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Subject: Excision of Thrombosed External Hemorrhoids
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The recommended surgical
tray for office surgery is listed in Appendix
G. Suggested suture removal times are listed in Appendix
A suggested anesthesia
tray that can be used for this procedure is listed in Appendix
accommodations appear in Appendix E.
One inch of
2% lidocaine jelly (Xylocaine) placed on the
corner of the drape.
Severe symptoms (e.g.,
pain, itching) requiring surgical intervention
Ulcerated or ruptured
external thrombosed hemorrhoids
after incision procedure
Coagulopathy or bleeding
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
PEARL: If solid tumors or unusual tissue
characteristics are discovered at the time of surgery,
histologic analysis of the tissue is warranted.
PITFALL: The perianal tissues are highly
vascular. Avoid intravascular injection of the anesthetic
when injecting into these tissues.
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
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.