This document discusses varicose veins and their treatment options. It begins by describing the anatomy of varicose veins and their branches. It then discusses various surgical treatment options for varicose veins including stripping, endovenous laser therapy (EVLT), sclerotherapy, and hook phlebectomy. It provides details on the procedures, risks, post-operative care, and complications. In summary, it provides an overview of varicose vein anatomy and treatments through both invasive and non-invasive surgical procedures.
15. Indications for Surgery
* Better results with early treatment:
For operative treatment:-
1.Positive Trendelenburg Test
2.Particularily saphenofemoral
incompetence
3.Causing discomfort to the patient
4.Complications like venous ulcer
5.Cosmetic reasons
16.
DVT- superficial varices developing after a venous
thrombosis, may be the only route of venous drainage
in lower limb and should not be removed until the
patency of deep veins of limb has been shown
*patient will depend on superficial veins for venous
drainage
Pregnancy
Woman on contraceptive pills
Thrombophlebitis
17. Pre-op
Operation postponed till
complications are rid of
Complete Local
examination : Perform all
Tests
Further investigations for
diagnosis:-
-Duplex USG imaging
-Doppler USG
-USG abdomen- rule out
abdominal pathology in
suspected cases
18. • Explain investigations
• Explain planned surgery
• Describe anaesthetic technique
• Risk of DVT
• Risk of superficial phlebitis
• Risk of bruising and swelling
• Risk of wound infection
• Damage to superficial nerves- sural,
saphenous,cutaneous
21. an oblique incision made in
the groin centered
2.5 cm below and lateral to
pubic tubercle
22. Skin incision exposes
the membraneous layer
of supericial fascia.
Incision deepened
adequately to expose
SFJ safely
23. Fat is brushed downwards .Long saphenous vein
found by blunt dissection & traced upto T-shaped
termination with femoral vein (must confirm the T
junction, before ligation)
24. Check correct identity of saphenous vein ,its junction
with the junction with the common femoral vein seen
from both medial and lateral aspects.
25. Once certain of its correct identity ,the saphenous vein is
divided and drawn forward to facilitate division of its
branches
26. When fully isolated,the saphenous stump is
ligated flush with the common femoral vein and
then again,more peripherally,with a transfixion
27. • All the tributaries that join the
saphenous vein near its termination
( supericial inferior epigastric,superficial
circumflex iliac,superficial external
pudendal) must be dissected out ,ligated
with 2/0 polyglactin ÷d.In
addition to this anterolateral and
posteromedial thigh veins terminate
close to s-f junction
29. • Main principle of surgical treatement is to
ligate source of venous reflux and remove
incompetent saphenous trunk
• Done alone, there is a high chance of
recurrence
• To ensure elimination of as much as reflux
as possible, must remove LSV
30. • Place a ligature around the
LSV trunk& hold it up ,to
occlude the flow of blood
from below.
• Make a side hole in the
vein above the ligature
through which the tip of
the stripper can be
introduced.
31. The conventional way of removing
the saphenous vein is with a
Babcock stripper.
Babcock stripper or a rigid metal
'pin stripper' consists of a flexible
wire that is passed down the long
saphenous vein
End is identified in the the upper
third of the calf and a 2mm incision
made to retrieve the stripper
An olive of about 8mm in diameter
is attached to the upper end and the
saphenous vein is removed by firm
traction on the wire in the calf
Closure: incision sutured and limb
elevated
32.
33. Saphenopopliteal Junction
Ligation & Stripping
• Pre-op USG for localization of junction
• A transverse skin incision made in popliteal fossa
just below termination of vein
• Deep fasia incised to reveal short saphenous vein
beneath
• Vein followed to SPJ, where SSV enters the side of
popliteal vein
• Vein then ligated and divided close to popliteal vein
• Can strip SSV using inverting technique; stripper
passed upwards from the ankle, carefully dissecting
off the sural nerve to ensure that the whole of the
lesser saphenous vein is removed
34.
