Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5179_Библиотеки_им_академика_М_И_Перельмана.pdf
234
Manipal Manual of Surgery
Key Box 30.5
Tests for Varicose Veins
Cough impulse test: SF incompetence
Trendelenburg I: SF incompetence
Trendelenburg II: Perforator incompetence
Multiple tourniquet test: Site of perforator in-
competence
Schwartz test: Superficial column of blood
Modified Perthes’ test: Deep vein thrombosis
Fegan’s test: To locate the perforators in the deep
fascia
Fig. 30.11: Classical blow out
Fig. 30.12: Dilated vein in
popliteal region
• Ankle flare is a group of reticular veins near the
medial malleolus.
• Complications such as ulceration, bleeding, eczema,
and dermatitis may be present. Pigmentation is often
seen. It is due to subcutaneous microangiopathy,
acute cellulitis, fasciitis, and panniculitis.
• Healed scar indicates previous ulceration.
• A dilated vein may be present over the popliteal fossa
region as well (Fig. 30.12).
Palpation
• First palpate along the whole length of vein for
tenderness. If present, it indicates thrombophlebitis.
A thrombosed vein will feel like a firm/hard nodule.
• The following tests are performed (Key Box 30.5).
1. Cough impulse test (Morrissey’s test): This test
should be done in the standing position. The
examiner keeps the finger at the SF junction and asks
the patient to cough. Fluid thrill, an impulse felt by
the fingers, is indicative of ‘saphenofemoral
incompetence’.
2. Trendelenburg test: This test is done in 2 parts
(Figs 30.13–30.15).
• Method: The patient is asked to lie on the couch in
the supine position. The leg is elevated above the
level of the heart and the vein is emptied. The
SF junction is occluded with the thumb (or a
tourniquet) and the patient is asked to stand.
• Trendelenburg I: Release the thumb or tourniquet
immediately. A rapid gush of blood from above
downwards indicates saphenofemoral incompetence.
• Trendelenburg II: The pressure at the SF junction
is maintained without releasing the thumb or
tourniquet. The patient is then asked to stand.
Slow filling of the long saphenous is seen which
indicates perforator incompetence (retrograde flow
of blood).
Fig. 30.13: Trendelenburg test part I Fig. 30.14: Rapid filling on releasing pressure Fig. 30.15: Tren-
Section II • General Surgery
delenburg test part
II—slow filling is seen
Varicose Veins and Deep Vein Thrombosis
235
3. Multiple tourniquet test: It is done to determine the
exact site of the perforators (Fig. 30.16).
• Method: The patient is asked to lie supine on the
couch. The vein is emptied by elevation. As the
name suggests, 3–4 tourniquets (multiple) may be
applied. Applying more tourniquets is not
practical. There are mainly ankle, knee, and thigh
perforators. Hence, four tourniquets may be
applied at the following levels:
• 1st tourniquet: At the level of the SF junction.
• 2nd tourniquet: At the level of middle of the thigh,
to occlude the perforator in the Hunter’s canal.
• 3rd tourniquet: Just below the knee.
• 4th tourniquet: Palm breadth (lower third of the
leg) above the medial malleolus/ankle.
Ask the patient to stand and observe the appearance
of veins.
Inference: Appearance of veins between the first and
second tourniquets indicates incompetence of thigh
perforators, between the second and third indicates
incompetence of knee perforators, and below the
fourth indicates incompetence of ankle perforators.
Most commonly, below-knee and ankle perforators
are incompetent.
On releasing the tourniquets one by one from below
upwards, sudden retrograde filling of the veins
occurs.
4. Schwartz test: It is done with the patient in the stand-
ing position. Place the fingers of the left hand over a
dilated segment of the vein and tap the vein with the
right index finger. A palpable impulse suggests a
superficial column of blood in the vein and incompetent valves between the segment (Fig. 30.17).
A
Figs 30.16A and B: Multiple tourni-
quet test (3 or 4)
B
Fig. 30.17: Schwartz test
(should be done in the
standing position)
1
5. Modified Perthes’ test
: It is done to rule out deep
vein thrombosis. The patient is asked to stand and a
tourniquet is applied at SF junction. He is then asked
to take a brisk walk-tip toe walking
Inference: If the patient complains of severe pain in
the calf region or if superficial veins become more
prominent, it indicates deep vein thrombosis and is
a contraindication for surgery.
