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Excision of Thrombosed External Hemorrhoids

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.

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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 1 View Original Step 1 View Original

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 2 View Original Step 2 View Original

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 3 View Original Step 3 View Original

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 4 View Original Step 4 View Original

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 5 View Original Step 5 View Original

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 6 View Original Step 6 View Original

Step 7

Apply bulky gauze dressing

over the defect (not in the anus), which may be changed as

needed.

Step 7 View Original Step 7 View Original

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

View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 46083 Incision of thrombosed external hemorrhoid $353.00 10 46221 Hemorrhoidectomy by rubber band ligation $360.00 0 46250 External hemorrhoidectomy, complete $1,045.00 90 46320 Enucleation or excision of external thrombotic

hemorrhoid $371.00 10 CPT is a registered trademark of the American

Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008

MMH-SI 's copyrighted Physicians ' Fees and

Coding Guide.

ICD-9 Codes

View Large Hemorrhoid uncomplicated 455.6 Hemorrhoid bleeding or prolapsed 455.8 Hemorrhoid external 455.3 Hemorrhoid external thrombosed 455.4 Hemorrhoid bleeding or prolapsed external 455.5 Hemorrhoid internal 455.0 Hemorrhoid internal thrombosed 455.1 Hemorrhoid bleeding or prolapsed internal 455.2

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.

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Inc. 'sPhysicians '

Fee and Coding Guide. Duluth,

Georgia. MAG Mutual

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