Acute thrombosis of external hemorrhoids can cause extreme discomfort and disability. The condition often 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 antiinflammatory 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.
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.
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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. Novice physicians may confuse external tags with alternate anal pathology, but the presence of tags signifies remote disease.
INDICATIONS
RELATIVE CONTRAINDICATIONS
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PROCEDURE
Appearance of a thrombosed external thrombosed hemorrhoid.
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(1) A thrombosed external hemorrhoid. |
The surrounding area is infiltrated with 3 to 5 mL of 1% lidocaine with epinephrine. Some physicians prefer a longer-acting anesthetic such as 0.5% bupivacaine with epinephrine. Make sure to infiltrate beneath the hemorrhoid.
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(2) Infiltrate the area with 3 to 5 mL of 1% lidocaine with epinephrine. |
PITFALL: The perianal tissues are highly vascular. Avoid intravascular injection of the anesthetic when injecting into these tissues.
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An elliptical incision is made over the hemorrhoid (Figure 3A). The incision should remain outside the anal verge. After the skin incision, grasp the central fusiform island of skin with an Allis clamp (Figure 3B). Undermine this central island of skin with scissors or a scalpel blade, cutting deeply enough to maintain attachment of the thrombosed hemorrhoid to the overlying skin (Figure 3C). If additional hemorrhoidal complex (vein) is seen beneath the clot, these can be excised with tissue scissors (Figure 3D).
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(3) Make an elliptical incision over the hemorrhoid outside the anal verge, and grasp the central fusiform island of skin with an Allis clamp. |
PITFALL: Bleeding can occur during the procedure. Clamping a hemostat on a bleeding vessel inside the wound often provides effective control. The instrument can be removed after a minute, and closure of the wound can be performed. Electrocautery is an alternate option for hemostasis, but it may leave char in the wound base.
PITFALL: The ellipse can be oriented parallel to the anal canal, rather than radially as pictured above. Parallel incisions expose more hemorrhoidal sinusoids beneath the skin, but are more difficult to close (suture doesn't hold well on the side near the canal).
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Many surgeons prefer to leave the area open, with healing accomplished by secondary intention (Figure 4A). A running subcuticular 4-0 polygalactin (Vicryl) suture can be placed. Tie the suture across the deep tissue on one end of the wound (Figure 4B). Run the suture back and forth across the wound to the other end (Figure 4C). Tie the suture at the far end, burying the knot into the wound base. Antibiotic ointment is applied to the site, and gauze can be placed between the buttocks over the wound. Encourage fluid intake, stool-bulking agents and stool softeners, and good hygiene until the follow-up visit in 1 to 2 weeks.
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(4) If the area is left open, healing occurs by secondary intention. Alternately, closure can be accomplished with a buried absorbable suture. |
PITFALL: Limit the use of narcotics postoperatively, because these medications can produce constipation that can interfere with wound healing. Consider alternating doses of ibuprofen and acetaminophen for discomfort.
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CODING INFORMATION
Most physicians report 46320 if the excision is performed for a thrombosed hemorrhoid. Because this is a starred surgical procedure (i.e., code with an asterisk), only the surgical service is included in the reimbursement. Separate billing may be permitted for evaluation and management services (i.e., office visit).
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INSTRUMENT AND MATERIALS ORDERING
The instruments on the office surgical tray (see Appendix A) 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 G.
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