Technique of saphenopopliteal junction ligation

Accurate preoperative ultrasound localisation of this junction makes the operation easy, as the position of the SPJ is notoriously variable. A skin incision is made over the junction and the deep fascia incised to reveal the short saphenous vein beneath. The vein is followed to the SPJ, where the short saphenous vein enters the side of the popliteal vein. The vein can then be ligated and divided close to the popliteal vein. This operation may not be enough to eliminate venous reflux in the short saphenous vein because communication with the gastrocnemius (muscle) veins in the calf is often present and may lead to further varicosities arising from the short saphenous vein. Many surgeons now routinely strip the short saphenous vein to prevent this problem. This is best done using an inverting technique as the sural nerve lies close to the vein and may be damaged if a large olive is used.

A pin-stripper (Oesch) is passed down the short saphenous vein as described above for the long saphenous vein. This is recovered through a 2-mm incision made at the mid-calf level. A heavy suture is used to attach the vein to the upper end of the stripper and gentle traction applied to the stripper. The inverted vein appears in the calf incision.

Removing superficial varices

Varicose veins do not disappear following saphenous vein stripping and should be removed through small incisions. It was standard practice to insert artery forceps through the incision in order to remove varices. However, this necessitates long incisions in the leg which require suturing and are unsightly. European phlebologists have developed instru­ments to minimise the size of incision required for this procedure. The technique is referred to as ‘hook phlebectomy’ and uses small hooks which may be inserted through incisions of only 1—2 mm. The hook is used to capture a small section of a varicosity and bring it to the surface where is may be grasped using a large artery forceps; the remaining vein is then teased through the tiny incision. The aim is to remove all the varicosities through incisions that require no suture. Closure of the incisions is achieved using adhesive strips or dressings. The cosmetic outcome from this procedure is excellent.

The results of varicose vein surgery depend on the care taken with the preoperative assessment, the preoperative marking and the determination of the surgeon to remove all the superficial varicosities. Patients may complain of symptoms of varicose veins, but most remain unsatisfied until they achieve a good cosmetic result following treatment!

Postoperative management

Compression bandaging is applied to the limb at the end of the operation to prevent excessive bruising. In fact, some surgeons apply compression to the limb before stripping the long saphenous vein. After 1 or 2 days the bandages may be replaced by a thigh-length high compression stocking (class 2 compression is appropriate). This can usually he removed easily to allow the patient to take a shower and can then be reapplied.

Complications of varicose vein surgery

Bruising and discomfort are common following removal of varices, especially where the veins were of very large diameter. However, the pain usually requires only mild analgesics.

Sensory nerve injury is seen occasionally after removal of varicose veins. The saphenous nerve and its branches accompany the long saphenous vein in the calf, the suraJ nerve accompanies the short saphenous vein. Damage to the main part of these nerves occurs in about 1 per cent of operations, but small areas of anaesthesia may occur more frequently (in up to 10 per cent of patients). The adoption of inverting stripping techniques and avoidance of stripping the long saphenous vein below mid-calf level have reduced the risk of damage to these nerves. All patients should be warned before surgery that they may experience small areas of numbness and tingling after the operation. These changes are usually reversible but can be quite persistent.

Motor nerve injury is an uncommon complication of varicose vein surgery and may occur during exploration of the popliteal fossa if care is not taken to protect the nerves in this region. Preoperative ultrasound localisation of the short saphenous vein helps in limiting the extent of the dissection in this region and risk to the nerves during dissection. Venous thrombosis is often seen in residual varices following varicose vein surgery and resolves without the need for specific treatment. The risk of this is reduced if all visible varices are removed at the time of surgery. Deep vein thrombosis occurs in about one operation per 1000 following varicose vein surgery. The factors which result in increased risk are described below. Patients who have previously suffered a deep vein thrombosis seem to be particularly at risk and should receive full prophylactic measures, usually low-dose subcutaneous heparin in addition to compression stockings. Patients receiving oestrogen treatment may also be at increased risk of venous thrombosis, and heparin prophylaxis should be considered.

Venous reconstructive surgery

Surgery to the deep veins is limited by the absence of suitable prosthetic grafts or any satisfactory way of creating a venous valve. Surgery may be carried out for venous occlusion and for deep venous insufficiency. Patients who might be considered for these procedures include those who have persisting swelling of the lower limb after a previous venous thrombosis, even when a number of years has passed and collateral veins have had the opportunity to develop. The presence of a functional obstruction must be confirmed using direct venous pressure measurements. In the case of suspected iliac vein obstruction, the pressure in the femoral vein is measured with the patient lying supine. If there is a substantial rise in venous pressure during exercise then venous obstruction is confirmed. An alternative method is to measure the venous pressure in the hand and foot veins with the patient lying supine (the Raju test). Normally the foot venous pressure is the same as the hand venous pressure or no more than 5 mmHg greater. If venous obstruction is present the pressure difference is greater, with pressure differences of 10—15 mmHg indicating significant venous obstruction

Venous obstruction

In patients with venous obstruction venous bypass procedures can be performed. Simple bypass with vein or prosthetic material may be used in the larger vessels, such as the iliac veins and vena cava. One problem is to find a vein of large enough calibre to insert in this region. These are sometimes constructed from opened out sections of saphe­nous vein reconstructed as a spiral graft. Alternatively a Palma operation can be carried out. This involves mobilising the long saphenous vein in the opposite leg, tunneling the distal end of the long saphenous vein across suprapubically and inserting it into the femoral vein below the obstruction. Blood then drains from the affected leg via the long saphenous vein into the femoral vein in the opposite leg.

In patients who have obstruction of the superficial femoral vein, the long saphenous vein may be connected to the popliteal vein in the same limb, allowing blood to flow along the superficial veins more easily (May—Husni procedure). However, in the majority of patients with chronic superficial femoral vein obstruction, the blood flows along the long saphenous vein to reach the groin and therefore this operation is not required.

Venous incompetence

The surgical treatment of deep venous insufficiency remains a difficult problem that is dealt with in a few centres. Venous valves in the deep veins may be repaired if their incom­petence is a consequence of primary valve failure. Kistner has described two methods of repairing incompetent valves, and successful completion of this operation may lead to long-term maintenance of leg ulcer healing. However, the operations are technically difficult and there is a risk of thrombosis which may destroy the reconstructed valve. In patients who have previously suffered a deep vein throm­bosis, transplantation of a segment of axillary vein has been carried out. This is usually attempted in patients who have damage to the deep veins following a previous venous thrombosis. The risk of further episodes of venous throm­bosis makes the likely success of such operations as low as 50 percent.