How I do Long Saphenous Vein Surgery
A
description of what happens to someone who has varicose vein surgery
Mr Braithwaite does several different operations, depending on the distribution of your varicose veins. They are:
1. High tie, strip and Multiple avulsions (L8510)
When you are asleep, your leg will be cleaned with a pink or brown coloured antiseptic solution. You will then have a small cut (about 5cm long) in the skin crease of your groin. Through this, the diseased vein will be removed. You may then have other cuts on your leg over the diseased veins. These will be about half a centimetre long or smaller. This part of the operation is called avulsions. You may have a cut near the knee that is about 1 cm long. Sometimes this cut is on the thigh or calf.
2. High tie, strip and TRIVEX avulsions
This operation is similar to number 1 above but the lumpy veins are removed using a special device that sucks the veins out. TRIVEX is a new technique that is not widely available to NHS patients. Mr Braithwaite is currently one of a few surgeons in the UK who uses the technique. If your veins are suitable for TRIVEX, Mr Braithwaite may discuss a study about the technique.
3. VNUS and avulsions
VNUS is a new method for removing the long saphenous vein without having a cut in the groin. It is not used in the NHS as the technique has not been proven to be more cost effective than no1 above. Mr Braithwaite's research has helped to show that patients who have VNUS suffer less pain and bruising and can return to normal activities sooner.
4. Avulsions only
If you do not have disease in the main superficial veins (A roads) then some of the smaller veins may be removed by little cuts in your skin.Mr Braithwaite uses a technique that causes little scars on your leg. If have large veins then you may need cuts that are about 2 or 3 mm long.
5. Short saphenous ligation
This operation is similar to 1 above but you will need a cut behind the knee or in the lower back of your thigh. Before the operation, Mr Braithwaite will arrange for you to have a duplex scan to mark the level of the junctions of your veins. Otherwise the opearation is similar to those above. There is a nerve called the sural nerve running close to the short saphenous vein. Very rarely this can get damaged. If this happens you will be able to walk normally but the feeling on then outside of you foot may not be normal. Mr Braithwaite will explain this to you.
6. Recurrent varicose vein surgery
This is more complex than having your veins done for the first time. Mr Braithwaite will discuss with you the details of the operation.
More information can be found by clicking here
The following is a detailed description of long saphenous vein surgery:
Mr
Braithwaite's method for long saphenous surgery starts at the time that he see
the patient for their first consultation in the outpatient department. This is
the most important part of their treatment, as patients should be fully informed
about the reasons for their surgery. A recent Medical Defence Union report about
litigation in general surgery, showed that
17% of claims were related to venous surgery. It is therefore imperative
that patients are fully informed and understand as much as possible. The
following is a description of the way that Mr Braithwaite does Long Saphenous
Vein Surgery.
Patients referred for
consideration of venous surgery are seen in a specific varicose vein clinics.
During their consultation, patients are asked about symptoms and past history
relevant to their varicose veins, particularly a history of suspected or
confirmed deep venous thrombosis or one of fracture of the leg. Those patients
with a positive history then have a duplex scan of the veins of their leg.
Patients without a positive history are examined clinically and with continuous
wave Doppler. The patient lies
supine on the examination couch and the Doppler probe is placed over the long
saphenous vein in the thigh. If there is a reflux signal with calf compression
and release, valsalva manoeuvre or plantar-flexion then the patient requires
long saphenous surgery. The Doppler probe is then placed behind the knee and the
assessment repeated. If there is a reflux signal then the patient has a duplex
scan to determine whether there is short saphenous or deep venous incompetence.
Once the patient has
requested superficial venous surgery for appropriately abnormal veins then they
are informed about the surgery that they require, the benefits and potential
complications. This is all done by or under the supervision of the consultant
vascular surgeon. Patients are given written information about their surgery. At
present, patients are offered a provisional operation date and a date for
preadmission. Women on the combined oral contraceptive pill are asked to stop
the drug one month before surgery. No change is made for those on Hormone
replacement therapy. The majority of unilateral procedures are offered a day
case procedure, provided that they qualify.
A multi-disciplinary team
approach is used to ensure the most efficient use of the operating time
available: Approximately one week before the date of their surgery, patients are
seen for preadmission by a nurse practitioner or Junior House Officer. The
pre-assessment is done in the one-stop vascular clinic so that the vascular
technologist can scan any patients that require pre-operative marking of
sapheno-popliteal junctions or perforators. The consultant then explains the
procedure and risks once again and then obtains consent. At the time of consent,
the risks discussed are noted, on the consent form. Currently risks of
Haemorrhage, Infection, Neuralgia, Scarring, Skin staining and recurrence are
noted. If necessary, further written information is given, including details
about their admission to the ward or day case unit. Once consent has been
obtained the patient then sees the anaesthetist who will be giving them their
anaesthetic.
