Besides the control of bleeding (Chapter 3) and the repair of injured vessels (Chapter 55), the only other ''primary vascular surgery' is that of varicose veins. You will seldom need to operate on them, because, although about 15% of the people in the world have them, few of these are in the developing countries. Firstly a little theory.
ANATOMY AND PHYSIOLOGY. The varicose veins in a patient's leg are the result of excessive pressure inside them, usually from failure of their valves. There are four kinds of leg vein, and they all have valves which stop blood flowing downwards away from the heart.
(1) The [f10]long and short saphenous veins [f09]run above the deep fascia, and are usually below the fibrous layer of the superficial fascia. They have numerous valves which direct blood upwards towards the heart. The most important of these is the ''femoral valve', in the long saphenous vein, just before it penetrates the deep fascia to join the femoral vein. The femoral valve prevents blood from the femoral vein flowing back into the saphenous vein.
(2) The [f10]superficial collecting veins [f09]are tributaries of the saphenous veins. They lie between the skin and the fibrous layer of the superficial fascia. These have valves, but they are poorly supported by the tissue around them, and easily dilate and become varicose.
(3) The [f10]deep veins [f09]accompany the arteries, and run among the muscles deep inside the leg. When the contractions of the muscles squeeze them, their valves direct the squeezed blood towards the heart.
(4) Several [f10]perforating veins [f09]go through the deep fascia, to join the superficial collecting veins to the deep veins. Their valves direct blood into the leg. The most important of these perforating veins are just behind the medial border of the tibia.
When a patient stands at rest, the superficial veins on the dorsum of his foot support a column of blood that reaches to his right heart. While his leg muscles are relaxed, this blood flows through his perforating veins, into the deep veins inside his leg. When he walks, the contractions of his leg muscles squeeze the blood from his deep veins up towards his heart. This cycle of contraction and relaxation reduces the pressure in his superficial veins, and in a normal person prevents varicosities.
However, if the valves of his deep perforating veins are incompetent, blood from inside his leg can squirt out at high pressure, into his unsupported superficial collecting veins. This distends them, and makes them varicose. It also alters the surrounding tissue, so that it is liable to ulcerate.
If the valves which guard his long and short saphenous veins are incompetent, the blood in his femoral and popliteal veins can flow downwards, into his saphenous veins, and make them varicose.
The aim of surgery is to stop blood flowing backwards through veins with incompetent valves.
Fig. 34-1 VARICOSE VEINS[md]ONE. A, varicosities of the long saphenous system. B, varicosities of the short saphenous system. C, D, and E, the Trendelenburg test. C, lay the patient on his back and raise his leg. Apply a venous tourniquet just below his saphenous opening. Stand him up and release the tourniquet. If his femoral valve is incompetent, his veins fill immediately from above (D). If it is normally competent, they fill slowly from below (E). F, the anatomy of the veins of the leg. G, a close-up view of a varicosity, and an incompetent perforating vein connecting it with the deep venous system.
1, the femoral vein. 2, the long saphenous vein. 3, the femoral valve. 4, a superficial collecting vein. 5, a perforating vein with its valves destroyed. 6, the deep veins of the leg. 7, muscular forces compressing the deep veins. 8, a varicosity in a superficial collecting vein. 9, a jet of blood squirting out of a perforating vein with incompetent valves to cause a varix in a superficial collecting vein. After Ellis H, and Calne RY, ''Lecture Notes on General Surgery', Fig. 13, Blackwell Scientific Publications, with kind permission. A few varicose veins are the result of obstruction, but most are due to failure of the valves of the musculovenous pumps that return blood from the leg. This ''valve failure' takes two forms: (1) In primary varicose veins the valves of a patient's saphenous system fail, while the deep veins of his legs remain normal; his symptoms are usually mild, and his legs rarely ulcerate. (2) In secondary or post-thrombotic varicose veins, his deep veins, or the communicating veins between his superficial and deep systems, have had their valves destroyed by thrombosis. Ulceration is more common, and treatment more difficult. Both kinds of varicose veins are associated with Western life-styles, but it is not known why.
