External hemorrhoid excision

Indications

• Acute (<48 hours) thrombosed hemorrhoid
• Pain/discomfort affects daily life

Contraindications

• Immunocompromised patient
• Pediatric patient
• Pregnant patient
• Portal hypertension
• Coagulopathy

Equipment Needed

• Scalpel
• Local anesthetic

Procedure

1. Place patient in side-lying or prone position
2. Apply EMLA 1 hr prior to procedure
   • Apply tape to each buttock with force directed laterally for better visualization
3. Inject local anesthetic (e.g. bupivacaine 0.5% with epi) with 30-gauge needle directly into dome of hemorrhoid as a single injection
   • Alternatively, a perianal block can be used for local analgesia
4. Make elliptical incision in overlying skin to expose the thrombosis
   • Remove the clot and the overlying skin through the incision site
5. Control bleeding by tucking corner of a small piece of gauze into the wound and tape buttocks together
   • Leave in place for a few hours
6. Apply pressure dressing have patient remove 6-12 hr later when takes first stiz bath
7. Patient may apply soothing ointments (preparation H, Anusol HC, Lidocaine ointment) after dressing is removed
8. Provide follow up in 24-48hr

Complications

• Continued bleeding
• Recurrence
• Infection
• Fistula
• Abscess
• Skin tags

See Also

• Hemorrhoids

References

Authors

Jordan Swartz, Matthew, Michael Holtz, Devin Smith, Ross Donaldson, Neil Young