On the day of operation
the surgeon using indelible ink along the line of the veins marks all
varicosities. All long saphenous surgery is done under General Anaesthesia.
Fragmin is given by subcutaneous injection to in-patients who are perceived to
be at risk of Deep Vein Thrombosis. These include patients who have a history of
deep vein thrombosis, have a body mass index of greater than 30, and
those in whom the operation is expected to
last more than one hour. Alcoholic skin preparation is used to prepare
the whole leg from umbilicus to foot. Disposable drapes are used and a cotton
Sock is used to cover the toes. This can be used to roll up the leg at the end
of the procedure prior to the application of bandages. The patient’s knee is
flexed and the leg is allowed to abduct and externally rotate. The patient is
then placed in a head down position.
With the surgeon wearing
protective eyewear, a short groin crease incision is made with a size 10 blade,
medial to the palpable femoral pulse and deepened until the vein is exposed. A
swab is then used to blunt dissect along the long saphenous vein (LSV) in a
sweeping motion both caudally and cranially. Provided the dissection has been
made into the correct layer, the proximal portion of the LSV and tributaries can
be exposed. A self-retaining retractor is inserted to open the wound and a
retractor is placed in the cranial end of the wound and traction applied to
reveal the saphenofemoral junction. The LSV is held with broad blunt forceps and
the back of a pair of McIndoe scissors are used to blunt dissect around all of
the tributaries, the Saphenofemoral junction and the medial and lateral sides of
the common femoral vein. These manoeuvre expose all tributaries in the vicinity
of the junction.
A clip is then passed
under each tributary and a 20 vicryl tie is brought around the vessel and tied
as far from the junction as possible. Once all tributaries have been tied, the
LSV is clipped and pulled up out of the wound. This brings the saphenofemoral
junction up into the opening of the wound so that a single 20 vicryl tie can be
placed under all vessels leading into the femoral junction. Once this ligature
has been tied, each tributary is cut and the LSV divided. If all tributaries
have been ligated and divided then the femoral vein falls back deep into the
wound. A final close inspection of the femoral vein is then done to ensure that
all tributaries have been ligated and that the junction has had a flush ligation.
A loose tie form a reel is
placed around the LSV within the wound and a disposable vein stripper (Impra-Bard,
Crawley, UK) is passed via a small venotomy into the LSV. At this time the clip
that was placed during the ligation of the junction holds the vein and pressure
with the index finger on the vein prevents bleeding through the venotomy. The
leg is straightened and the stripper is passed to just below the knee where it
is retrieved through a small stab incision. A stripper head is normally used and
is attached to the cranial end of the stripper. The loose tie is tightened and a
clip is applied to its end. The vein is stripped out to the level of the knee
and retrieved through the small stab incision. Usually, the stripper head is
retrieved via the groin wound by pulling on the ligature. Occasionally, the stab
incision needs to be extended to allow the stripper and vein to be retrieved.
Multiple stab incisions
are made using an 11 blade or venflon over some of the marks done
pre-operatively. The dilated veins are then retrieved using a phlebectomy hook
followed by a haemostatic clip. The veins are divided and avulsed. An attempt is
made to remove all varicosities and to avoid leaving short lengths of vein that
may cause discomfort from phlebitis post-operatively. Wrapping a swab around the
leg at the level of the avulsion treats any bleeding that does not stop with
simple digital pressure. This is then clipped to apply a tourniquet pressure
device while other avulsions are done. In the near future it is hoped that a
roll on tourniquet will be used to reduce blood loss.
The groin wound is closed
with 20 vicryl to the fascia and 30 Vicryl rapide, subcutaneous to the skin.
After cleaning the leg, steri-strips of dressings are applied to the avulsion
sites. The foot sock is then rolled up the leg and a 4 inch crepe bandage is
applied.
Post operatively,
inpatients are encouraged to keep their leg elevated. For day case patients, a
double tubigrip is applied from the metatarsophalangeal area to the top of the
thigh. Patients with the crepe bandages have their dressings changed by the ward
staff or district nurse the day after surgery. They are then asked to wear a
graduated pressure stocking for one week, night and day and then for one further
week during the day.