Varicose veins are unsightly; they cause aching and cramps, a scaly, itchy, varicose eczema, swelling of the legs, and ulceration; occasionally they bleed. A patient's symptoms may bear little relationship to the size and extent of his varicose veins. If they are primary, the swelling usually only involves his feet and ankles, and resolves completely overnight. If they are secondary, his lower legs may be swollen all the time.
If he has primary varicose veins, there are several things you can do, either alone, or more often in combination: (1) You can inject a little irritant solution into 2 cm of a vein (sclerotherapy), so as to inflame its walls, and make it shed its endothelium. If you then keep the vein empty, by compressing its inflamed walls together for 6 weeks without interruption, they will stick together and not recanalize. (2) If he has varicosities in his long saphenous system, you can tie his long saphenous vein flush with his femoral vein, and at the same time tie: (a) the tributaries that enter it nearby, and (b) any incompetent connections it has with the deep system. (3) If he has varicosities of his short saphenous system, you can tie his short saphenous vein at his saphenopopliteal junction. (4) You can pass a stripper through his long and short saphenous veins, pull them out completely, and so disconnect the varicosities in his superficial collecting veins from the high pressure in his saphenous veins. (5) You can remove some varices when indicated.
If he has posthrombotic (secondary) varicose veins, it may be possible to cure him by tying every incompetent perforating vein; but these are difficult to find and tie, so we don't tell you how to do it here.
The surgery that you are prepared to do on a particular patient will depend on your circumstances, and his. Any form of treatment is of limited value, if his deep and his perforating veins, his skin, and his subcutaneous tissues, have already been severely damaged. Sclerotherapy needs careful attention to detail, but it can be very effective, and has few dangers. The main danger of surgery is that, if you tie his superficial veins when the valves of his deep ones are incompetent, you may make him worse.
STRIPPER, for varicose veins, Nabatoff, in sterilizer case, complete with 3 metal olives, cable and handle, one only. Optional. This is the complete outfit.
BE SURE THAT THE VALVES OF HIS DEEP VEINS ARE COMPETENT BEFORE YOU TIE HIS SUPERFICIAL VEINS Fig. 34-2 VARICOSE VEINS[md]TWO. A, the stripper cable introduced at the ankle. B, the long saphenous vein with the stripper in place. C, the end of the cable emerging from the saphenous vein in the groin, with the head of the stripper attached. D, the handle of the stripper attached to the cable. E, the crumpled long saphenous vein removed with the stripper. After Sir Charles Illingworth, ''Surgical Treatment', Fig. 5, Pitman Medical, with kind permission.
VARICOSE VEINS EXAMINATION. Examine the patient standing in a good light. Feel his veins. If he is obese, percuss the course of his saphenous veins. Examine his peripheral pulses.
If there is ulceration, brawny induration, and marked hyperpigmentation, the valves of his deep veins are almost certainly incompetent, and his varicose veins are secondary. Otherwise they are probably primary.
To test the competence of his perforating veins and the valves of his greater saphenous system, lay him down, raise his leg, and massage his veins proximally to empty them. On his upper thigh apply a rubber tube tourniquet, tight enough to compress his veins. Stand him up and ask him to move his forefoot up and down, so as to actuate his calf muscle pump. Inspect his varices for 30 seconds, and then remove the tourniquet.
If his veins gradually fill from below as he stands, and continue to fill gradually from below when the tourniquet is released, the valves in the veins of his legs are normal.
If his veins fill rapidly from below, his varices are being filled from his deep veins, and the valves of his perforating veins are incompetent.
If blood flows rapidly into his greater saphenous vein from above after removing the tourniquet, his femoral valve is incompetent.
To test the competence of the valves of his short saphenous vein, apply two tourniquets, one above his knee to occlude his long saphenous vein and another just below his popliteal fossa. Stand him up, leave the long saphenous tourniquet on, and remove the tourniquet obstructing his short saphenous vein. Observe how his short saphenous system fills.
To find the sites of major incompetent perforating veins: (1) Look for visible and palpable ''blowouts' of subcutaneous veins. (2) Repeat the tourniquet test at lower levels, and occlude the vein just distal to each blowout. (3) Feel for circular gaps in his deep fascia in the anatomical sites where you expect to find them.
