Varicose Veins

Indications

Surgery for varicose veins, involving long or short saphenous system in the lower limb, is considered when they are symptomatic or present with complications.

Assessment

• The assessment of patients should be done clinically to determine the incompetence in the superficial system and to rule out incompetence of deep venous system.

• This may be followed by investigations, like venous Duplex studies or venography, for the deep system.

• When the decision for surgery is made then the patient is assessed regarding fitness for surgery.

Fig. 5.3.15: The principle of varicose vein surgery involves sapheno-femoral junction ligation, stripping of the l ong saphenous vein and multiple avulsions.

Operation

Operative technique for varicose veins affecting long saphenous system

The operation for varicose veins for long saphenous system comprises of:

• High ligation of long saphenous vein at its junction with the femoral vein.

• Stripping of long saphenous vein.

• Multiple avulsions of the superficial varices.

Pre-operatively the varices are marked with skin marker.

Initially an oblique incision is made in the inguinal skin crease medial to the palpable femoral pulsations.

The junction between the long saphenous vein and the femoral vein is dissected out. All the tributaries draining into the saphenous vein are ligated and cut and the long saphenous vein is then ligated at its junction with the femoral vein and divided (Figure 5.3.15).

Fig. 5.3.16: The position of the sapheno-popliteal junction has been marked with an (X) preoperatively by Duplex scan.

A stripper is passed into the distal end of long saphenous vein until it is palpable around the level of the knee. It is identified and retrieved through a small transverse incision. Stripping below the level of knee joint may cause damage of the saphenous nerve. The whole length of the vein is examined after it is stripped.

For multiple avulsions small (1-2 mm) stab incisions are made over the marked sites and the superficial varices are hooked out and avulsed. The inguinal incision is closed with sub-cuticular skin stitch. The small stab incisions may be closed by skin adhesive strips or clips.

Post-operative dressing consists of compression bandage which is changed, before discharge, to compression stockings for 2 weeks.

Operative technique for sapheno-popliteal junction ligation

The operation for varicose veins for short saphenous system comprises of:

• ligation of short saphenous vein at its junction with the popliteal vein;

• multiple avulsions of the superficial varices;

Pre-operatively the sapheno-popliteal junction needs to be marked by Duplex scan as it may be very variable in position in the popliteal fossa. The superficial varices are marked with a skin marker (Figure 5.3.16).

Fig. 5.3.17: The sapheno-popliteal junction has been disconnected and is about to be ligated.

A transverse 4 cm incision is made over the pre-marked site, in the popliteal fossa, over the sapheno-popliteal junction.

A further transverse incision is made in the deep fascia and dissection is carried down, deep to the fascia, to expose the junction between the short saphenous vein and the popliteal vein.

All the tributaries draining into the saphenous vein are ligated and divided. The short saphenous vein is then ligated at its junction with the popliteal vein and divided (Figure 5.3.17).

Stripping of short saphenous vein may be performed, although many surgeons prefer not to do that as it may result in damage to the sural nerve.

Operation for perforators

Sub-fascial endoscopic perforator surgery is used for ligation of incompetent perforators in the case of leg ulcers or to treat lipodermatosclerosis. However, the exact role of this procedure remains controversial.

Complications

The complications are as follows:

1. Bruising and discomfort in the leg.

2. Damage to the sensory nerves, i.e. saphenous or sural nerves.

3. Damage to motor nerves, i.e. femoral in the inguinal region and branches of sciatic in the popliteal fossa.

4. Venous thrombosis in the residual superficial veins.

5. Deep venous thrombosis and incompetence.

6. Recurrence in the long term.

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