· 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.
-
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 -
Occlusion of the deep
venous system -
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 -
General anaesthesia -
Spinal anaesthesia -
Supine on the
operating table -
Can have 30 degrees
of head down tilt -
Hip abducted -
Knee slightly flexed -
Ankle on a padded
board -
1 assistant -
Palpate for the
artery -
2.5cm below and
lateral to the pubic tubercle -
Short, transverse
incision -
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 -
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 -
Not required -
2/0 Vicryl -
Monocryl 3/0
subcuticular -
Compression bandage
to the leg (long combine,
elastic bandage – firmly placed but not too firm) -
Dressing down the
next day and fit with a grade
2 venous compression stocking -
Mobilise early Varicose Veins
Indications
Contraindications
Preoperative preparation
Anaesthesia
Position of the patient
Special equipment
Incision
Exploration
Options arising during surgery
Drainage
Closure
Dressing
Post-operative instructions