Varicose Veins


Saphenofemoral incompetence

 

· I ensure routine Duplex to exclude deep venous insufficiency and mark site of SFJ, incompetent perforators and to mark SP if SSV disconnection being performed. I ask for this to be performed on the day of surgery in permanent black marker

·— I ensure administration of prophylactic use of LMWH should be considered in any patient

over 40

overweight

over 1 hr operation

· I also mark pre-operatively in the anesthetic bay, site the site of any prominent varicosities as tram lines to guide below knee stab avulsions

 

· “In an appropriately Ix, prepared and consented patient”

· GA, supine hip abducted & knee flexed,

· Leg(s) & groin free draped perineal exclusion (U drape), foot wrapped

30 degree head down

· » 5cm groin crease incision centered over a point 3cm lateral & inferior to pubic tubercle

— Use artery as guide

· Incises skin, subcutaneous tissue, superficial fascia

· Self retainer Travers

· Identify LSV or one of its tributaries and follow it through the fossa ovalis towards the femoral vein

· I identify the LSV entering femoral vein, displaying the latter clearly.

· Ligate branches in continuity suing 2/0 Vicryl ties

Anterolateral

Posteromedial

Superficial & deep external pudendal

Superficial epigastric

Superficial Cx iliac

v Watch for superficial external pudendal artery

· Identify S-F junction

· Flush ligate LSV flush with femoral vein, using an 2/0 Prolene suture tie and 0 Vicryl for distal end

· I introduce a flexible plastic stripper with a blunt tip through a small venotomy distal to my tie on the divided end of the LSV and pass it to about 1 hands breadth below knee

— May need manipulation to keep in LSV

· Cut down onto vein, ligate distal LSV, deliver stripper through small venotomy

· Tie vein round stripper at the groin

· I attach the olive to stripper in the groin & eversion strip from groin ® knee, divide vein @ knee.

· My assistant and I apply firm constant pressure over the course of the LSV for 2-3 minutes to minimize bruising.

· Ligation of incompetent perforators

— 1cm incision over point marked

— T juntion identified , ligated & excised

· Multiple stab avulsion @ points marked

   15 blade & mosquito forceps

   I draw up the vein and clamp it proximally and distally with mosquito forceps.

   I then roll the forceps applying continous pressure until the vein starts to tear.

   I then reapply a forceps and ligate the vein with 3/0 Vicryl ties

· S/c 3/0 Monocryl to skin

· Dressings, orthoban & crepe

· Bandages for 1 week, encourage mobilization rather than standing or sitting with legs dependnat

· Compression stockings following for 3 weeks, review in OPD

 

 

QUESTIONS

 

You can’t pass the stripper from the groin

Withdraw it slightly and try again with a rotating action twisting the free end to help negotiate valves and other irregularities

 

You can’t pass it beyond the knee

Flex and extend the knee and place external pressure on the tip of the stripper

 

You still can’t negotiate the stripper

Make an incision below the knee over the LSV and pass a second stripper from proximal to distal until the two meet. Then advance the first stripper from the groin whilst withdrawing the lower one.

 

You still can’t get either of these strippers to pass an obstruction.

Cut down onto the tips of both and avulse it both directions leaving the middle segment, which you can avulse if varicose.

 


Sapheno-popliteal incompetence

 

· I ensure routine Duplex to mark SPJ. I ask for this to be performed on the day of surgery in permanent black marker

·— I ensure administration of prophylactic use of LMWH should be considered in any patient

over 40

overweight

over 1 hr operation

· I also mark pre-operatively in the anesthetic bay, site the site of any prominent varicosities as tram lines to guide below knee stab avulsions

· I place the patient prone with ET intubation and pillow under the chest and hips

 

· 20 degree head down and slightly abduct the legs.

· I make a 4cm incision in the region of the popliteal fossa over the marked junction

· I make a vertical incision in the deep fascia and expose the termination of the vein by blunt dissection

· I insert Langenbeck retractors to display confidently the T-junction between the popliteal and saphenous veins

· I look for the vein of Giacomini joining the SSV from above and ligate it with 2/0 Vicryl ties

· I am careful not to damage the sural nerve emerging laterally in popliteal fossa.

· I divide the SSV with 2/0 vicryl ties and doubly ligate the stump flush on the popliteal vein.

 


Varicose Veins

 

Indications

-       Cosmetic appearance

-       Symptomatic

o   Ache at the end of the day

-       Recurrent attacks of superficial thrombophlebitis

-       Chronic venous insufficiency

-       Venous hypertension

o   Extensive bleeding from a ruptured varix

-       Venous ulceration

 

 

Contraindications

-       Occlusion of the deep venous system

 

Preoperative preparation

-       Venous duplex and Doppler

-       Consent

o   Recurrence

o   Wound infection

o   Seroma

o   Damage to great vessels

o   Saphenous nerve injury

o   Common peroneal nerve injury

-       Perioperative antibiotics

-       Mark veins preoperatively with the patient standing up  (permanent marker)

-       Short saphenous insufficiency – mark SSV with duplex US

 

Anaesthesia

-       General anaesthesia

-       Spinal anaesthesia

 

Position of the patient

-       Supine on the operating table

-       Can have 30 degrees of head down tilt

-       Hip abducted

-       Knee slightly flexed

-       Ankle on a padded board

 

Special equipment

-       1 assistant

 

Incision

-       Palpate for the artery

-       2.5cm below and lateral to the pubic tubercle

-       Short, transverse incision

 

Exploration

-       Deepen the incision through the subcutaneous fat

-       Long saphenous vein appears as a dark blue longitudinal trunk in the centre of the dissection as the subcutaneous fat is spread

-       Dissect out of the surrounding fat, following it up to the saphenofemoral junction

-       Dissect out, ligate with 2/0 Vicryl or 3/0 Ethilon and divide all tributaries to the LSV

o   Superficial inferior epigastric

o   Superficial and deep external pudendal

o   Posteromedial and anterolateral thigh veins

o   Superficial circumflex iliac vein

-       LSV dips down through the cribriform fascia over the foramen ovale to the femoral vein

-       Separate the subcutaneous fat off the vein by blunt dissection to trace its path

-       Display the femoral vein for 1cm above and below the sapheno-femoral junction and clear any branches entering from either side

-       Place a ligature around LSV with one throw (use for control)

-       Ligate LSV in continuity with 0 Ethilon/Vicryl and divide

o   4/0 Prolene suture ligation of SFJ an alternative

-       Make a small venotomy in the LSV to introduce a stripper

-       Pass stripper down to just below the knee

 


-       Make a small incision over the olive (longitudinal), dissect out LSV and loop with 2 ties (proximal and distal, leaving the proximal tie a full length)

-       Ligate distally

-       Proximally – venotomy and place an olive on the stripper

-       Antegrade strip to the groin – assistant puts compression on the tract

-       Stab avulsion of varicosities

 

Options arising during surgery

-       Stripper stuck

o   Twist the free end to rotate the tip

o   Flex and extend knee

o   Pass a 2nd stripper from below the knee

o   Cut down on the tip of the stripper

 

Drainage

-       Not required

 

Closure

-       2/0 Vicryl

-       Monocryl 3/0 subcuticular

 

Dressing

-       Compression bandage to the leg (long combine, elastic bandage – firmly placed but not too firm)

 

Post-operative instructions

-       Dressing down the next day and fit with a grade 2 venous compression stocking

-       Mobilise early