II. Indications

  1. Thrombosed External Hemorrhoid
  2. No benefit if >72 hours from onset of thrombosis
    1. Thrombosis Hemorrhoid will resolve spontaneously

III. Management: Preparation

  1. Patient positioning
    1. Left lateral decubitus position
    2. Assistant spreads patient's buttocks
  2. Prepare perianal skin
    1. Topical povidone-Iodine (betadine) applied
  3. Anesthesia
    1. Avoid multiple injection sites (heavier bleeding)
    2. Inject 5 cc Lidocaine 1% into Thrombosed Hemorrhoid
      1. Epinephrine may be used in Lidocaine
      2. Post-Epinephrine late heavy bleeding may occur
    3. Lidocaine 2% jelly applied to anal canal
  4. Anoscopy
    1. Assess for other perianal pathologic findings

IV. Management: Hemorrhoidectomy

  1. Repeat perianal skin preparation with Betadine
  2. Confirm adequate anesthesia
  3. Make radial incision over Thrombosed Hemorrhoid
    1. Extends from anal skin to distal edge of thrombosis
    2. Avoid circumferential incision (use radial only)
    3. Create eliptical incision (not linear)
    4. Consider using straight clamp placed below clot
    5. Use 15 blade or iris scissors to make incision
    6. Do not cut into underlying muscle sphincter
    7. Avoid excessive cautery use (risk of scarring)
  4. Remove clot from incision
    1. Examine wound fo residual clots
  5. Close skin with subcutaneous Suture (4-0 Vicryl)
    1. Skin closure reduces bleeding without infection risk
    2. Place several interrupted buried Sutures
    3. Sutures should not protrude through skin
  6. Bandage
    1. Apply topical antibiotic (e.g. Bacitracin)
    2. Apply 4x4 gauze

V. Complications of Excision

  1. Late heavy bleeding (when patient is at home)
    1. Higher risk if Epinephrine used in local anesthetic
    2. Educate patient to apply direct pressure with gauze
  2. Peri-anal Scarring
    1. Associated with excessive cautery use
  3. Anal stenosis (rare)
    1. Associated with circumferential incision

VI. Post-Procedure Instructions

  1. Follow-up at 4-6 weeks
  2. Maintain soft stools (e.g. Colace, maximize hydration)
  3. See Hemorrhoid Management for general measures

VII. References

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