Excision of Thrombosed External Hemorrhoids

E. J. Mayeaux, Jr., MD, DABFP, FAAFP and Larry S. Sasaki, MD, FACS
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Introduction

Acute thrombosis of external hemorrhoids can cause extreme discomfort and disability. The condition frequently manifests in younger individuals, and up to one third of women experience the condition immediately postpartum. Straining with defecation is believed to be causative, and individuals often report pain after severe bouts of diarrhea or constipation. Examination often reveals a tender, enlarged, perianal mass, with the blue clot seen through the skin. Drainage or mild bleeding can occur if the clot ruptures through the skin. 
External hemorrhoids are composed of the dilated tributaries of the inferior rectal vein, and they appear below the dentate line. Because the specialized anoderm in the anal canal below the dentate line is heavily innervated, thrombosed external hemorrhoids can produce excruciating discomfort. Acutely thrombosed hemorrhoids benefit from surgical intervention, and many physicians still consider this the treatment of choice. Thrombosis that has been present more than 72 hours generally should be treated conservatively, because the pain from the surgery often exceeds the pain experienced from slow resolution of the lesion. Conservative management includes sitz baths, oral analgesics, stool softeners, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical anesthetics such as lidocaine. Topical nifedipine and topical nitroglycerin appear to be promising interventions for more rapid symptom resolution in patients not surgically treated. 
Primary care physicians historically have performed incision and drainage procedures on thrombosed hemorrhoids. This procedure can remove large clots, but reports of high recurrence rates within 24 hours have led many physicians to advocate more extensive surgical intervention. A fusiform excision is recommended, with removal of the clot adherent to the overlying skin. Many physicians advocate removal of the entire underlying hemorrhoidal complex. Some have reported increased discomfort in individuals whose wounds are closed with sutures, but subcutaneous closure provides the benefit of more rapid healing and less drainage from the surgical site. Arterioles in the hemorrhoidal complex may experience spasm when cut. Sutured wounds are less likely to experience brisk bleeding from the surgery site several hours after the procedure once the spasm is relieved. 
The natural history of thrombosed hemorrhoids is slow resolution over 1 to 2 weeks. The swollen tissue diminishes to form an external skin tag. Tags are almost always asymptomatic, and surgical removal usually is not indicated. 

Equipment

  • The recommended surgical tray for office surgery is listed in Appendix G. Suggested suture removal times are listed in Appendix J.

  • A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

  • Skin preparation accommodations appear in Appendix E.

  • One inch of 2% lidocaine jelly (Xylocaine) placed on the corner of the drape.

  • Ive’s anoscope.

  • Surgical scissors.

  • Surgical forceps.

  • Electrocautery.

Indications

  • Severe symptoms (e.g., pain, itching) requiring surgical intervention

  • Ulcerated or ruptured external thrombosed hemorrhoids

  • Recurrent thrombosis after incision procedure

Contraindications (Relative)

  • Uncooperative patient

  • Coagulopathy or bleeding diathesis

  • Presence of symptoms for more than 72 hours (may still consider surgery, but pain of surgery may exceed pain of conservative management)

  • Presence of complicating disease (e.g., fissures, fistulas, cancer) that require more extensive surgery

The Procedure

Step 1

The patient is placed in the left lateral decubitus position on an absorbent pad. A gloved assistant should be available. Inspect the area. Flex the right hip and knee, and place a drape over the patient’s waist and legs. 
  • PEARL: If solid tumors or unusual tissue characteristics are discovered at the time of surgery, histologic analysis of the tissue is warranted.

Step 2

The surrounding area is generously infiltrated with 3 to 5 mL of 1% lidocaine with epinephrine. Some providers prefer a longer-acting anesthetic such as 0.5% bupivacaine with epinephrine. Make sure to infiltrate beneath the hemorrhoid. 
  • PITFALL: The perianal tissues are highly vascular. Avoid intravascular injection of the anesthetic when injecting into these tissues.

Step 3

Make a fusiform (elliptical) incision around the external hemorrhoid. The long axis of the incision should be in a radial, not transverse, orientation. Start the incision at the distal end of the incision, and then extend proximally. The proximal end of the elliptical incision should be near the anocutaneous junction. 
  • PITFALL: Do not extend the proximal end of the incision too proximally (i.e., dentate line or above). This may result in a proximal end that is difficult to expose and control bleeding.

  • PEARL: You can use scalpel for the initial incision; however, many providers find that they have better control of both making the incision and subsequently removing the hemorrhoid with the scissors. Scissors also save some time because you do not have to switch instruments.

Step 4

After the skin incision, grasp the central island of skin. Undermine this central island of skin with scissors, cutting deeply enough to maintain attachment of the thrombosed hemorrhoid to the overlying skin. If additional hemorrhoidal complexes (veins) are seen beneath the clot, these can be excised with tissue scissors. 

Step 5

Bleeding can occur during the procedure. The electrocautery is used for hemostasis. Clamping a hemostat on a bleeding vessel inside the wound also often provides effective control. The instrument can be removed after a minute. 

Step 6

Leave the area open, with healing accomplished by secondary intention. The final appearance after hemorrhoidectomy is shown. 
  • PEARL: Most providers do not close the defect because the wound heals nicely without suturing and time is saved without suturing. Also, the wound frequently dehisces with suture closure anyway.

Step 7

Apply bulky gauze dressing over the defect (not in the anus), which may be changed as needed. 

Complications

  • Bleeding

  • Scarring

  • Anal stenosis

  • Infection

  • Pain

Pediatric Considerations

This condition is very rare in the pediatric population. 

Postprocedure Instructions

Arrange for the patient to have a follow-up visit at 4 to 6 weeks postprocedure. If coexisting internal hemorrhoids are found during the procedure, they can be treated at this visit. Emphasize to the patient the need for soft stools. Use multiple modalities to soften the stools, such as stool softeners, stool-bulking agents, fiber-rich foods, and increased daily consumption of fluids. 

Coding Information and Supply Sources

ICD-9 Codes

Instrument and Materials Ordering

The instruments on the office surgical tray (see Appendix G) are appropriate for hemorrhoidal surgery. The addition of two straight hemostats may be beneficial. Some physicians prefer to grasp and elevate the clot and hemorrhoidal complex using an Allis clamp. All instruments are available from surgical supply houses or instrument dealers. A suggested anesthesia tray that can be used for this procedure is listed in Appendix F

Bibliography

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