Excision of Thrombosed Hemorrhoid

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Jess Mason reviews how to excise a thrombosed hemorrhoid, which will typically be tender and purple in color. After local anesthesia an elliptical incision is made through which the blood clots are extruded.

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Tim V. -

Great video

I’ve always been scared off from doing this because of a concern for developing a fistula. Any truth to this?

Also, does the orientation of the incision (anus to apex) really matter?

Thanks as always

Jess Mason -

Tim, I think the fistula issue is more relevant to infections, like a perianal abscess. I don't see a lot about this with regards to an uninfected thrombosed hemorrhoid.

Greg M. -

Jess; what is the return rate after healing or does it depend on their fluid intake, fiber etc?

Angela S. -

why We’re the elipticle incisions done in different directions?

Jess Mason -

Great questions!

Regarding the direction of the elliptical cut, the textbooks advise going radially out from the anus. Think of the hands on a clock face going out from the center.

In terms of recurrence rate, I found this:
"The rate of recurrence in the conservative group was 25.4 percent (4/29; 14 percent were excised) whereas only 6.3 percent of the surgical patients had recurrence (P < 0.0001)"
Greenspon J, Williams SB, Young HA, et al. Thrombosed external hemorrhoids: outcome after conservative or surgical management. Diseases of the colon & rectum. 2004 Sep 1;47(9):1493-8.

The downsides to surgical excision are increased pain and bleeding. BUT, if the hemorrhoid is large and painful, or has already recurred after conservative mgt, this is likely a better option.

Andrew A. -

Jess,

Two questions:

1. Why do you do an elliptical incision. A single incision is more than ample to remove all clot and avoids any risk of inadvertently cutting deeper or more than is intended. Likewise, these tend to ooze, and adding a larger wound via ellipse only prolongs the bleeding. I understand the desire to prevent a second thrombosis, but ellipse would not necessarily prevent this. I have always done a single linear incision and the clot is easy to remove

2. Why pack the hemorrhoid. The packing will not stay in more than an hour at best. Seems unnecessary and one additional thing to do with no real benefit. First time they go to the bathroom the pack will be gone.

Laura P. -

I have done many of these excisions, but have never packed the cavity with gauze. Is there data on the efficacy of packing?

Carla M., Carla -

Hello! I have a question. How long should you keep de packing?

Thanks

Adan A. -

I tell patients keep it until falls off. Most of the times, this falls off in 1-2 days, and what I don't want is the patient coming back the next morning saying "I am here to have my hemorrhoid re-packed b/c the thing fell off when I showered"

Adan A. -

Scissor instead of scalpel. Safer, faster easier. Just use the pick up forcers creating a dome and snip. This gives you a perfect elliptical incision, then get the clots out!

Anne Marie G. -

Good idea, I'll definitly do that instead!

Louis J. -

Nice I like that, will try in the future.

Joe H. -

Quick question.
What is the disposition afterwards, meaning, do they follow up with PCP or Gen Surg? Any prophy AB's?

Jess Mason -

This appeared to be simple external thrombosed hemorrhoids so we recommended primary care follow up, no antibiotics.

Joe H. -

Perfect! Thank you Dr. Mason!

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