eMedicine Specialties > Clinical Procedures > Soft Tissue Procedures

Thrombosed External Hemorrhoid Excision: Treatment & Medication

Author: Brett Wallace Lorber, MD, MPH, Staff Physician, Emergency Department, Olive View/UCLA Medical Center
Coauthor(s): Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Contributor Information and Disclosures

Updated: Apr 30, 2009

Anesthesia

• See Technique for details on local anesthesia.
• For more information, see Local Anesthetic Agents, Infiltrative Administration.

Equipment

• 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 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 X 4 gauze squares
• Adhesive tape, 2 inch
• Absorbable suture, 3-0
• Sterile packing gauze, quarter inch
• Sterile dressing

Positioning

• Position the patient in the prone or lateral decubitus position with the gurney at a height that accommodates the practitioner.

Technique

• 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.
• 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.
• 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.
• 
  

  

  Taping of patient prior to procedure (thrombosed external hemorrhoid is at the 9-o'clock position).

  [ CLOSE WINDOW ]

  

  Taping of patient prior to procedure (thrombosed external hemorrhoid is at the 9-o'clock position).

• Prepare light source for sterile field.
• 
  

  

  Light source preparation for sterile field.

  [ CLOSE WINDOW ]

  

  Light source preparation for sterile field.

• After cleaning the area with an alcohol swab, locally inject approximately 2-6 mL of local anesthesia (eg, lidocaine with epinephrine) at the base of the thrombosed hemorrhoid, and inject approximately 1-2 mL of the local anesthesia within the hemorrhoid.
• 
  

  This feature requires the newest version of Flash. You can download it here.

  Local anesthesia injected at hemorrhoid base and within the hemorrhoid.

  [ CLOSE WINDOW ]

  

  Local anesthesia injected at hemorrhoid base and within the hemorrhoid.

• Use skin swabs and antiseptic solution to clean the skin. Start at the hemorrhoid and work outward in progressively larger circles. Next, create a sterile field with sterile drapes surrounding the projected work area.
• 
  

  This feature requires the newest version of Flash. You can download it here.

  Application of povidone-iodine (Betadine) antiseptic.

  [ CLOSE WINDOW ]

  

  Application of povidone-iodine (Betadine) antiseptic.

• Make an elliptical incision in the roof of the hemorrhoid, taking care to avoid the anal sphincter muscle. The incision should be directed radially from the anal orifice. The elliptical incision allows the thrombosed hemorrhoid to be unroofed. It is preferred over a simple incision and evacuation of clot because of the usual presence of multiloculated clots and their tendency to close and re-clot, if not unroofed.
• 
  

  This feature requires the newest version of Flash. You can download it here.

  Primary elliptical incision over hemorrhoid.

  [ CLOSE WINDOW ]

  

  Primary elliptical incision over hemorrhoid.

• Remove the blood clot from the elliptical opening. Multiple clots are often present; all clots should be removed.
• 
  

  This feature requires the newest version of Flash. You can download it here.

  Further incision with removal of clot.

  [ CLOSE WINDOW ]

  

  Further incision with removal of clot.

• Use quarter-inch packing material to pack any space left by the removal of the clot. Take care not to pack tightly.
• 
  

  This feature requires the newest version of Flash. You can download it here.

  Gauze packing postprocedure.

  [ CLOSE WINDOW ]

  

  Gauze packing postprocedure.

• Dress wound with 4 X 4 gauze pads folded over once and taped into place in a transverse fashion.
• 
  

  

  Dressing postexcision.

  [ CLOSE WINDOW ]

  

  Dressing postexcision.

• 
  

  

  Dressing postexcision.

  [ CLOSE WINDOW ]

  

  Dressing postexcision.

Pearls

• Pain control is extremely important for this procedure.  Assurance of adequate local anesthesia is important; at times, procedural sedation may be warranted.
• Have rescue techniques (eg, suturing equipment, silver nitrate) at the bedside in case direct pressure does not control the bleeding.
• Use direct lighting. Do not rely on ambient light alone.
• Always make an elliptical incision rather than a simple incision to decrease the rate of complications.¹¹

Complications

• Bleeding is probably the most common complication of this procedure and usually can be well controlled with direct pressure. If hemostasis is not obtained with direct pressure alone, either silver nitrate cauterization or a figure-of-eight stitch with an absorbable suture can be used.
• Infection rate is not known but is believed to be less than 5%. Prophylactic antibiotics are not routinely indicated.
• Perianal skin tag is a common benign complication after the incised area has healed.
• Stricture is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle.
• Incontinence is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle.
• Pain is a common but avoidable complication. Any combination of parenteral and local anesthesia with or without procedural sedation may be used to avoid pain completely during this procedure.

Discharge Information

• 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.
• 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.)
• Patient should begin taking some type of stool softener to avoid traumatic passage of feces. This should be continued for 2-4 weeks.
• Acetaminophen or ibuprofen should be prescribed for pain control. Avoid opiate analgesics because of constipating and, thus, stool-hardening effects.
• Antibiotics are not necessary.
• A wound check is necessary if pain or bleeding persists for more than 36-48 hours postprocedure.

• Search for CME/CE on This Topic »