Please note: The vein is not emptied in modified Perthes’ test.
6. Fegan’s method (test): It is done to detect the site of
perforators. The patient is asked to stand and the
varicosity is marked with methylene blue. Patient is
then asked to lie down. The leg is elevated to empty
the vein and the vein is palpated throughout its
course. The defects in the deep fascia have a circular,
buttonhole consistency.
Examination of varicose ulcer: It should be done by
inspection and palpation.
Evidence of deep vein thrombosis: Homan’s test must
be done in chronic DVT. Moses’ test (vide infra) not to be
done.
Examination of the abdomen: To rule out pelvic
tumours. Look for inferior vena caval obstruction in the
form of dilated veins in the lateral abdominal wall.
CLINICAL DISCUSSION
At the end of clinical examination, you should be ready
to answer the following questions:
1. Which system is involved?
• Medial veins: LSV—long saphenous vein
• Lateral veins: SSV—short saphenous vein
. Is the SF junction incompetent?
2
Yes—Trendelenburg I is positive, No—Trendelenburg I is negative
3. Is there perforator incompetence?
Yes—Trendelenburg II is positive, No—Trendelenburg II is negative
4. Which group of perforators is incompetent?
According to the results of multiple tourniquet test—
usually ankle and below knee.
5. Is there deep vein thrombosis?
Yes—Perthes’ test is positive, No—Perthes’ test is
negative.
6. Is there any abdominal mass?
There may be a pelvic tumour.
1
In original Perthes’ test, the limb is wrapped and elastic bandage is applied.
Section II • General Surgery
236
Manipal Manual of Surgery
7. Are any complications present?
Eczema, dermatitis, ulcer, etc.
8. Is it unilateral or bilateral?
Determine by hand-held Doppler—extension of
clinical examination.
9. What is the CEAP classification?
Example: C1 Ep A-LSV Pr.
10. What is the gait of the patient?
Equinus deformity in long standing ulcers.
INVESTIGATIONS
. Hand-held Doppler is the first, minimum-level
1
investigation done before treating a patient with
venous disease. Patient is asked to stand.
• When the blood flows, the wave emits a signal—
the Doppler signal.
• If there is SF incompetence, forward and backward
flow may be detected.
• Biphasic signal: Gently squeeze calf muscles and
assess the flow in the SF junction with the Doppler
probe.
• It may also pick up an accessory long saphenous
vein in the groin.
• Can be used to mark the SF junction and SP junction.
• Patient can be asked to cough and reflux can be
confirmed at SF junction.
• It is not used to identify perforators (Key Box 30.6).
2. Duplex ultrasound imaging: In this investigation,
high resolution B-mode ultrasound imaging and
Doppler ultrasound are used (Figs 30.18 and 30.19).
• It provides images of the veins and measures the
flow in them.
• The origin of venous ulcers and varicose veins may
also be assessed.
• Retrograde flow in the veins may be demonstrated
by compression, release, and the Valsalva
manoeuvre.
Fig. 30.18: Duplex scanning showing venous reflux
Fig. 30.19: Popliteal vein thrombosis
(Courtesy: Dr Rajgopal, Head, Department of Radiology and
Imaging, KMC, Manipal)
Fig. 30.20: Mickey Mouse sign—as seen in duplex ultrasound
Key Box 30.6
Doppler Ultrasound
This investigation is carried out with the patient
standing/sitting.
Incompetence of SFJ and saphenopopliteal junction
(SPJ) can be assessed by this method—reflux.
Gentle squeezing of calf muscles helps in detecting
saphenopopliteal incompetence.
To identify and locate perforators.
It also helps to rule out arterial diseases.
It can detect patency of veins.
It can detect deep vein thrombosis.
Section II • General Surgery
• Mickey Mouse sign: The three prominent structures—
the common femoral artery and the great saphenous
vein above and the common femoral vein below
mimic Mickey Mouse (Fig. 30.20).
• Saphenous eye sign: In the fascial compartments of
the thigh, the dilated saphenous vein in cross-section
resembles an ‘eye’ in transverse ‘B’ mode scan. .
3. Venography: Both ascending and descending
venographies may be done in a case of deep vein
thrombosis. It is an invasive procedure and carries
the risk of spreading infection and septicaemia.
Duplex ultrasonography has largely replaced this
investigation (rarely done now). Varicography refers
Varicose Veins and Deep Vein Thrombosis
237
to injecting contrast into surface veins (indicated in
recurrent varicose veins). It may be followed by
sclerosant injections.