DIAGNOSIS. Here we are only concerned with the common causes of varicose veins. Any causes of inguinal or retroperitoneal compression that might produce varicose veins are usually obvious. If there is a thrill or bruit (rare), he has an arteriovenous fistula.
Suggesting primary varicose veins[md]usually start at an early age (15 to 25). No incompetence of the perforators shown by the test above. Incompetence demonstrated by back-flow on release of the upper thigh tourniquet (long saphenous), or just below his popliteal fossa (short saphenous).
Suggesting post-thrombotic varicose veins[md]a history of venous thrombosis (unusual), an older age, less obvious veins partly hidden by eczema, fat necrosis, or ulceration. His long saphenous vein may be dilated.
NON-OPERATIVE TREATMENT INDICATIONS. (1) Minor symptoms.
CONTRAINDICATIONS. These are also the indications for surgery. (1) Large varicosities. (2) Symptoms, such as aching of sufficient intensity to merit sclerotherapy or surgery.
METHOD. Aim to improve his general health and to reduce his symptoms. Encourage him to lose weight (he is usually overweight), to walk, to avoid prolonged standing and sitting, and to raise his leg frequently. If possible, have him fitted with elastic stockings from his distal metatarsals to just below his knee.
CAUTION ! If he uses elastic bandages, make sure that they do not have a tourniquet effect.
SCLEROTHERAPY INDICATIONS. (1) The cosmetic treatment of small primary varicose veins. (2) Incompetent perforating veins without an incompetent femoral valve. (3) Varicose veins which persist or recur after surgery.
CONTRAINDICATIONS. (1) An incompetent femoral valve. (2) Varicosities at or above the knee. (3) Gross obesity (it is difficult to maintain compression). (4) Deep venous thrombosis is a contraindication to any operation on the superficial venous system, which is now the only route for blood to return to the heart.
CAUTION ! (1) Pregnancy is not a contraindication. (2) If a patient is on oral contraceptives, she should change to another method one month before sclerotherapy or operation.
EQUIPMENT. Five small syringes fitted with fine needles (preferably with transparent shanks) and filled with 0.5 ml of 3% sodium tetradecyl, or 5% ethanolamine oleate. ''Sorbo' rubber pads, marking pens, suitable bandages and elastic stockings.
METHOD. Treat him as an outpatient. His veins must be almost empty when you inject, and be kept empty so that their walls adhere.
Stand him up, observe, palpate, and percuss his veins; mark them with a pen. Lay him down, put his foot on your shoulder, and feel the course of his veins for gaps in his fascia (sites of incompetent communicating veins). Mark these with a pen of a different colour. Press with the tips of your fingers on as many of these gaps as you can, and, still pressing, ask him to stand. Remove your lowermost fingers first.
If removing your finger from a gap in his fascia immediately causes the vein to fill, that gap is the site of an incompetent perforating vein. If it does not fill, there was no perforator in it. The sites where pressure controls the filling are the best sites for injection. Inject the lowest sites first.
Bandage up to the injection site with a crepe bandage. With his leg lowered so that his vein is full, insert the mounted needle, and aspirate only as far as the transparent hub (to be sure you are in the vein); then empty the vein by raising his leg above the horizontal. Isolate the the segment to be injected by pressing with your fingers above and below it, and inject 0.5 ml of sclerosant. Apply a ''Sorbo' rubber pad over the injection site to keep it empty, bandage it on, move up to the next site, and repeat the process until all your chosen sites have been injected. Don't inject more than 5 sites.
Apply an elastic stocking over the bandages, the moment the last one is secure, and immediately start him walking for an hour, and thereafter for 3 miles daily. Advise him to avoid standing, and, where possible, to raise his legs when he sits. Leave the bandages on for at least 2 weeks to maintain pressure without interruption. Most surgeons leave them on for at least 6 weeks, renewing them when they become loose. If they have to be renewed, reapply them with his leg raised.
CAUTION ! (1) Don't inject the sclerosant into an artery. Remember that the posterior tibial artery runs deep, near the commonest site of the perforating veins. (2) Never inject more than 1 ml at a site, because if it extravasates, the tissues may necrose. (3) Careful bandaging is critical. The pressure on both borders of the bandage should be the same.
If his leg becomes painful, advise him to take an analgesic and walk. If his pain is not relieved, remove the bandage with his leg raised, and reapply it with his leg raised.
