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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3953_Библиотеки_им_академика_М_И_Перельмана
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Figure 1 Preoperative vein marking. (See color insert.)
Figure 2 Groin incision. The foot is to the left. The silk loop on the right is just distal to the
saphenofemoral junction. (See color insert.)
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anterior or posterior branches are visible. Clipping and dividing the branches will reduce
bleeding in the upper thigh. A disposable plastic Codman stripper is then passed into the
open end of the saphenous vein down to below the knee. The tip of the stripper then can
be palpated posterior to the medial edge of the proximal tibia. Sometimes the tip will be
felt a short distance into the posterior or anterior arch vein. A 4 or 5 mm incision is then
made on the skin directly over the tip of the stripper, and with blunt dissection the vein
containing the tip can be exposed. The vein is incised and the stripper pushed or pulled
out above the skin.
Sometimes the stripper will enter a branch and end up near the skin of the medial or
anterior thigh. The stripper can be retracted and by twisting it, can be reoriented in the
main trunk. Occasionally, the saphenous itself is tortuous enough to prevent passage down
to the knee. In those cases, the saphenous vein can be exposed in the thigh where the tip
is held up, and a second stripper can be passed from there to the proximal calf. Another
option, when the location of the saphenous vein below the knee has been marked, is to
bluntly deliver the saphenous vein through a small incision there and pass the stripper to
the groin.
Once the distal end of the stripper has been delivered through the skin incision,
a long #1 silk suture is tied securely around the proximal end of the vein. The acorn head
that comes with the stripper is not used. The bed is placed in slight Trendelenberg to
reduce bleeding. The distal end of the stripper is pulled toward the foot causing the
bulbous end of the stripper to invaginate into the lumen of the saphenous vein. Continued
traction causes the proximal end of the vein to follow the stripper into the vein, with
tearing of branches, and inversion of the vein. As the stripper exits the distal incision, the
inverted vein follows it and the entire segment cannulated by the stripper can be removed.
If the vein breaks before the distal end is delivered, the silk suture can be used as a guide to
allow retrieval of the retained segment through limited incisions on the thigh. After the
vein is delivered, manual compression is applied for a few minutes along the course of
the vein to stop bleeding from the avulsed branches. The groin incision is closed with
absorbable suture and skin approximated with subcuticular suture and steristrip. The distal
incision may use a single subcuticular stitch or just a steristrip.
SMALL SAPHENOUS LIGATION AND STRIPPING
The small saphenous vein may require ligation alone or ligation and stripping. Since the
termination of the small saphenous vein is quite variable, its location should be marked
on the skin with duplex ultrasound evaluation prior to surgery. After anesthesia is
administered, the patient is placed prone. A skin crease incision is made at the popliteal
fossa or more proximally where the saphenopoliteal junction has been marked. After
incision of the fascia, the saphenous vein is identified and dissected proximally to the
popliteal vein. The gastrocnemial and Giacomini veins are often encountered and may be
confused with the saphenopopliteal junction. The true saphenopopliteal junction is clear
when the popliteal artery and common peroneal nerve are identified. Ligation and division
of the saphenopopliteal junction is performed as for the saphenofemoral junction.
Stripping of the small saphenous vein is not considered necessary by many surgeons and
often only a few centimeters within reach of the incision are avulsed. A stripper may be
passed distally and various lengths may be stripped with the inversion technique as
described above. The incision is closed in similar fashion to the groin expect that a heavier
suture (0 or 2–0) is used for the fascia.
Surgical Treatment of Varicose Veins 279
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STAB AVULSIONS
The previously marked varicose veins are removed piecemeal. A 3 or 4 mm incision
is made by stabbing the skin with an 11 scalpel blade deep enough to penetrate the
subcutaneous fat. These incisions are oriented vertically except in the groin, knee, and
ankle creases, where Langer’s line are followed. Various crochet-type hooks are available
to fish out the vein. The hook is inserted into the incision and bluntly moved back and
forth across the course of the varicose vein to isolate it from the surrounding tissues. The
adventitia of the vein is then caught with the hook and the vein is drawn out above the
skin (Fig 3). Instead of hooks, a very fine-tipped mosquito clamp may be used to dissect
and pull up the vein. Once the vein is exposed outside of the incision, it is grasped with
a heavier mosquito clamp or the loop of the vein controlled (Fig. 4). Additional clamps are
placed on either end of the loop and each end is pulled. As more length of vein is exposed,
Figure 3 A crochet hook delivers the varicose vein out of the stab incision. (See color insert.)
