Hemorrhoidectomy

CPT 46260
Approach Open
Add-on / Variant CPTs
  • 46255 — Hemorrhoidectomy, internal and external, simple (single column)
  • 46261 — Hemorrhoidectomy, internal and external, complex or extensive
  • 46083 — Incision of thrombosed hemorrhoid, external
  • 46947 — Hemorrhoidopexy, stapling (PPH / stapled hemorrhoidopexy)
Preoperative Diagnosis:

Symptomatic [grade III / grade IV] internal and external hemorrhoids — [bleeding / prolapse / pain / failure of conservative management]

Postoperative Diagnosis:

Same

Procedure Performed:

[Ferguson / Milligan-Morgan / stapled] hemorrhoidectomy — [two / three] column

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

[General / spinal / MAC with local]; local — [X] mL 0.25% bupivacaine with epinephrine perianal block

Indications:

The patient is a [age]-year-old [male/female] with a [duration] history of symptomatic [grade III / IV] hemorrhoids refractory to [conservative management / rubber band ligation / office procedures] presenting for surgical hemorrhoidectomy. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.

Findings:

In the lithotomy position with the anoscope, grade [III / IV] internal and external hemorrhoidal complexes were identified at the [right anterior / right posterior / left lateral] positions ([3 / 7 / 11 o'clock in lithotomy]). [Degree of prolapse, bleeding, skin tags noted.] No other anorectal pathology was identified.

Description of Procedure:

The patient was brought to the operating room and placed in the [prone jackknife / lithotomy] position. [Anesthesia type] was induced. A surgical timeout was performed. A perianal block was performed with [X] mL of 0.25% bupivacaine with epinephrine using a [4-quadrant / 8-point] injection technique.

The anal canal was gently dilated to admit two fingers. An anoscope was inserted and the hemorrhoidal complexes were identified. The three primary columns at the [right anterior / right posterior / left lateral] positions were confirmed.

[Ferguson (closed) technique:] Beginning with the [right anterior] column, a [Kelly / Allis] clamp was placed on the external skin component of the hemorrhoid and the tissue was placed on traction. An elliptical incision was made at the mucocutaneous junction using [electrocautery / scissors] incorporating the external and internal components. The hemorrhoidal vascular pedicle was suture-ligated at its base with [2-0 Vicryl] figure-of-eight suture. The wound was closed from apex to the anal verge with a running [3-0 Vicryl] suture. This was repeated for the [right posterior] and [left lateral] columns.

Adequate skin bridges (>1 cm) were confirmed between all three wounds to prevent anal stenosis. Hemostasis was confirmed. A [4x4 gauze / anal tampon] was placed. A perianal [bupivacaine] block was supplemented as needed.

Complications:

None

Specimens:

[Hemorrhoidal tissue sent to pathology / None — routine pathology not sent per institutional protocol]

Estimated Blood Loss:

Minimal (less than 20 mL)

Drains:

None

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition. Post-operative instructions including stool softeners, sitz baths, and pain management were provided.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Symptomatic grade *** hemorrhoids — ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** hemorrhoidectomy — *** column
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: ***; perianal block with *** mL 0.25% bupivacaine with epinephrine

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with symptomatic grade *** hemorrhoids refractory to *** presenting for surgical hemorrhoidectomy. Risks, benefits, and alternatives discussed, consent obtained.

FINDINGS: Grade *** internal and external hemorrhoidal complexes at right anterior/right posterior/left lateral positions. No other anorectal pathology.

DESCRIPTION OF PROCEDURE:
Patient in *** position. *** anesthesia. Timeout. Perianal block performed.

Anal canal dilated to two fingers. Anoscope inserted — three columns identified. Ferguson/Milligan-Morgan hemorrhoidectomy performed:
- Right anterior column: elliptical incision, pedicle suture-ligated with 2-0 Vicryl, wound closed with running 3-0 Vicryl.
- Right posterior column: same.
- Left lateral column: same.

Skin bridges >1 cm confirmed. Hemostasis confirmed. Anal tampon placed.

EBL: Minimal
SPECIMENS: ***
COMPLICATIONS: None
DISPOSITION: Patient taken to PACU in stable condition. Post-op instructions provided.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Stapled Hemorrhoidopexy (PPH)

A procedure for prolapse and hemorrhoids (PPH) was performed using a circular stapling device. A purse-string suture was placed circumferentially in the rectal mucosa [4 cm above the dentate line] using the provided purse-string anoscope. The PPH stapler was introduced, the purse-string was tied and the ends drawn through the stapler. The stapler was fired, excising a circumferential ring of hemorrhoidal tissue and mucosa with simultaneous anastomosis. The anastomotic ring was inspected circumferentially — [two complete tissue rings were confirmed / additional sutures were placed at X o'clock for hemostasis].

Thrombosed External Hemorrhoid — Excision

The patient presented with a [right / left / posterior] acutely thrombosed external hemorrhoid within [72 hours] of onset. Under local anesthesia (0.5% bupivacaine with epinephrine), an elliptical excision was performed over the thrombosis removing the entire clot and hemorrhoidal tissue en bloc. Hemostasis was achieved. The wound was left open. The patient was discharged with wound care instructions. Note: incision and drainage (enucleation only) is associated with higher recurrence than formal excision.

Rubber Band Ligation (Office)

For grade I–II internal hemorrhoids, rubber band ligation was performed in the office. Using an anoscope, the [right anterior / right posterior / left lateral] internal hemorrhoidal column was identified above the dentate line. The rubber band ligator was applied [1.5 cm above the dentate line] and the band deployed. The procedure was well-tolerated. The patient was instructed to avoid NSAIDs and strenuous activity for 48 hours and to return if significant bleeding or urinary retention develops.

Charting Tips
  • Document that skin bridges were preserved (>1 cm between each excision site) — anal stenosis is a major morbidity following hemorrhoidectomy and is directly related to inadequate skin bridge preservation. This is the most preventable serious complication.
  • Document the hemorrhoid grade and column positions in clock-face orientation (lithotomy position) — this allows unambiguous communication and is important if reoperation is required. Specify whether internal only, external only, or internal and external components were addressed.
  • For stapled PPH, document that both tissue donuts were complete and the anastomotic ring was inspected circumferentially for hemostasis — bleeding from the staple line is the most common early complication and documenting a complete hemostatic inspection is important.
Billing Tips
  • Bill 46250 for hemorrhoidectomy of two or more external hemorrhoid groups (4.14 wRVU, 90-day global). Use for external hemorrhoidectomy only.
  • Bill 46255 for combined internal and external hemorrhoidectomy, single group (4.84 wRVU). Bill 46260 for combined internal and external, two or more groups (6.56 wRVU). Bill 46261 when combined hemorrhoidectomy is performed with anal fissure repair (7.57 wRVU).
  • Code selection depends on number of column groups treated and whether internal, external, or both are excised. Document each column treated (right anterior, right posterior, left lateral) and the extent of each excision.
  • 90-day global period: postoperative wound care, sitz bath instruction, and routine follow-up are bundled. Delayed bleeding requiring return to the OR uses modifier -78.
  • Rubber band ligation (46221) and infrared coagulation (46930) are minor procedures with 0-day global periods and are not interchangeable with surgical hemorrhoidectomy codes — use the code that matches the actual technique performed.