At 2 weeks. If any injections are found to have failed (the vein still fills with liquid blood), reinject these sites.
At 6 weeks remove the bandages. If his first leg is satisfactory, start on the other one (it is inconvenient to have both legs done simultaneously).
At 6[nd]20 weeks it may be obvious that further sites are suitable for injection. Persist until the effect is satisfactory.
FLUSH LIGATION [s7]OF THE LONG SAPHENOUS VEIN INDICATIONS. (1) Incompetence of the femoral valve, causing the varices to fill from above.
CONTRAINDICATIONS. (1) Obstruction of the femoral vein above the saphenous opening. (2) Deep venous thrombosis.
ANAESTHESIA. (1) Give him a general anaesthetic (preferably not halothane), in a cool theatre (to reduce his peripheral blood flow). (2) Local, or (3) subarachnoid anaesthesia.
PREPARATION. The evening before the operation shave his groin and leg. Stand him up and mark the vein to be operated on, and all its tributaries and pouches, with an ink that will not be washed off by the surgical scrub. Also find and mark his perforating veins, using the finger-pressure method described above.
TO TIE HIS LONG SAPHENOUS VEIN, lay him supine with his feet apart. Give the table a 10[de] head-down tilt to reduce the venous pressure in his legs. Support his parted heels on foam cushions.
Make a 7 cm oblique incision 1[nd]2 cm below and parallel to his inguinal ligament, ending medially below his pubic tubercle. Deepen it, until you reach his superficial fascia. Dissect out the terminal part of his saphenous vein. Define its tributary veins (his superficial circumflex iliac, his superficial epigastric, and his external pudendal). Tie all these tributaries as they enter his saphenous vein. Tie his saphenous vein next to its entry to his femoral vein, and proximal to the entry of the tributaries. Divide his saphenous vein between ligatures of 2/0 or 1/0 multifilament.
CAUTION ! If he bleeds, don't clamp blindly with haemostats, or you may damage his femoral vein, or even his femoral artery. Instead, apply pressure, and raise the foot of the table. After 3 minutes pressure you can usually control bleeding, either with a haemostat or a fine silk stitch.
Tie all his other perforating veins through 3[nd]5 cm incisions. Dissect these perforators carefully, and tie them flush with his deep fascia.
FLUSH LIGATION [s7]OF THE SHORT SAPHENOUS VEIN INDICATION. Incompetence of the terminal valve of his short saphenous vein, causing the varices of this system to fill from above.
METHOD. Lay him prone (see A 16.12) with his feet apart, and his knees slightly flexed. Make a transverse incision across the middle of his popliteal fossa. Make a transverse or longitudinal incision in his deep fascia to expose his short saphenous vein (which lies deep to it), and is accompanied by, and may be closely applied to, his saphenous nerve. Raise the vein, divide it, trace its proximal end down into his popliteal fossa, and tie it flush. There is usually at least one large proximal branch. Tie this.
CAUTION ! The anatomy of the short saphenous/popliteal junction is notoriously variable.
FLUSH LIGATION AND STRIPPING INDICATIONS. Symptomatic varices of either saphenous system.
CONTRAINDICATIONS. (1) Deep venous thrombosis. (2) Obstruction of the femoral or other vein above the saphenous opening. One contributor considers these ''Cautions' rather than contraindications.
METHOD. You will have just tied his long and/or short saphenous vein by the methods above.
To strip his long saphenous vein, open it anterior to his medial malleolus. Pass the small end of the stripper up to the distal groin wound. Try to make sure that it remains in his superficial veins and does not enter his deep ones. If it sticks, or passes into a tributary, redirect it by twisting, pressure, and to and fro movements. If it will not advance, cut down on it and redirect it, or strip the vein in segments.
When the stripper has passed successfully, unscrew the small head and replace it with a larger one. Tie this head in place. Raise his leg high and slowly withdraw the stripper from his groin to his ankle. Keep his leg high for a few minutes afterwards to reduce bleeding. Close his ankle and groin wounds, and bandage his leg firmly.
To strip his short saphenous vein, proceed as for his long one. Enter it behind his lateral malleolus.