Figure 4 A clamp is placed through the loop of vein prior to clamping the vein on either end. (See
color insert.)
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the clamps are moved closer to the incision so that when the vein breaks, it will not retract
so much. After both ends have broken off, another stab incision is made far enough away
from the previous incision to find another segment of vein. Bleeding points are controlled
with manual compression. Incisions are approximated with steristrips only.
POSTOPERATIVE CARE
The foot and leg are wrapped with gauze rolls and compression bandages. Patients are
discharged after a short recovery. They are instructed to walk at least several minutes
every waking hour and to elevate their legs when not walking. The bandages are removed
after four or five days. Compression stockings are worn daily for at least one month.
KEY POINTS
† Preoperatively the varicosities should be marked on the skin with the
patient standing
† The sapheno-femoral junction should be clearly identified before division
† The great saphenous vein should be stripped from groin to below knee using an
invaginating technique
† The sapheno-politeal junction should be marked on the skin with
Duplex preoperatively
† Stripping of the short saphenous vein is not always needed
† Small “stab” incisions are used to avulse varicosities as marked using hooks
or fine clips.
Surgical Treatment of Varicose Veins 281
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22
Assessment and Surgical Treatment
of Recurrent Varicose Veins
James E. McCaslin and Ronald K. G. Eifell
Department of Vascular and General Surgery, Queen Elizabeth Hospital,
Gateshead, U.K.
Gerard Stansby
University of Newcastle upon Tyne, Newcastle upon Tyne, U.K.
Recurrent varicose veins are relatively common and pose a particular problem to the
surgeon. Prevention is better than cure and the rates of recurrence can be minimized by
preoperative color duplex scanning and meticulous technique at primary surgery such as
ensuring the ligation of the long saphenous vein is flush with the femoral vein and
stripping the long-saphenous vein (1). Before any surgical intervention can be planned, a
careful assessment of the sites of recurrence has to be rigorously performed. Re-do surgery
is altogether more complex and should be dealt with in a different manner to primary
surgery. The patient’s expectations must be carefully managed and the surgery should be
carried out only by an experienced surgeon.
First, a thorough history of the patients symptoms and expectations should be taken.
In some cases all that is required is reassurance rather than further intervention. In other
cases sclerotherapy may be appropriate—but usually this will not provide long-term
benefit if there are major sites of deep to superficial reflux. This should be carefully
discussed with the patient. During the taking of the history the patients should be
specifically asked about previous surgery and sclerotherapy including dates and an enquiry
as to whether groins or popliteal fossae were operated on. Secondly the limb should be
carefully examined to assess the pattern of the varicose veins and the sites of any previous
surgical scars. Groin scars particularly can be very hard to identify and patients frequently
fail to remember that a groin exploration had previously been performed.
The main investigation in most centers will be duplex scanning which has now
largely replaced venography. This can define the anatomical pattern of recurrence and aid
planning of surgical intervention. In most reports of recurrent varicose veins the majority
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of recurrences are from the groin, with other major sites being thigh or calf perforators and
short saphenous disease (2–5). There may also be multiple sites in a significant number of
patients. Duplex scanning will also help assess deep venous disease which may be
contributory in some cases.
The main causes of groin recurrence are either inadequate original surgery or
neovascularization (6–8). In inadequate original surgery the sapheno-femoral junction will
not have been ligated at it origin. In neovascularization thin-walled, new veins have
developed to reconnect to the saphenous stump. Another important issue is whether the
recurrence is feeding into a residual long saphenous trunk or accessory saphenous vein. It is
important that these are identified, as surgery should aim to remove this to make clinical
recurrence less likelyif further groin neovascularization occurs. There is good evidence that
neovascularization often occurs without leading to clinically relevant varicosities. Duplex
scanning is good at classifying the nature of groin recurrences and residual or accessory
trunks can be marked preoperatively to ensure complete removal. Likewise saphenopo-
pliteal reflux and recurrence due to perforators can be identified and marked. In our view all
patients with recurrent varicose veins require color duplex scanning preoperatively and
failure to do so should be regarded as negligent.
Several studies have investigated the technique of interposing a barrier to
neovascularization around the saphenofemoral junction. Material used include a reflected
flap of pectineus fascia (9) and artificial materials such as PTFE, silicone and polyester
mesh (10–12). Although there are some promising results more data would be needed
before these could be recommended for routine practice in recurrent varicose vein surgery.
