First of all, saphenous vein high ligation with stripping is indicated for simple saphenous varicose veins. The preoperative venogram should especially mark the traffic branches with abnormal valve function for intraoperative management, in addition to understanding the venous system of the lower limbs.
1. The five branches of the genus saphenous vein near the cleft must be identified and ligated one by one, and there should be no doubt.
The middle and lower thighs are generally thought to have no geniculate branches, but in fact, there is a collecting duct penetrating the middle and lower 1/3 with deep vein traffic.
In the knee plane there are mainly anterior calf veins and posterior arcuate veins. The main impact on the procedure is that they can lead the top-down striker astray and deviate from the main stem. In addition, because they have traffic branches with the small saphenous vein and are not terminal type veins, the depth of free ligation is often not easy to grasp.
2.Venous valves
In the lumen of the great saphenous vein, there are 9~10 pairs of valves, more in the calf, and the valves are mostly of double-valve type, which can block the top-down striker.
Upper incision and saphenous vein exposure
The longitudinal incision is indicated in cases where the deep vein or femoral artery needs to be addressed simultaneously. For simple saphenous varicose veins, a parallel oblique incision below the inguinal ligament provides good visualization. The incision is positioned slightly lower to facilitate first access to the main saphenous vein. After cutting the skin, a small incision is made in the center of the fascia, and a small pulling hook is inserted and pulled up and down to reveal the saphenous vein trunk directly and to avoid damaging the parallel saphenous nerve. After finding the trunk, we should not rush to free upward first, but should free downward first to further identify the saphenous vein trunk. The saphenous vein trunk is first separated upward along the anterior aspect of the saphenous vein trunk until the saphenous vein fissure, revealing the entire upper end of the saphenous vein, and then ligating the geniculate branches separately. This will facilitate accurate differentiation of the individual branches and will avoid too deep a separation.
The length of the ligated stump of the root of the saphenous vein should not exceed 5 mm. The ligation must be followed by a suture.
Is it necessary to dissect down the main trunk of the saphenous vein?
Because there are many variations in the branches of the saphenous vein, a proper downward dissection can reveal the variation in the branches.
Ligation of the myocardial perforator
After inserting the striker through the proximal end of the saphenous vein trunk, double ligating the proximal end, inserting the striker downward to the maximum, and using this as a marker, making another small incision in the middle and lower third of the thigh, revealing the saphenous vein trunk, backing off the striker, picking out the saphenous vein, freeing it up and down, and ligating the closed canal muscle penetrating vessels. If the stripper can be inserted further downward, the trunk can be left uncut here, and another incision can be made where the head of the stripper is blocked. If it is not possible to isolate and ligate the closed canal muscle, the trunk can be cut under the incision and the vessel can be slowly dragged out downward, which can be raised out of the incision.
Note that it is not mandatory to ligate this perforator, so do not force it!
Advance along the correct trunk
In fact, most of the cases we encounter are those where the vessel is right in front of us, but the stripper just can’t get through, or it deviates from the main trunk and enters the geniculate branch and can’t continue.
What is blocking our way forward?
1.Venous valve, not allowed to go up or down
2, the geniculate branch. Goes astray.
3.Venous flexion.
What to do?
You can find the trunk from the bottom up before you mess up the calf veins. Neither the venous valves nor the geniculate branches will form an obstruction, but what about flexion?
The good thing is that the convergence of the flexed vessels and the major geniculate branches is mainly concentrated in the upper middle of the calf, so you can make an incision at each of the obstructed parts of the head of the stripper at the upper and lower ends, and cut the upper one downward and the lower one upward, which basically solves the problem of the main trunk and the main geniculate branch trunk.
Should we turn the curve into a straight one and advance step by step? Or to enlarge the incision and remove the whole group?
Advance along the correct trunk ——- inch
Is it better to turn a curve into a straight one and advance step by step? Or expand the incision and excise the whole mass?
Whichever approach is better, it is important to separate the vessel from the surrounding tissue. Perhaps, this is the least smooth part of the entire procedure. When you lift the severed end of the vessel to free it, no matter how careful you are, whether you use blunt or sharp separation, you will inevitably tear or even rip the vessel, putting the surgery in jeopardy.
Why is it so difficult to separate the vessel?
The main reason is that the vessel flexes, and the flexed vessel often blocks the front of the vascular clamp.
Second, the dilated vessel wall becomes thin and brittle, losing its original elasticity and breaking when touched.
Third, the long-term chronic inflammation of the varicose vessels leads to adhesions to the surrounding tissues, as if they were closely adhered to the skin. The strength of the adhesions has exceeded the strength of the vessels, with the result that the vessels are not separated but broken first.
These difficulties are common, and it takes skill and experience to overcome the difficulties to divide the vessels intact ———- and so on! Do you really have to cross the snowy mountains and grasslands to get to Shanbei?
Bright turn
Let’s think again about the characteristics of the blood vessels and the surrounding tissues.
Behind the blood vessels are loose tissues that are easier to separate ——– from here first???
It does make for irresistible bait!
But, after dividing the blood vessel, it is free? No, detached from the connection with below, the blood vessels are more closely related to the skin, you push the intermediate molecules completely into the arms of the enemy!
The adhesions between the vessels and the skin should be separated first. Although the adhesions are tight, there is still a gap under the skin, which is clearly seen when the separation is made under direct vision of the incision. What kind of gap is this? How can we advance along this gap?
As mentioned earlier, the vessels are heavily flexed and fragile, but the skin is basically straight, smooth, tough and reliable, and this gap is firmly attached to the back of the skin, and freeing the skin covering the vascular mass is the same as freeing the mass of vessels!
If the two incisions are close together, the two ends of the close incision can be lifted separately, separated and lifted tightly from each other, and then separated along the stretched tight skin with mosquito forceps or dissecting scissors until the incision on the opposite side is divided?!!!
You see it!!! How is it the same as transection of the hernia sac?!!!
How to spread which to both sides?
You can sew a few skin traction lines in the area to be separated and pull the skin that needs to be free ——–
If the vascular mass is free, should I turn the curve into a straight one and advance step by step? Or is the whole mass removed? Is there any difference!
For the varicose vessels that point to both sides, I really want to remove them all!
But they are mostly traffic branch vessels, and complete resection is not realistic.
Since we can’t cut all of them, we can only cut as many as possible. But it is impossible to ligate them if they are far away, and tearing them off is certainly possible, but it is indeed reluctant and not perfect.
Perhaps you could percutaneously suture the traffic branch vessel where you want to cut it off! What’s not to like?