4. Plethysmography: It is based on the measurement
of volume changes in the leg. By placing a lightemitting diode above the medial malleolus and
having the patient perform tip-toe movements,
venous recovery time may be measured. This is called
photoplethysmography (PPT).
With the advent of venous duplex scan, venography
and plethysmography are rarely done.
TREATMENT
A. Pharmacotherapy: It helps reduce oedema of the leg,
and thereby improves night cramps. Flavanoids affect
leucocytes and vascular endothelium, which helps heal
cutaneous ulcers. Diosmin and hesperidin are the two
commonly used vasoactive drugs. Diosmin prolongs the
vasoconstrictor effect of norepinephrine on the vein wall.
Thus, venous tone is increased and the venous volume,
distensibility, and stasis are reduced. This increases the
venous return, which helps patients with CVI.
B. Non-surgical treatment:
1. Elastic compression stockings
. Injection line of treatment (compression sclerotherapy)
2
3. Foam sclerotherapy
4. Endovenous laser ablation
5. Radio-Frequency Ablation (RFA)
1. Elastic Compression Stockings (Key Box 30.7)
These are also called graduated compression stockings.
It is the fundamental treatment for varicose veins. This
may be advised in asymptomatic cases of varicose veins
and in cases of venous oedema and secondary varicose
veins.
Key Box 30.7
How Graduated Compression Stockings Work?
Increases the interstitial pressure
Promotes fluid reabsorption
Improves ambulatory venous pressure
Improves skin micro-circulation
• Usually 20–30 mmHg stockings are sufficient.
• It should be worn from the ankle to below the
knee.
• It should be worn during working hours (entire day).
• It should be removed while lying down but the legs
should be kept elevated.
• Above knee stockings should never be prescribed as
they are difficult to put on and tend to roll down.
Advantages
• Require minimal patient involvement
• Provide continuous compression (Table 30.3)
• Provide topical therapy
Disadvantages
• Bulky and uncomfortable
• Ulcers cannot be monitored once applied
• Dermatitis
Indications
• Pregnancy, pelvic tumour
• Perthes’ test—positive patient
• AV fistula
Contraindication: Occlusive arterial disease.
Extreme care to be taken while applying compression stockings
in a patient with arterial occlusive disease. Incidences of
gangrene has been reported.
2. Injection Line of Treatment (Compression
Sclerotherapy) (Key Box 30.8)
Key Box 30.8
Compression Sclerotherapy
Endothelial cells in the vein wall are damaged
Effective sclerosant
Empty vein
Elastic compression stockings
Exercises Observe 5 Es
Table 30.3 Compression stockings
Class Pressure Strength Indication CEAP
I 15–20 mmHg Mild Minor varicosities, mild oedema 1, 2, 3
II 20–30 mmHg Moderate Moderate varicosities, phlebitis, 3, 4
moderate oedema, postoperative ablation
III 30– 40 mmHg Firm Severe varicosities, active ulcer, DVT 4, 5, 6
IV >40 mmHg Extra firm Lymphoedema N/A
Section II • General Surgery
238
Manipal Manual of Surgery
Indications
Below knee varicosity and recurrent varicosity after
surgery.
Procedure
Varicose veins are marked in the standing position.
Doppler can be used to puncture the vein. The veins
are punctured with a needle attached to a syringe
containing a sclerosant agent and the patient is asked
to lie down. 3% sodium tetradecyl sulphate or 1–2 ml
of ethanolamine oleate or hypertonic saline is injected
into the column of vein. Aseptic thrombosis and fibrosis
occur, which shrinks the vein. A tight elastic compression
bandage is applied. Success of sclerotherapy depends
on the use of an effective sclerosant, injection into an
empty vein, and compression followed by exercise.
Injection sclerotherapy is useful in varicose veins <3 mm in
diameter. Large veins require surgery.
Complications of Compression Sclerotherapy
Allergy, pigmentation, deep vein thrombosis, thrombophlebitis and skin necrosis.
3. Ultrasound-guided Foam Sclerotherapy by Tessari
(Key Box 30.9)
• 2 syringes are used here with a 3-way stopcock is used
to inject the foam. It was described by Lorenzo Tessari.
• Very useful and better when there are large veins.