Once the pattern of the recurrence has been defined, appropriate surgical management can
be planned. In some cases, where inadequate surgery has left an intact saphenofemoral
junction, surgery will essentially be the same as a primary procedure with the additional
feature of difficulty in the groin due to scar tissue. This difficulty will be increased if
neovascularization is present. Surgery in these cases is fraught with hazards, as thin-walled
neovessels surround the sapheno-femoral junction encapsulated in scar tissue from the
previous surgery (13). The surgical maxim of dissecting from normal to abnormal should
be used. We favour the approach of Li (14–16). The incision is made either through the
previous scar, or else just above the groin skin crease. The previous wound should be
assessed in relation to the anatomical landmarks as often, in the case of a missed junction,
it will be found to have been placed too low. It is usually sensible to make the wound
somewhat longer than would normally be necessary for primary procedures, to allow
better access and to approach the junction from a lateral direction. Li describes first
dissecting down to the femoral artery, with care taken not to damage the femoral nerve.
The femoral sheath is then opened, and the femoral vein carefully identified. The gives a
safe guide to the level of the sapheno femoral junction and reduces the risk of damage to
the femoral vein. Progress is made inferiorly, until the residual stump of the long
saphenous vein is found, dissected, surrounded and clamped. Another approach which is
sometimes useful is to identify the inguinal ligament and use this to identify the femoral
vein superiorly and then dissect downwards to the saphenofemoral junction.
Any residual saphenous trunk should be removed and should have been marked
preoperatively. Stripping or multiple avulsions can be performed, but stripping is to be
preferred, and this may be done in an anterograde fashion. If this is not possible, retrograde
stripping has been described (17). Preoperative duplex marking of the vein as it traverses
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the medial condyle of the femur allows a stripper to be passed superiorly along its course
via a small transverse incision. This technique can also be used in the patient who does not
require groin exploration, but has a significant portion of residual long-saphenous vein on
duplex scanning. Care must be taken when employing this method not to pass the stripper
into the deep venous system by way of a large mid-thigh perforator.
The recurrence rate following short saphenous surgery is higher than after
saphenofemoral disconnection (18–20). Reported recurrence rates range from 40% to 61%
following saphenopopliteal junction disconnection, despite the use of preoperative duplex
marking (21–23). Saphenopoliteal re-exploration needs careful identification and avoidance
of damage to the popliteal and sural nerves and the patient needs to be carefully counselled
about the risks of nerve injury beforehand. Duplex marking or varicography to identify
the junction is absolutely essential. If a Giacomini vein is present it should also be marked
preoperatively.
Complications are more likely after redo than primary surgery. One of the more common
complications seen in redo surgery for recurrent veins is the formation of a lymphocoele or
lymphatic fistula (15). It is important to minimize disturbance to lymphatic channels in the
groin if possible and ligation should be performed rather than relying on diathermy.
Lymphocoele and lymphatic fistulae usually resolve spontaneously (24), although it may
take many months and occasionally they have to be aspirated or excised (15). With the
increased incidence of lymphatic leakage and consequent infection following redo groin
dissection for recurrence (24), there may be a role for routine antibiotic prophylaxis in
patients undergoing redo groin dissection, although no direct evidence exists to support or
refute this.Certainly if there is pre-existing intertrigo then we recommend their use. Careful
attention should be paid to closure of the wound to eliminate dead space and we advocate the
use of interrupted (not continuous) absorbable sutures. We do not routinely use any wound
drains although careful attention should be paid to hemostasis. Interestingly, advocates
of endovenous ablation have postulated that haematoma formation after surgery may be
a stimulus for new vessel formation after open surgery (25). We also routinely use
subcutaneous low-molecular weight heparin as prophylaxis against DVT in these patients
and have not noticed any major problem with bleeding or wound haematoma.
Recurrent varicose veins need careful assessment and an experienced surgeon. The use of
color duplex scanning to plan intervention is now widely accepted as standard practice.
The advent of new treatment modalities such as endovenous ablation may further improve
the results of surgery for recurrence in the future.
† Recurrent varicose veins are relatively common.
† Patients should undergo color duplex scanning preoperatively.
† Common reasons for recurrence include inadequate previous surgery,
neovascularization and missed perforators.
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† Surgery for long saphenous recurrence may require re-exploration of the groin,
local avulsion of varicosities or a combination of both.
† Residual long saphenous segments should be stripped or avulsed.
† Complications are more common than with primary surgery and patients should
be warned of this.
† Newer modalities may improve long-term results in both primary and redo surgery.
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