Thrombosed External Hemorrhoid Excision 

Background

External hemorrhoids (piles) occur distal to the dentate line and develop as a result of distention and swelling of the external hemorrhoidal venous system (see the first image below).^[1] Engorgement of a hemorrhoidal vessel with acute swelling may allow blood to pool and, subsequently, clot; this leads to the acutely thrombosed external hemorrhoid, a bluish-purplish discoloration often accompanied by severe incapacitating pain (see the second image below).

Thrombosed external hemorrhoid is a common problem, but it remains a poorly studied topic. Reported risk factors for thrombosed external hemorrhoid include a recent bout of constipation^{[2, 3]} and traumatic vaginal delivery.^{[4, 5]}

Although conservative nonsurgical treatment (stool softeners, increased dietary fiber, increased fluid intake, warm baths, analgesia) ultimately results in resolution of symptoms for most patients, surgical excision of the thrombosed external hemorrhoid may often be the best treatment.^{[6, 7, 8]}

Newer conservative treatments, such as topical nifedipine, show promise of having advantages over traditional conservative treatments, such as lidocaine ointment^[9] ; however, in comparison with surgical excision, they have not yet been shown to shorten the time to symptom resolution or reduce the frequency of recurrence.

Surgical excision of the acutely thrombosed external hemorrhoid is within the purview of an office-based or emergency practitioner.^{[10, 11]} This safe procedure offers low recurrence and complication rates and high levels of patient acceptance and satisfaction.^[12]

Go to Hemorrhoids and Anal Surgery for Hemorrhoids for complete information on these topics.

Indications

Acute pain and thrombosis of an external hemorrhoid within 48-72 hours of onset is an indication for excision.

In a retrospective study by Greenspon et al, surgical treatment resulted in much faster symptom resolution (3.9 d vs 24 d), as well as a lower frequency of recurrence (6.3% vs 25.4%), in the study population.^[13] A study by Cavcić et al demonstrated that in comparison with simple incision or topically applied 0.2% glycerin trinitrate ointment, thrombosed external hemorrhoid excision improved recurrence rates, symptoms, and residual skin tags at 1-year follow-up.^[14]

Contraindications

Absolute contraindications to thrombosed external hemorrhoid excision in the emergency department (ED) include the following:

• Any concern that the lesion may be something other than a thrombosed external hemorrhoid, such as a painless rectal mass (thrombosed external hemorrhoids are always painful)
• A grade IV internal hemorrhoid associated with a thrombosed external hemorrhoid
• Known severe coagulopathy
• Hemodynamic instability

Relative contraindications to ED excision of a thrombosed external hemorrhoid include the following:

• Allergy to local anesthetic
• Perianal infection
• Anorectal fissure
• Portal hypertension
• Inflammatory bowel disease
• Known coagulopathy
• Any serious systemic illness or comorbidity that would significantly increase the risk of the procedure

Preoperative planning

Explain the procedure, benefits, risks, complications, and alternatives to the patient, the patient’s representative, or both. Obtain a signed informed consent. Ask the patient or the patient’s representative if he or she would like others to be present for the procedure.

Anesthesia

Pain control is extremely important for excision of a thrombosed external hemorrhoid. Assurance of adequate local anesthesia is important; at times, procedural sedation may be warranted. Local anesthesia for this procedure is discussed further below (see Technique). For more information, see Local Anesthetic Agents, Infiltrative Administration.

Equipment

Equipment required for the procedure includes the following:

• Direct dedicated lighting
• Sterile gloves
• Antiseptic solution with skin swabs
• Sterile drape
• Local anesthetic solution (0.5% bupivacaine or 1% lidocaine with epinephrine)
• Syringe, 5 mL
• Needles, 18-gauge and 25- or 27-gauge
• Small forceps for grasping tissue
• Iris scissors to cut tissue or packing gauze
• Scalpel blade on a handle, No. 11 or No. 15
• Multiple 4 × 4 gauze squares
• Adhesive tape, 2-in
• Absorbable suture, 3-0
• Sterile packing gauze, 0.25-in
• Sterile dressing

It is important to have the equipment required for rescue techniques (eg, suturing equipment, silver nitrate) available at the bedside, in case bleeding occurs that is not controlled by direct pressure.

Positioning

Place the patient in the prone or lateral decubitus position, with the gurney at a height that accommodates the practitioner. Position the patient prone on the gurney, and use 2 overlapping sheets to cover the patient’s buttocks. One sheet extends down the legs and the other extends up the back.

Overview

To increase exposure to the area, tape each buttock in a T pattern. First, place 2 long strips of tape (approximately 40 cm long) longitudinally on each buttock. These strips should extend from the lower back down to the upper thigh. Next, place another long strip of tape horizontally across the 2 vertically oriented strips. Pull the horizontal strips out to the side, and tape them to the gurney.

Prepare a light source for the sterile field. Use direct lighting; do not rely on ambient light alone.

After cleaning the area with an alcohol swab, locally inject approximately 2-6 mL of local anesthetic (eg, lidocaine with epinephrine) at the base of the thrombosed hemorrhoid, then inject approximately 1-2 mL of the local anesthetic within the hemorrhoid (see the video below).

Use skin swabs and antiseptic solution to clean the skin, starting at the hemorrhoid and working outward in progressively larger circles (see the video below). Next, create a sterile field with sterile drapes surrounding the projected work area.

Make an elliptical incision in the roof of the hemorrhoid, taking care to avoid the anal sphincter muscle (see the video below). The incision should be directed radially from the anal orifice. The elliptical incision allows the thrombosed hemorrhoid to be unroofed. It is preferable to a simple incision and evacuation of clot because of the usual presence of multiloculated clots and their tendency to close and reclot if not unroofed. The use of an elliptical incision reduces the complication rate.^[15]

Remove the blood clot from the elliptical opening (see the video below). Multiple clots are often present; all clots should be removed.

Use 0.25-in. packing material to pack any space left by the removal of the clot, taking care not to pack tightly (see the video below).

Dress the wound with 4 × 4 gauze pads folded over once and taped into place in a transverse fashion (see the images below).

Postoperative care

Patient should start sitz baths as soon as possible. Sitz baths should be taken 3-4 times a day for 20 minutes at a time in warm but not hot water. Packing gauze can be removed in 48 hours if it has not yet fallen out.

Acetaminophen or ibuprofen should be prescribed for pain control. Avoid opiate analgesics because of constipating and, thus, stool-hardening effects. Antibiotics are not necessary. Patient should begin taking some type of stool softener to avoid traumatic passage of feces. This should be continued for 2-4 weeks.

Complications

The following are potential complications of thrombosed external hemorrhoid excision:

• Bleeding - Probably the most common complication of this procedure, bleeding can usually be well controlled with direct pressure; if hemostasis is not obtained with direct pressure alone, either silver nitrate cauterization or a figure-eight stitch with an absorbable suture can be used
• Infection – The infection rate is not known but is believed to be lower than 5%; prophylactic antibiotics are not routinely indicated
• Perianal skin tag - This is a common benign complication after the incised area has healed
• Stricture - This is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle
• Incontinence - This is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle
• Pain - This is a common but avoidable complication that generally is completely preventable with any combination of parenteral and local anesthesia, with or without procedural sedation

Long-term monitoring

Return precautions should be given both verbally and in written form. They should include the following:

• Uncontrolled pain
• Signs of infection (eg, pus, redness, fever)
• Moderate-to-severe bleeding (minor bleeding is extremely common)

A wound check is necessary if pain or bleeding persists for more than 36-48 hours postoperatively.