• Foam is visible in ultrasound, thus obliteration of
veins can be visualised better.
• Foam sclerosant C (polidocanol) is used. It is prepared
by mixing air with a sclerosant.
• It is injected into the superficial veins under ultra-
sound guidance.
• LSV should be compressed in the upper thigh to
prevent entry of foam into the femoral vein.
• The leg should be elevated to prevent entry of foam
into the calf veins.
Complications of Foam Sclerotherapy
• Skin ulceration due to extravasation.
• Deep vein thrombosis due to escape into deep veins.
• Headache and stroke due to air entry into the brain.
4. Endovenous Laser Ablation (EVLA) (Fig. 30.21)
It is a minimally invasive, outpatient procedure that uses
lasers to ablate varicose veins. It gives excellent cosmetic
and functional results and is ideal for veins >12 mm in
diameter. It is done after giving tumescent anaesthesia.
Tumescent means tissue is swollen and firm. It is done by
extensive
regional anesthesia of skin and subcutaneous
tissue with a high total dose (200 ml of 0.1% lignocaine
with adrenaline and bicarbonate) but a low risk of systemic
toxicity. Thus it avoids skin burns and other reactions.
Advantages
• Simple outpatient procedure
• Ideal for junctional and truncal incompetence
• Less expensive than radiofrequency ablation
Disadvantages
• Expensive and not ideal for smaller, tortuous, and/
or thrombophlebitic veins.
Key Box 30.9
Foam Sclerotherapy
Used to treat small and medium-sized varicose veins.
Sclerosant is mixed with air or preferably carbon
dioxide plus oxygen.
Carbon dioxide plus oxygen is soluble in blood and
hence safe.
Foam causes inflammation of vein wall, obliteration of
venous lumen and vein occlusion.
Success rates range from 60 to 90%.
Complications include cutaneous ulceration, thrombo-
phlebitis, deep vein thrombosis and allergy.
Foam displaces blood (unlike sclerosant which mixes
with blood), requires small quantity to be in touch with
vein wall.
Extravasated foam is much better tolerated.
It is echogenic.
Section II • General Surgery
Fig. 30.21: Endovenous laser ablation
Varicose Veins and Deep Vein Thrombosis
5. Radiofrequency Ablation (RFA)
• Ideally suited for long saphenous vein with a
diameter <12 mm.
• It is also a minimally invasive ablation technique
that uses a bipolar catheter electrode at a temperature
of 110–120°C with a power of 2–4 W. It is a
highfrequency alternating radiofrequency current that
leads to venous spasm, collagen shrinkage and
physical contraction.
• The position of the patient, accurate marking of the
veins, and tumescent anaesthesia are similar to that
of EVLA. The vein is cannulated with a 7F sheath.
• The catheter tip should be placed 2.0 cm inferior to
the saphenofemoral or saphenopopliteal junction.
• A vein segment >7 cm long may be ablated in
20 seconds cycles.
• Compression stockings to be used after the RFA.
• Complications include thrombophlebitis, pain, and
skin burns.
• It is a safe and effective treatment for varicose veins.
6. Surgery
. Trendelenburg’s operation (Figs 30.22–30.27):
1
• An inguinal incision is made, the long saphenous
vein is identified, and the 3 tributaries are ligated.
The long saphenous vein is ligated close to the
femoral vein and divided. Up to this step is called
Trendelenburg operation (juxtafemoral flush
ligation).
• An incision is made on the medial side of the upper
leg and the long saphenous vein is isolated. The
lower end is ligated and the vein is incised. A long
metallic stripper is introduced within the vein and
brought out from the long saphenous vein below
a knee incision. A metallic head is connected to the
stripper and the vein is avulsed. A tight crepe
bandage is applied, the inguinal incision is sutured,
and the limb is elevated (retrograde avulsion).
239
Fig. 30.24: Trendelenburg operation. Long saphenous vein
should never be ligated in the groin unless you demonstrate
‘T’ junction—LSV joining femoral vein (Key Box 30.10)
Key Box 30.10
Wisdom in Juxtafemoral Flush Ligation
1. Demonstrate T junction—long saphenous vein joining
femoral vein.
2. Demonstrate 3–4 tributaries before ligation.
3. Double saphenous vein can be present as an anomaly.
4. Receives large anterolateral thigh veins and posteromedial thigh veins.
5. Demonstrate femoral vein for a centimetre both above
and below the SF junction.
