA butyrate. The manner in which this interac-
tion occurs illustrates the essential symbiotic interaction between
the colon and its resident bacterial flora.
The main source of energy for intestinal bacteria is dietary
fiber, composed of complex carbohydrates (starches and nonstarch
polysaccharides [NSPs]). This fiber is metabolized by the process
of fermentation. Not all complex carbohydrates are fermented in
the same manner, which underlies many of the dietary recom-
mendations for bulking agents. Lignin and psyllium are compo-
nents of plants that are not fermented by human colonic flora;
they are hydrophilic, thus leading to water resorption and stool
1322 SECTION X Abdomen

Epicolic
nodes

Paracolic
nodes
Principal
nodes

Intermediate
nodes

Upper zone

Middle zone Internal

iliac glands

Lower zone

FIGURE 51-12 Lymphatic drainage of the colon. (From Corman ML, editor: Colon and rectal surgery, ed 4,
Philadelphia,1998, Lippincott-Raven, p 21.)

Superior Inferior
rectal artery mesenteric artery

Common
iliac artery

Middle
rectal artery

Inferior
rectal artery

A B To inguinal nodes
FIGURE 51-13 Lymphatic drainage of the rectum (A) and anal canal (B). (From Gordon PH, Nivatvongs S,
editors: Principles and practice of surgery for the colon, rectum and anus, ed 2, St. Louis, 1999, Quality
Medical Publishing, p 32.)