Is lancing the same as surgical excision for a thrombosed hemorrhoid?

Lancing vs. Surgical Excision for Thrombosed Hemorrhoids

No, lancing (simple incision and clot evacuation) is not the same as surgical excision for a thrombosed hemorrhoid. Surgical excision involves complete removal of the hemorrhoidal tissue, while lancing only involves making an incision to remove the clot without removing the hemorrhoidal tissue itself.

Differences Between Lancing and Surgical Excision

Lancing (Incision and Evacuation/Thrombectomy)

• Involves making an incision over the thrombosed hemorrhoid and removing only the blood clot
• Preserves the hemorrhoidal tissue
• Has been largely abandoned by specialists due to:
  • Higher recurrence rates
  • Issues with persistent bleeding 1
  • Worse pain outcomes compared to excision 1

Surgical Excision (Hemorrhoidectomy)

• Involves complete removal of the entire hemorrhoidal tissue
• Removes both the clot and the affected hemorrhoidal plexus in one piece 2
• Performed through an elliptical incision over the thrombosis 2
• Requires careful technique to avoid cutting into the underlying sphincter muscle 2

Clinical Outcomes Comparison

Time to Symptom Resolution

• Surgical excision: 3.9 days
• Conservative management: 24 days 3

Recurrence Rates

• Surgical excision: 6.3%
• Lancing/conservative management: 25.4% 3

Mean Time to Recurrence

• Surgical excision: 25 months
• Conservative management: 7.1 months 3

Procedural Considerations

When performing surgical excision:

• An elliptical incision is made over the thrombosis
• The entire hemorrhoidal plexus is removed in one piece
• Care must be taken to avoid cutting into the anal sphincter muscle
• Suture closure is typically used with low risk of infection due to the rich vascular network in the anal area 2

Recent Evidence

A 2023 multicenter prospective study comparing local excision to thrombectomy (incision) found:

• Success rates were relatively higher in the thrombectomy group (86.8%) compared to local excision (67.2%), though this difference approached but did not reach statistical significance (p=0.054)
• Quality of life scores were significantly better in the thrombectomy group
• Thrombectomy appeared particularly advantageous in patients with constipation and travel history 4

Clinical Implications

Despite the 2023 study suggesting some potential benefits of thrombectomy in specific patient populations, the overall body of evidence still indicates that:

• Simple incision and clot evacuation (lancing) has been largely abandoned by specialists due to higher recurrence rates and persistent bleeding issues 1
• A randomized prospective study by Cavcić showed that thrombus evacuation provided worse pain results compared to excision 1
• Surgical excision results in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals 3

Conclusion

The key distinction is that lancing only removes the clot while preserving the hemorrhoidal tissue, whereas surgical excision removes the entire affected hemorrhoidal tissue. The evidence strongly suggests that complete surgical excision provides better long-term outcomes for patients with thrombosed external hemorrhoids compared to simple lancing procedures.