Fig. 30.22: Perforators
marked
Perforators are marked before surgery
to facilitate identification of perforators
and communicating
veins so that they
can be ligated and
excised (Fig. 30.22).
You can see in this
picture the prominent veins are marked (Fig. 30.23).
Fig. 30.23: Ankle veins marked
Fig. 30.25: LSV is divided at the
groin and stripper is introduced
within the lumen
Fig. 30.27: Multiple ligation
Fig. 30.26: One segment of
the vein is isolated followed by
ligation at both ends and if it is
very tortuous, it is excised
Section II • General Surgery
240
Manipal Manual of Surgery
• During the procedure, a few tributaries of the long
saphenous vein get avulsed and thrombosed
(ligation with stripping operation). It is indicated
in cases of saphenofemoral incompetence.
• Once stripping is done, small incisions are given
where perforators are marked. They are ligated
and excised.
2. Subfascial ligation of Cockett and Dodd: In this
operation, the perforators are identified deep to the
deep fascia and ligated subfascially. This is indicated
in cases of perforator incompetence with saphenofemoral competence. This may also be done
endoscopically.
3. Subfascial endoscopic perforator surgery (SEPS)
(Fig. 30.28)
• Small port incisions are made in the skin over the
calf region and deepened through the fascia.
• Carbon dioxide insufflation is done. A balloon
expander may also be used to distend the subfascial plane.
• 2–6 perforators are identified and ligated.
• The procedure is simple and quick with least
morbidity and is becoming popular.
• It is indicated for below-knee perforators.
4. Smaller veins have also been treated with phlebectomies.
Fig. 30.28: SEPS
SU27.6: Describe the pathophysiology, clinical features,
investigations and principles of management of DVT and
varicose veins.
COMPLICATIONS OF VARICOSE VEINS
1. Eczema and dermatitis (Figs 30.29 and 30.30): It occurs
due to extravasation and breakdown of RBCs in the
lower leg. It gives rise to itching, which precipitates
varicose ulcer. It is treated by applying zinc oxide
cream or silver sulfadiazine cream (stasis dermatitis).
2. Lipodermatosclerosis (Figs 30.31 and 30.32) refers to
various skin changes in the lower leg associated with
varicose veins such as thickening of subcutaneous
tissue, indurated wood-like feel, pigmentation, etc.
It is due to increased venous pressure resulting in
capillary leakage with extravasation of blood and
fibrin into the surrounding tissues. Blood is broken
down and haem is released, which combines with
iron to form haemosiderin, which is responsible for
pigmentation. Classically, this affects the gaiter area
of the leg just above the malleoli.
3. Haemorrhage: It occurs due to trauma or eczema. It
may be controlled by elevating the leg and applying
a crepe bandage. Do not try to catch bleeders with
artery forceps.
4. Thrombophlebitis (Key Box 30.11): It refers to
inflammation of a superficial vein. The vein is tender,
hard and cord-like. The skin is inflamed and pyrexia
is usually present. It is treated with bedrest, elevation,
crepe bandage, antibiotics, and anti-inflammatory drugs.
5. Venous ulcer (Figs 30.32–30.35): It is also called
gravitational ulcer. Its precipitating factors are
venous stasis and tissue anoxia. Deep vein thrombosis
is also an important cause of venous ulcer wherein
valves are either destroyed or incompetent due to
damage. Sustained venous pressure results in
extravasation of cells and activation of capillary
endothelium, resulting in the release of free radicals.
These free radicals cause tissue destruction and
ulceration. Lipodermatosclerosis and tissue anoxia
are the other factors. The following hypotheses may
explain the genesis of varicose ulcers.
Fig. 30.29: Eczema Fig. 30.30: Dermatitis
Section II • General Surgery
Fig. 30.31: Observe pigmentation, lipo-
dermatosclerosis and ulcer formation
Varicose Veins and Deep Vein Thrombosis
Fig. 30.32: A case of lipodermato-
sclerosis
(Courtesy: Dr Maruthu Pandyan, Government Medical College,
Madurai, Tamil Nadu)
Key Box 30.11
Fig. 30.33: Varicose
vein with venous ulcer
Thrombophlebitis—Causes
Spontaneous TAO, malignancy
Trauma
Blood transfusion
IV fluids, chemotherapeutic drugs
Varicose veins
241
Fig. 30.34: Gaiter areas are those areas where skin changes
and venous stasis ulcer occurs due to ambulatory venous
tension and incompetent perforators. Damage to capil-
hyper
laries results in protein-rich fluid and blood extravasation
Fig. 30.35: Venous ulcer (Courtesy: Dr Maruthu Pandyan,
Professor of Surgery, Government Medical College, Madurai,
Tamil Nadu)
Fibrin cuff hypothesis: The combination of capillary
proliferation and inflammation (in the form of
macrophages) is a major factor in the development
of venous ulcers. As a result of chronic inflammation,
a perivascular cuff develops around the capillaries.
