Excision of Acutely Thrombosed External Hemorrhoids

A thrombosed, painful external hemorrhoid that has been symptomatic for less than 72 hours, not improved with conservative measures

Decision to excise should also be based on severity of pain and clinical course. If the patient presents with improving pain, medical management is likely preferable.

After 72 hours, most patients have decreased pain and spontaneous resolution of symptoms

CONTRAINDICATIONS

Relative Contraindications

Inflammatory bowel disease—high rate of fistula formation

Perianal infection

Known coagulopathy

Portal hypertension

LANDMARKS

Internal hemorrhoids originate above the dentate line

Can prolapse and extend outside the anal canal (FIGURE 33.1)

External hemorrhoids originate below the dentate line

General Basic Steps

Prepare patient

Anesthetize

Incise

Remove clot

Pack wound

TECHNIQUE

Patient Preparation

Place the patient in the prone jackknife or left lateral decubitus position

For prone jackknife positioning, place rolled towels beneath the patient’s pelvis to elevate buttocks

Gently spread the buttocks and maintain the positioning with tape

Prepare the area with povidone–iodine solution (Betadine) using sterile gloves

Inject 1% lidocaine with epinephrine or 0.5% bupivacaine into the base of the thrombosed hemorrhoid

Avoid multiple injection sites to decrease bleeding

Topical lidocaine gel can be used in the anal canal to supplement local anesthesia

Intravenous analgesia is highly recommended

Alternatively, a perianal block can be performed by injecting a local anesthetic into the sphincter complex in the anterior, posterior, and lateral positions

Incision

Test the adequacy of the local anesthesia by grasping the hemorrhoid with forceps

Using a no. 15 scalpel blade, make an elliptical incision around the thrombosis with the long axis in the radial direction relative to the anus

Never incise in a circumferential axis

Control bleeding with direct pressure

Elevate skin edges with a forceps and excise to expose underlying thrombus

Remove the clot and any overlying skin using a forceps or by applying pressure

After the clot is removed, have an assistant spread the incision, exposing the base of the hemorrhoid to allow visualization and removal of additional clots

If significant bleeding occurs that is not controlled with direct pressure, hemostasis can be achieved with a suture or silver nitrate

Pack the wound loosely with standard cotton gauze or iodoform packing to prevent skin edges from reapproximating prematurely, and apply a pressure dressing

Follow-up Care

Counsel the patient to apply direct pressure if bleeding occurs

Dressing may be removed after 12 hours, at which point the patient should begin taking sitz baths three to four times daily

Prescribe stool softeners and fiber supplements as needed. Avoid opiate pain medication, and instruct the patient to increase oral fluid intake.

Follow-up should be arranged in 2 to 4 weeks. The patient must return sooner if he or she experiences severe pain, uncontrolled bleeding, or signs of infection.

FIGURE 33.1 Varicosed tributary of the superior rectal vein forming the internal hemorrhoid. (From Snell RS. Clinical anatomy, 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2004:427, with permission).

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