Abstract
OBJECTIVE: To discuss a modified saphenous vein high ligation and stripping procedure
METHODS: The main trunk of the saphenous vein was ligated below the beginning of the external pubic vein, and the second branch was cut off by ligating at the beginning of the medial and lateral femoral veins. The trunk of the saphenous vein from the medial ankle to the medial knee is stripped, and if there are varicose veins above the knee, the trunk of the saphenous vein here is stripped. The varicose vein mass was completely stripped and the traffic branches were ligated.
Results: 135 patients were treated surgically with no recurrence at follow-up.
Conclusions The advantages are: less trauma, shorter time, less chance of damaging the femoral vessels, less leakage of inguinal lymphatic fluid, increased chance of forming collateral circulation, preservation of vascular graft material, and prevention of varicose vein recurrence.
In our department, we performed a modified high ligation procedure in 135 patients with saphenous varicose veins in 1995D2006, preserving the superficial spinococcygeal vein, superficial abdominal wall vein and external pubic vein, ligating the medial femoral vein and lateral femoral vein, and ligating and stripping the main trunk of the saphenous vein according to the disease in 201 legs, with no recurrence in 2-10 years of postoperative follow-up. It is reported as follows.
1 Clinical data
1.1 General data
135 patients with 201 limbs, 107 males and 94 females, aged 20-68 years old, 49 patients with varicose saphenous vein in both lower limbs and bilateral surgery at the same time, 61 cases with simple left saphenous varicose vein, 42 cases with simple right saphenous varicose vein, and 35 cases with superficial varicose veins in the thigh. All patients had superficial varicose veins in the lower leg, 55 cases of combined calf ulcers, 60 cases of hyperpigmentation and eczema-like changes, 47 cases of venous calculi, 8 cases of para-saphenous varicose veins, and 8 cases of incomplete saphenous vein branches. The operation time was 1-1.5 hours, the bleeding volume was 50-100 ml, and the patients were discharged with cure and were followed up for 2-10 years without recurrence.
1.2 Surgical points
1Epidural anesthesia was used in all cases, 2an oblique incision of about 5 cm in length parallel to the inguinal ligament was made along the direction of the saphenous vein, centered on the oval fossa, 3The operation was unnecessary to deliberately dissect the oval fossa, to find the superficial abdominal wall and the superficial iliac vein, to find the main trunk of the saphenous vein, to fully free the external pubic vein and the medial femoral vein and the lateral femoral vein, which is the main point of the modified operation, to clearly separate the anatomical position, to pay attention to the variant This is the main point of the modified procedure, the anatomical position should be clearly separated and noted, especially when incomplete branching of the saphenous vein is encountered. The trunk of saphenous vein should be cut off and ligated at the inner ankle, and its trunk should be ligated and stripped routinely to the medial knee, if there are varicose veins in the thigh, the trunk of saphenous vein in the thigh should be stripped and ligated together.7 The varicose vein mass should be completely stripped and the traffic branch should be ligated.
2 Discussion
Trendenburg proposed high saphenous vein ligation in 1891, Homans added stripping of varicose veins in 1916, and Dnton proposed traffic branch vein ligation in 1918, since then varicose saphenous vein high ligation + stripping and traffic branch vein ligation are the traditional radical procedures (1234), but there are obvious disadvantages, many incisions, In 1988, sclerotherapy was proposed, which is suitable for varicose veins with no significant reflux or reflux has been corrected in superficial trunks, and its treatment principle is to inject sclerosing agent into the varicose vein and then apply pressure and bandage to occlude the vein wall by mutual adhesions in response to inflammation, with the disadvantage of incompleteness and local formation of sclerotic nodes (5). 1991 Lutten proposed that only the superficial venous segments with reflux lesions need to be selectively surgically removed. (6) On the basis of this theory, this paper improved the traditional surgical method and avoided the disadvantages and shortcomings of the traditional surgical method. Modern view.
”selective GSV stripping”, i.e., the surgery only strips or removes the segment of the saphenous vein with lesions. This method has a small surgical scope, low traumatic response, low saphenous nerve injury rate (4.8%), and preserves the lesion-free venous segment for future vascular bypass diversion procedures. Weakness of the venous wall, defective venous valves and elevated pressure in the superficial veins are the main causes of superficial varicose veins, the farther the venous valves and walls are from the heart, the worse the strength, but the superficial venous pressure is higher the farther from the heart, the direction of blood flow in the superficial iliac and superficial abdominal wall veins is top-down, while the direction of the external pubic veins is close to horizontal, even in severe saphenous varicose veins, the above three branches do not Therefore, there is no need to cut off the above three branches, and Liu Jifan and seasonal reports propose to preserve the five major branches of the saphenous vein and the upper trunk with satisfactory results ( 10, 11).
The direction of blood flow in the medial femoral vein and lateral femoral vein is from bottom to top, under the effect of gravity, if the valve of the traffic branch of the saphenous vein in the femoral segment is dysfunctional, deep venous blood will flow backwards through the traffic branch to the main trunk of the saphenous vein and within the medial and lateral femoral veins, thus increasing the pressure in the medial and lateral femoral veins and causing varicose veins, and cases of varicose veins in the medial and lateral femoral veins can be seen in clinical Therefore, the root of the medial and lateral femoral veins must be ligated, and the same is the complete stripping of the saphenous vein trunk below the medial knee, and the complete stripping of the varicose veins and ligating the traffic branches in the lower leg is the key to improve blood flow and eliminate discomfort symptoms such as soreness and pain, and dealing with the traffic branches between the saphenous vein trunk and the deep veins is the key to prevent recurrence after surgery.
The advantages of using secondary high ligation and stripping with preservation of the superior segment of the saphenous vein and the three major branches are.
(i) it reduces trauma and avoids the hemodynamic changes of the relevant tissues and organs caused by cutting the superficial abdominal wall vein, spinning the superficial iliac vein and the external pubic vein, and increases the chance of forming collateral circulation.
(ii) Preserves the upper segment of the great saphenous vein, the longest and less branched segment of the human body, which is a good segment of vascular graft material.
③Ligation of the medial femoral vein and lateral femoral vein has positive implications for preventing varicose vein recurrence.
④It is not necessary to excessively strip the proximal end of the saphenous vein trunk to effectively avoid damaging the femoral vein, and double ligation of the saphenous vein is far from the femoral artery and deep vein to reduce the chance of damaging the femoral vessels.
⑤Double ligation of the main trunk of the saphenous vein without cutting it off, in case of mistakenly ligating the femoral vein, the ligature can be surgically released and there is still room for compensation.
⑥Reducing surgical operation, shortening operation time, reducing bleeding and saving surgical materials.
(7) The possibility of hematoma and ecchymosis at the root of the thigh is removed, and the leakage of lymphatic fluid from the thigh is reduced.