This perivascular cuff is made up of many connective
tissue proteins, including fibrin, collagen IV, and
fibronectin. Slowly, a venous ulcer develops.
White cell trapping hypothesis: Venous hyper-
tension causes trapping of leucocytes, which become
activated and release proteolytic enzymes that cause
damage to the capillary endothelium.
Whatever be the exact mechanism of ulceration, ambulatory
venous hypertension is the only accepted cause of ulceration
(Fig. 30.34).
Features of a venous ulcer (Fig. 30.35)
• Typically situated just above the medial malleolus.
• Oval, small, painless, and superficial with
surrounding pigmentation.
• Dilated veins above the ulcer give a clue to the
diagnosis (Key Box 30.12).
Key Box 30.12
Factors Predisposing to Nonhealing Venous Ulcers
1. Ambulatory venous hypertension.
2. Perivascular fibrin cuff resulting in poor diffusion of
oxygen to the tissues.
3. White cell trapping.
4. Reactive oxygen species are increased and they
generate free radicals leading to tissue damage.
5. Inhibition of growth factors leading to poor repair.
Treatment of venous ulcers: Bisgaard’s method
(Nowadays, it is not recommended)
• Rest with elevated limb (Fig. 30.36).
• Elastic crepe bandage helps in venous return.
Fig. 30.36: Elastic crepe bandage for varicose ulcer. Elevation
of the leg is the most important factor for healing of the ulcer
Section II • General Surgery
242
Manipal Manual of Surgery
• Active exercises should be taught to the patients
(to contract calf muscles).
• Passive exercises
• Correct method of walking with the heel down first.
• If the ulcer is infected, antibiotics are given and a
four-layered dressing is applied. Once the ulcer
heals, Trendelenburg’s operation is performed.
Four-Layered Dressing
Content Uses
Layer 1 Wool bandage Absorbs exudates.
Redistributes pressure
around the limb and protects
bony prominences.
Layer 2 Crepe bandage (light Holds stockings better and
compression) provides padding in place.
(15 mmHg)
Layer 3 Bandage (medium
compression) Applied with graduated
compression.
300% extensible and 100%,
elastic.
Layer 4 Cohesive bandage Self-adhesive bandage of
added reinforcement.
Holds 3 layers in place,
thereby retaining the compression.
6. Calcification may be seen in the walls of the vein.
7. Periostitis of the tibia may occur due to the location
of the ulcer on the medial surface of the leg. Due to
involvement of the periosteum, there is severe pain.
8. Equinovarus deformity occurs due to improper habit
of walking on the toes which results in shortening of
the tendo-Achilles.
9. Marjolin’s ulcer is a squamous cell carcinoma arising
from a healed varicose ulcer with scarring.
SHORT SAPHENOUS VARICOSITY
The short saphenous vein originates from the lateral part
of the dorsal venous arch and ends in the popliteal vein
in the popliteal fossa (Fig. 30.37).
Incompetence of the saphenopopliteal
valve results in short saphenous
varicosity. It produces prominent
veins on the lateral aspect of the leg
with or without ulceration. These are
treated by ligation of the short
saphenous vein in the popliteal fossa
(Table 30.4).
Ligation of the Saphenopopliteal
Junction
• Preoperative ultrasonographic
marking is essential.
• The vein should be ligated deep to
Fig. 30.37: Short
saphenous vein
and its perforators
the deep fascia.
• Branches—the Giacomini vein and gastrocnemius
veins may be seen. They must be ligated.
• It may be stripped up to the mid-calf to avoid injury
to the sural nerve.
• It is important to close the deep fascia to avoid an
unsightly cosmetic bulge behind the knee.
