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SURGICAL TREATMENT OF VARICOSE VEINS

Pre-operative Workup

Most patients require a duplex (ultrasound) scan of the veins of the leg, to confirm which system (long or short saphenous) is involved.

The majority require little else, as the operation is generally performed in young, relatively fit patients. However, those with a significant past medical history may require a complete workup to determine fitness for anaesthesia.

 

Day of Procedure

You will be admitted on the day of the operation. You will need to fast for 6 hours prior to the operation. Your anaesthetist will meet you and discuss the relevant aspects of the anaesthetic with you. I will see you in the holding bay, and mark your veins with a permanent marker.

 

The operation

The operation is performed with the aim of eradicating the troublesome veins, and preventing others from emerging.

There are three aspects to the operation. 1. Deal with the underlying cause. This may involve ligating the saphenous vein in the groin or behind the knee, or any incompetent perforating veins, which is the root of the problem. 2. Remove the unsightly or uncomfortable varicose veins via multiple nicks in the skin. 3. Remove or strip the saphenous vein as this will dramatically reduce the change of other veins emerging.

 

Post-operative course

At the time of surgery, the leg is bandaged. These are removed the following morning and replaced by stockings, which are to be worn for 2 weeks.

You are encouraged to remain as active as possible, but not overdo things. It is common to experience some bruising, particularly on the inner thigh from where the saphenous vein was stripped. This is generally the greatest source of discomfort.

 

How are varicose veins diagnosed?

The diagnosis of varicose veins can be made with simple examination of the leg.

A duplex ultrasound scan will show which valves or veins are involved, and will also help determine how best to deal with the varicose veins.

 

What are the treatment options?

Treatment is determined by the extent to which the veins bother the patient. If the varicose veins are not troublesome, and there is no concern about their appearance, then there is no real need to intervene.

Mild symptoms can often be controlled with compression stockings which may also prevent the veins from enlarging.

For relatively minor varicose veins with trivial venous reflux, injection sclerotherapy alonemay be sufficient to control the veins.

For prominent varicose veins, a more definitive procedure is required. This can be achieved by either:

  1. Open Surgery.
  2. Endovenous Laser Treatment (EVLT)

Surgical treatment ( a more detailed description is given in procedures performed) of the varicose veins requires interruption of the reversed flow from the deep veins to the superficial through the faulty valves.

For varicose veins arising from the long saphenous system, this requires ligation of the sapheno-femoral junction in the groin. In order to reduce the possibility of recurrent veins, the long saphenous vein is removed (or stripped) from the groin to the knee using a vein stripper. For varicose veins arising from the short saphenous system, the sapheno-popliteal junction is ligated behind the knee. The precise location of this junction is variable, and it needs to be accurately located with ultrasound prior to surgery. The varicose veins are removed by “stab avulsions”, via a series of tiny skin incisions.

The leg is bandaged immediately to reduce bruising and swelling. In most cases the bandages are removed the following morning and replaced with compression stockings, which need to be worn continuously for 14 days.

Another method involves Endovenous laser ablation of the long saphenous vein (EVLT) (see procedures performed). This involves the passage of a laser probe along the saphenous vein, following cannulation of the vein under ultrasound guidance. The laser probe is then used to ablate the saphenous vein by inflicting a thermal injury to the inner lining of the vein, causing it to thrombose or clot. This has the advantage that it can be performed under local anaesthesia, with the expectation of an earlier return to work.

 

What are the complications of surgery?

Some bruising is inevitable following surgery for varicose veins. This is usually most prominent on the inner aspect of the thigh from where the long  saphenous vein has been stripped. Not uncommonly, patients notice residual tender lumps at the site of prevous veins, which usually disappear with time.

It is important to emphasize that complete eradication of ALL veins can NEVER be guaranteed.

Moreover, even in the very best hands, a number of patients (10-15%) will develop recurrent veins in due course.