How to Excise Thrombosed External Hemorrhoid

• Indications:
  Painful thrombosed external hemorrhoid
• Contraindications:
  • Coagulopathy (PT or PTT >1.3× control)
  • Thrombocytopenia (platelet count < 50,000/mm³)
  • Nonthrombosed prolapsed hemorrhoid
• Anesthesia:
  1% lidocaine (mixing lidocaine with 1/100,000 epinephrine may reduce bleeding)
• Equipment:
  • Scalpel handle and #15 blade
  • Sterile prep solution
  • 25-gauge needle and syringe
  • Forceps
  • Small clamps
  • Vaseline or Xeroform gauze

• Positioning:
  Lateral decubitus or lithotomy
• Technique:
  • Prep and drape the anal area with sterile prep solution.
  • Identify the thrombosed external hemorrhoid. By definition, it lies exterior to the dentate line, and it is firm and tender.
    
  • Perform a field block of the hemorrhoid by infiltrating the surrounding skin and soft tissues with lidocaine using a 25-gauge needle.
  • Using a scalpel, make an elliptical incision over the thrombosed hemorrhoid.
    
  • Using the forceps to hold one side of the incision, enucleate the clot within the hemorrhoid with the aid of a clamp. Apply a Vaseline gauze or Xeroform dressing.
  • The patient should be instructed to do sitz baths three times a day and after each bowel movement.

• Complications and Management:
  • Bleeding
    • A small amount of dark bloody ooze is to be expected. Bright red bleeding indicates that the hemorrhoid is not thrombosed, and the incision should be stopped.
    • Direct pressure or packing may be required to control bleeding.
  • Fissure
    • Usually results from extending the incision beyond the hemorrhoid into anoderm.
    • Treat conservatively with sitz baths and Anusol suppositories.
    • Manage operatively if conservative treatment fails.