TEN COMMANDMENTS OF
VENOUS ULCER TREATMENT
1. Should lose weight
2. Should perform venous Doppler to rule out deep vein
thrombosis or thrombophlebitis
3. Should take rest with the leg elevated above the level of
the heart
4. Should receive antibiotics if infection is present
5. Should apply a wound cover with suitable dressings
6. Should apply compression stockings
7. Should consider surgery only once infection is under
control
8. Should ligate long or short veins if they are incompetent
9. Should ensure that all perforators are ligated
10. Should look for an accessory long saphenous vein near the
termination of the vein—if present, it should be ligated to
avoid recurrence
Table 30.4 Comparison between long saphenous and short saphenous veins
Features Long saphenous vein Short saphenous vein
1.Origin Medial part of dorsal venous arch Lateral part of dorsal venous arch
2.Location Front of medial malleolus Behind lateral malleolus
3.Relation with nerve Saphenous nerve Sural nerve
4.Number of valves 15–20 valves 1 valve
5.Termination Saphenofemoral junction Saphenopopliteal junction
Section II • General Surgery
Varicose Veins and Deep Vein Thrombosis
243
RECURRENT VARICOSE VEINS
• Incidence is about 10–30%.
• Important causes of recurrence include failure to
ligate the LSV at the SF junction, failure to ligate
tributaries at the SF junction, and a possible accessory
long saphenous vein (Fig. 30.38).
• Other factors for failure include neovascularisation
and reflux in residual veins.
• Recurrence is less after stripping of veins than after
multiple ligation.
• Injection sclerotherapy and EVLA/RFA may be done.
• Re-surgery may be performed. However, wound infec-
tion, wound gaping, and lymph leak are more common.
Fig. 30.38: Accessory long saphenous vein
DEEP VEIN THROMBOSIS (DVT)
ACUTE DEEP VEIN THROMBOSIS
It is also called phlebothrombosis. It can be acute or
chronic. Acute deep vein thrombosis is very common
in western countries, the exact cause of which is
unknown. Postoperative immobilisation, pressure on
the calf muscles, sluggish blood flow, and prolonged
bedrest are some of the precipitating factors for deep
vein thrombosis. It commonly affects venous sinuses
in the soleal muscles. It is a common starting place. It
may also involve pelvic veins. The various factors
responsible for deep vein thrombosis can be remembered as THROMBOSIS (Key Boxes 30.13 and 30.14). It
should be suspected in the postoperative period when
Key Box 30.13
Thrombosis—Virchow’s Triad
Endothelial injury
Stasis
Increased coagulability
Key Box 30.14
Causes of Deep Vein Thrombosis
(Lower Limb DVT)
Trauma—injury to the vessel wall
Hormones—increased coagulability
Road traffic accidents
Operations—cholecystectomy
Malignancy—sluggish blood flow
Blood disorders—polycythaemia
Orthopaedic surgery, obesity, old age
Serious illness—stroke, MI
Immobilisation
Splenectomy
Remember as THROMBOSIS
Upper limb DVT
is rare. Can occur
due to trauma or
surgery.
patient complains of pain in the calf region or complains
of limb oedema. The maximum incidence occurs on the
2nd and 5th–6th postoperative days.
Signs of Acute DVT
1. Homan’s test: Forcible dorsiflexion of the foot results
in severe pain in the calf region.
. Moses’ test (ideally should not be done due to risk
2
of embolism): Tenderness over the calf muscle on
squeezing the muscle from side to side.
3. Pitting oedema
4. Low grade fever with an increased pulse rate is
characteristic.
5. Phlegmasia alba dolens refers to white leg. It occurs
when the thrombus extends from the calf region to
the iliofemoral vein.
6. Phlegmasia coerulea dolens refers to blue leg with
loss of superficial tissues of the toes.
7. Superficial blebs in the skin—can be confused for
necrotising fasciitis.
Treatment
Acute DVT
1. Bedrest and limb elevation.
. Injection heparin 10,000 units IV bolus with conti-
2
nuous infusion of 30,000–45,000 units/day. During
heparin therapy, activated partial thromboplastin
time (APTT) should be maintained at twice the
normal value. Heparin is given for 7–10 days.
Warfarin, an oral anticoagulant, is started 2–3 days
before heparin is withdrawn because of its slow
onset. Treatment with warfarin should continue for
6–12 months. A repeat Duplex scan should be done
to look for recanalisation of the veins. The dose of
warfarin should be 10 mg twice a day. Treatment is
Section II • General Surgery