35. What is inversion stripping?
Aim is to reduce damage to tissues around vein
Less pain and bleeding
Rigid metal pin stripper (Oesh) passed down
the inside of the saphenous vein and recovered
through a small incision in the upper part of calf
A strong suture attached to the end of the
stripper and firmly ligated to the proximal end of
the vein
During pulling of stripper, LSV will invert and
can be delivered through 2mm incision in midcalf
region
No olive used
41. 1. A tourniquet is placed above the knee and an
Esmarch band is placed tightly around the
lower extremity to empty the blood from the
surgical site.
2. The tourniquet is inflated to supra systolic
blood pressure (usually 300 mm Hg).
3. An incision is made one-hand’s width below
the tibial prominence and two-finger’s
breadth posterior to the anterior border of the
tibia. This provides access for the camera and
carbon dioxide insufflation.
42. 4. A large balloon trocar is placed through
this incision into the subfascial plane
and filled with 180 cc of saline to
expand the space. The balloon is
emptied and removed. Carbon dioxide
insufflation is started through the
trocar, maintaining a pressure of 30
mm Hg to keep the subfascial space
expanded and to allow visualization of
the structures.
43. 5. Frequently, a second incision is placed
inferior and posterior to the first,
allowing insertion of the instruments
that perform the vein ligation (either
cautery hook or clip applier and
scissors).
6. The camera follows the instruments in
a caudal direction and perforating
veins are identified traversing the
subfascial space. The veins are divided
and the instruments are removed. The
incisions then are closed in two layers
and a pressure dressing is applied
before the tourniquet is released
44. .7.The procedure is frequently performed
in an ambulatory care setting. The
pressure dressing is left in place for 2 to
5 days. Lower extremity activity is
limited for 5 to 7 days. Full recovery is
usually attained in 2 weeks.
46. Involves a long incision along the
medial or posterior aspect of the calf
and blind division of the perforators.
Has a high chance of haematoma and
chronic skin changes and is rarely used
today.
47.
48. A Detergent is injected directly into the superficial veins
The detergent destroys the lipid membranes of endothelial cells
causing them to shed,leading to thrombosis,fibrosis and
obliteration.
Continued local compression is given following sclerosant injection
to reduce the incidence and amount of superficial thrombosis and
improve the sclerosis of the vein.
49.
50.
51.
52.
53. Foam injected under ultrasound
monitoring
Top of saphenous vein
compressed by ultrasound to
prevent foam entering the deep
veins,until spasm in the main trunk
develops
POLIDOCANOL
56. •A laser probe is passed up inside a
catheter inserted ino the lower part o the
saphenous
vein under ultrasound guidance
•Crystalloid fluid - L.A& prevents burns
•Duplex ultrasound confirms LASER probe
is at SFJ and the LASER probe is then
withdrawn, administering a set number of
joules to the endothelial lining
57.
58. Aim is to remove all the varicosities through incisions
that require no suture
After stripping, residual veins and tributaries are left
behind.
Veins are taken care of by means of small hooks,
inserted through incisions of 1-2mm size
Hook is used to capture a small section of a varicosity
and bring it to the surface, where it is grasped with large
artery forceps; remaining vein is then teased through
tiny incision.
Closure of small incision achieved using adhesive
strips ;Very good cosmetic outcome
59.
60.
61. THIS IS A PERCUTANEOUS
TECHNIQUE FOR REMOVING
SUPERFICIAL VEINS BY
SUCTION FOLLOWING
INJECTION OF LARGE
QUANTITIES OF FLUID
THIS IS A PERCUTANEOUS
TECHNIQUE FOR REMOVING
SUPERFICIAL VEINS BY
SUCTION FOLLOWING
INJECTION OF LARGE
QUANTITIES OF FLUID
IINDURATION
BRUISING
SUBCUTANEOUS GROOVES
62. •Legs are elevated
•Analgesia given
•Compression bandaging
applied to the limb to
prevent excessive
bruising ;1-2 days later,
replaced with thigh-
length compression
stocking