Saphenous varicose vein is a common disease with a prevalence of 16.4% in people over 45 years of age in China. The traditional surgical methods are high saphenous vein ligation and stripping, traffic vein ligation, and superficial varicose vein excision. This surgical method is highly invasive, has many incisions, and seriously affects the aesthetics of the limb after surgery. We treated 23 cases of simple saphenous varicose vein from May 2006 to October 2010 by using the surgical method of microincision with good results, which are reported as follows.
1.Clinical data and methods
1.1 General information In this group, there were 23 cases, 13 males and 10 females. Age 31-73 years. There were 10 cases of left saphenous varicose vein, 8 cases of right saphenous varicose vein and 5 cases of bilateral saphenous varicose vein. 6 limbs had pigmentation in the foot and shoe area and 3 limbs had skin ulcers in the ankle. Twenty-six limbs were operated. One case was suspected of having deep venous valve insufficiency. 26 limbs had traffic vein valve insufficiency.
1.2 Surgical methods
1.2.1 The varicose veins were carefully marked with gentian violet before surgery. Continuous epidural anesthesia was applied. A transverse incision of approximately 1-1.5 cm in length is made above the anterior aspect of the medial ankle to isolate the main trunk of the saphenous vein, and a stripper is placed in a parallelepipedal fashion straight to the groin. An oblique incision of 1.5-2 cm in length is made parallel to the inguinal ridge and approximately 1 cm below the ridge to expose the saphenous vein trunk and cut the medial and lateral femoral veins. The superficial iliac vein, superficial abdominal wall vein and external pubic vein are not ligated.
The saphenous vein trunk is ligated and cut 0.5 cm below the point where the above superficial veins converge into the saphenous vein, and is not stripped for the time being. The guide wire is left at both ends of the stripper.
1.2.2 At the site marked by gentian violet, multiple small incisions of 0.3-0.5 cm in length are made along the varicose vein. Cut the skin to reveal part of the varicose vein. The varicose vein is raised with a mosquito-type vascular forceps, and the varicose vein is slowly raised by rotating, pressing, and lifting, etc. Another vascular forceps is passed under the raised vein with another vascular forceps close to the skin, and the vein is clamped and cut, and the broken end is twisted and pulled, and the vein is gradually withdrawn. The vein is gradually withdrawn. After each 3-5 mm of withdrawal, it must be clamped with a vascular clamp against the skin.
This is repeated until the vein cannot be withdrawn, then the vein is ligated, the withdrawn vein is cut, and the ligated end is allowed to retract and be withdrawn from the adjacent incision. The adjacent incisions of the same vein are about 5 cm apart, and the entire varicose vein can be stripped out by one tap at a time. In case of bleeding, local pressure is applied to stop the bleeding. The small incision is closed by one stitch with 5-0 “Aishikang” suture close to the incision edge.
1.2.3 Subcutaneous suturing of the lesser varicose veins distant from the main trunk of the saphenous vein is performed. Method: The first stitch is entered from point A, passes through the skin, surrounds the varicose vein from below, and exits from point B. The second stitch is entered from point B with the same needle and thread, passes through the subcutaneous tissue immediately after the skin, and exits from point A and is tied. The knot is not inserted into the needle hole at point A. The suture is tied with 5-0 “Aishikang” absorbable thread, which does not need to be removed and leaves no scars on the skin.
1.2.4 The affected limb is wrapped with a sterile bandage with pressure from the bottom up, and the saphenous vein trunk is stripped. If the saphenous vein trunk is pulled off in the middle of stripping, the stripper can be pulled out of the tunnel by the guide wire reserved at both ends of the stripper and stripped in the opposite direction. After the incision is sutured, the affected limb is wrapped with an elastic bandage with pressure.
1.2.5 From the first postoperative day onwards, 500 ml of 6% low-molecular dextrose drip and 50 mg of enteric aspirin were administered orally, and the ankle joint flexion and extension exercises of the affected limb were performed autonomously or passively to prevent deep vein thrombosis of the affected limb.
2.Results
Of the 26 operated limbs in this group of 23 patients, 25 limbs in 22 patients recovered well. 3 limbs with skin ulcers on the ankle, 1 ulcer healed 2 weeks after surgery and the other 2 ulcers healed about 3 weeks after surgery. 6 limbs with pigmentation in the foot and shoe area, 5 patients had hypopigmentation 2 weeks after surgery, 1 patient had deep vein thrombosis in the affected limb 3 weeks after surgery, and the pigmentation in the foot and shoe area did not change significantly. All patients were discharged 1 week after surgery and stitches were removed 2 weeks after surgery, and there was no recurrence of varicose veins within a short period of time. At 2 months after the operation, the tiny incisions were not easily distinguishable when observed at a distance of about 1m.
3.Discussion
3.1 There are about 80 million to 100 million cases of patients in China [2]. High saphenous vein ligation, stripping, traffic vein ligation and varicose vein resection are the standard procedures for the treatment of saphenous varicose veins. Although this procedure is effective and reliable, it has many incisions, trauma, bleeding, long hospital stay, and affects the morphology of the affected limb, which obviously can no longer meet today’s requirements for the beauty of limb morphology.
The surgical method of microincision discards the long incision in the leg during the traditional saphenous vein stripping, which can completely strip the saphenous vein and its branches and minimize the damage to the skin and soft tissues of the limb, and no special equipment and instruments are needed, and the incision heals well and the scar is small after the operation, which is a practical technique with good therapeutic effect.
3.2 Although the etiology of saphenous varicose vein is not completely clear, weakness of the vein wall, defective venous valves and elevated pressure in the superficial veins are considered to be the main causes of superficial varicose veins.
The direction of blood flow in the superficial rotating iliac and superficial abdominal wall veins is top-down, whereas the direction of blood flow in the external pubic veins is nearly horizontal, and even in patients with severe saphenous varicose veins, the above three branches of the genus rarely develop varicosities. Satisfactory results of saphenous vein stripping with preservation of the five major branches of the saphenous vein and the upper trunk have been reported. Therefore, the necessity of ligation of the five branches of the saphenous vein in every patient with saphenous varicose vein needs to be investigated.
The advantages of using a surgical approach that preserves the three major branches of the saphenous vein are.
(1) Avoid hemodynamic changes in the relevant tissues and organs caused by severing the superficial abdominal wall vein, the superficial iliac vein and the external pubic vein.
(2) Reduces tissue damage and decreases the possibility of damaging the femoral vein. (3) Shorten the operation time.
3.3 In this group of patients, the sequence of saphenous vein stripping is as follows: placing the stripper in the main trunk of the saphenous vein, stripping the varicose branches of the saphenous vein, wrapping the affected limb with a sterile bandage and stripping the main trunk of the saphenous vein. If the trunk of the saphenous vein is stripped first and then the branches of the saphenous vein are stripped, on the one hand, it is not easy to stop bleeding by compression of the saphenous vein bed, and on the other hand, there is more bleeding when the branches of the saphenous vein are stripped. In addition, after stripping the varicose saphenous vein branches, the resistance to stripping the main trunk of the saphenous vein is significantly reduced. In this group of patients, there was less postoperative subcutaneous bruising.
Surgical operation precautions.
(1) Preoperative marking of varicose veins should be carefully and thoroughly to avoid missed stripping.
(2) The peri-ulcer and deep penetrating branch veins should be thoroughly aspirated.
(3) For aesthetic reasons, small incisions should be made along the skin line.
(4) Segmental suturing of varicose veins should be done within the subcutaneous tissue and not over deep fascia to avoid damage to nerves.