CAUTION ! The sural nerve is closely related to the vein at the lateral malleolus.
TIES AND AVULSIONS [s7]tying perforating veins INDICATIONS. (1) To supplement tying varicose veins (with or without stripping) especially when varices are gross. (2) To treat varices and perforators after unsuccessful sclerotherapy. (3) To identify and control perforators in varicose vein surgery. (4) Post-thrombotic varicose veins. The best results are obtained early, when there are only preulcer signs, or when an ulcer has only been present for a few months. Long lasting ulcers ([mt]2 years) have a poor prognosis. Refer him.
METHOD. Aim to pull out as much vein as you can through multiple small incisions across the vein at previously marked sites, especially where varices communicate with the main saphenous veins, or with the deep system. Raise a loop of varicose vein by gentle blunt dissection. Follow the vein as carefully as you can in each direction and along other connecting veins as you find them. When you have exposed a length of vein pull it out. There is usually no need to tie it unless it is large or perforates the deep fascia. Close small incisions with adhesive tape unsutured (54-7). For the subfascial tying of perforators see below under varicose ulceration.
POSTOPERATIVELY, (after flush ties, long and short saphenous vein stripping, and multiple ties and avulsions, and tying perforators). Don't let him stand at first, and only let him sit when necessary for meals and toilet purposes. Let him walk actively as soon as he is comfortable, and as soon as possible for 1 hour daily. Most patients can go home the same day. Leave the pressure bandage applied at operation until the 6th day, then remove the stitches. Tell him to wear elastic bandages for another fortnight.
VARICOSE ULCERATION DIAGNOSIS. Most lower leg ulcers in the tropics are chronic tropical ulcers (31.2). Varicose ulcers due to incompetent perforators are less common.
A varicose ulcer is usually on the lower third of the leg, especially just behind and above the medial malleolus. It may be of any size and shape, its edges are usually brown and eczematous, and it has red granulations under the slough on its base. The patient is usually fat. Progressive fibrous atrophy of the subcutaneous of his lower leg (''inverted bottle leg'), and brown pigmentation, may precede ulceration. He may have either or both: (1) Gross primary varicose veins of many years' standing (most primary varicose veins don't lead to ulceration). (2) Incompetent deep perforating veins (50% of varicose ulcer cases), which may be not be easy to find under his ulcer.
THE DIFFERENTIAL DIAGNOSIS includes: (1) Chronic ulcers starting as tropical ulcers (31.2). (2) Ischaemic ulceration (feel his pulses). (3) Squamous cell carcinoma (which may develop in any chronic ulcer, 32.19). (4) Buruli ulcer (31.2a). (5) Factitious ulcer.
TREATMENT. Put him to bed with frequent sterile saline soaks until his ulcer is clean and oedema has gone. Either:
(1) Apply strong elastic webbing bandages capable of withstanding 100 mm Hg from the base of his toes to just below his knees, over a plain non-adherent dressing. Ask him to remove the bandage at night, to clean his ulcer, to sleep with the foot of his bed raised, and to reapply the bandage each morning. Recent ([lt]3 months) ulcers will often heal this way; but he should wear an elastic stocking for life.
Or, (2) if his ulcer will not heal or keeps breaking down again, and you can find the venous abnormality, treat it by injection and/or operation. This is usually easy if his varicose veins are primary (uncommon), but is more difficult if they are secondary (common).
If venous insufficiency due to incompetent perforators, is the cause of persistent ulceration, consider referring him to have these tied by a subfascial approach (eg. Cockett's operation). The commonest perforator responsible is usually within 2 cm of the upper border of the ulcer.
DIFFICULTIES [s7]WITH VARICOSE VEINS If varicose veins BLEED, haemorrhage can be alarming. Lay him down, apply pressure to the bleeding vein, and then tie it.
If an INDURATED LINE, develops along the course of the stripper, reassure him that it will usually be gone in a month.
If you INJURE HIS SAPHENOUS VEIN during surgery, see Section 32.34D.
Fig. 34-3 ABNORMAL SCARS. A, an extensive keloid. B, hypertrophic scars and contractures following burns. Although both these scars are abnormally large and are identical histologically, they behave differently. After Charles Bowesman. THE SURGERY OF THE SKIN