Br. J. Surg. Vol. 62 (1975) 913-917
The surgical cure of primary varicose veins STANLEY RIVLlN* SUMMARY
A prime requisite of successful varicose cein surgery is a detailed clinical examination. This reveals a new test for short saphenous incompetence and shows that 14 per cent of’ varices stem from a saphenopopliteal reflux. The intimate details oj juxtajemoral and juxtapopliteal ligation are emphasized and the common causes of failure pointed out. The technique of ‘scarless’ varicose irein surgery is described. A 6-10-year follow-up of some 2000 patients reveals an overall recurrence rate o f 7 per cent.
EXCURSIONS into the literature of varicose vein surgery reveal a variety of surgical opinions. Many treatments have been propounded, and all have been followed by varying degrees of recurrence. In fact, many surgeons feel that since varicose veins are so difficult to cure they hardly justify the use of surgical beds for their treatment, when such cases might be better temporarily sclerosed as outpatients and thus take up less of the National Health Service’s time and money (Piachaud and Weddell, 1972). A method is described here whose beginnings date back to 1951 (Rivlin, 1951), and which has now been developed to the point where a 10-year follow-up demonstrates an overall recurrence rate of not more than 7 per cent. This paper is concerned only with primary varicose veins (which account for 85 per cent of varicose vein sufferers), that is, varices arising directly as a result of local, probably congenital, superficial-deep valve failure. It is not a study of the numerically far smaller problem of secondary varices, whose valvular incompetence is spread widely up and down the limb as a result of deep vein thrombosis. Examination The long saphenous system The examination of varicose veins is based upon one simple fact: namely, that if a leg bearing normal veins is emptied by elevation, when the subject stands up the veins take 25-30 seconds to refill (from below), whereas, depending upon the degree of varicosity, and this always correlates with the patient’s symptoms, varicose veins will refill from above in 0-20 seconds after emptying the leg. However, if the retrograde flow is prevented by the application of a venous tourniquet placed distal to the source of the reflux, then the filling time will return to normal, the veins slowly filling in 30 seconds from the arterial side (as opposed to rapidly from the venous side) of the circulation. Hence, by moving the venous tourniquet down the leg in steps and noting the improvement in the filling time
67*
towards normality, it becomes, with experience, a relatively straightforward matter to determine the point sources of reflux in the lower limb. This method of examination has previously been described in detail (Rivlin, 1951), and the technique has stood the test of time. The number of sources of reflux in the lower limb below the knee has been exaggerated in the past, no doubt to explain away past surgical failures. In the long saphenous system there are, for all practical purposes, four point sources of reflux only: the saphenofemoral junction (most common and most important), the mid-thigh perforator, the lower thigh perforator and the tibia1 tubercle level perforator. The surgery of primary varicose veins has been much influenced in recent years by insistence upon the importance of the so-called ‘ankle blow-out perforators’ (Cockett, 1955). These, in fact, only become of note in secondary varices due to deep vein thrombosis, and even then are merely part of a massive and widespread failure of most of the perforating veins in the lower limb. They can be safely ignored in the 5 million cases of primary varicose veins at risk at any given moment in Great Britain. The shorf saphenous system In 1 out of every 7 cases (14 per cent) of varicose veins, application of the venous tourniquet to the upper thigh has the paradoxical effect of increasing the strength of the reflux, as shown by a faster instead of slower filling time. This sign, which has not been described before, is pathognomonic of varices of the short saphenous system. The mechanics of this phenomenon are quite simple, for in these cases of short saphenous insufficiency, application of the upper thigh tourniquet blocks off the normal internal saphenous system which is carrying most of the superficial venous return, and thus throws into greater prominence the retrograde leak from the saphenopopliteal junction. Final definitive proof of short saphenous incompetence is obtained by temporarily blocking the saphenopopliteal junction with thumb pressure. The proximal portion of the short saphenous vein, although quite impalpable in the erect posture with a straight leg, can easily be found just lateral to the midline of the popliteal crease when the knee is slightly flexed. Jt should be marked with a pen with the patient standing, and then as soon as the veins are emptied by leg elevation, firm thumb pressure can be applied to the spot whilst the patient stands. The varices will remain empty until 25 seconds
* 99 Harley
House. 1.ontlon.
913
Stanley Rivlin have elapsed o r will refill immediately the thumb pressure is removed, whichever happens first. It should be stressed that there are. for all practical purposes, no other incompetent perforating veins in the short saphenous system. Consequently it is quite unnecessary, and in the author’s view harmful, to ‘strip’ the external saphenous vein. Treatment Once the routine of a careful clinical examination has been established, treatment should be axiomatic: a faulty long saphenous system requires juxtafemoral ligation combined with ablation of the incompetent thigh and knee perforating veins and removal of varices, whilst an incompetent short saphenous system demands juxtapopliteal ligation alone, plus extirpation of varices.
The long saphenoris system Jiixtafernoral ligation : The term ‘juxtafemoral ligation’ is one to which more lip service than surgical skill is generally applied. Should this seem a sweeping statement, it is supported by the fact that of the last 5500 patients personally seen and examined by the author, 1453 had been subjected to previous unsuccessful surgery. At reoperation n o less than 72 per cent were found to be recurring as a result of failure to carry out a true juxtafemoral ligation (Rivlin, 1966). This is in line with other previously published studies. Haeger (1961) found saphenofemoral recurrent reflux in 77 per cent of 54 legs, whilst Dodd and Cockett (1956) found 73 per cent in 33 legs. Attempts have been made to list the variations in so-called ‘normal’ venous anatomy a t the saphenofemoral junction. In fact there is no ‘normal’. The arrangements of venous tributaries are seemingly infinite, and the ways in which they join the long saphenous or femoral vein seem to be decided only by the laws of chance. So forget the tributaries by name and treat them as they deserve by dividing each and every one as it stands in your path whilst you make your way towards your goal-the saphenofemoral junction. This at least is constant. The long saphenous vein always joins the femoral vein within the femoral sheath medial to the femoral artery and within 1 or 2 cm of the groin crease. It is at this point, flush with the femoral vein, within the femoral sheath that it must be ligated. At the same time the femoral vein must be exposed on its anterior, lateral and medial aspects for at least 3 cm proximal and distal to the saphenofemoral junction in order to facilitate the division of further tributaries, found in over 50 per cent of cases, which join the femoral vein direct, and will if left lead to recurrence. Ablation oj incompetetit perforating zieins: Having secured the major source of reflux, the next step is to deal with the incompetent perforating veins, and this is the point at which the stripper comes into its own. When Foote ( 1 960) popularized the stripping technique he did a great service. Unfortunately, the attractions of removing an entire internal saphenous vein in one manceuvre so overshadowed the surgery of varicose 914
veins that the importance of juxtafemoral ligation tended to be overlooked. The operation for varices became known as ‘stripping’. The long term results were as poor as the short term effects were dramatic, and contributed not a little to the gloomy view of varicose vein surgery held by many members of the profession and the public. The stripper is, however, still a very valuable tool (provided that it is not allowed to take oker the operation!), for it enables the long saphenous vein, together with the incompetent perforators which join it, to be removed. Since, as pointed out earlier, the most distal incompetent perforating vein is within a centimetre o r two of the level of the tibial tubercle, there is n o longer any need for the old-fashioned ankle-length stripper, and in fact the stainless steel piano-wire strippers made by Down Bros have a standard length of 73 cm. The stripper is inserted into the upper end of the divided internal saphenous vein and passed down the main channel (avoiding ‘lay-bys’ and minor tributaries) until it can be felt lying one finger’s breadth medial t o the medial border of the tibia about 4 c m distal t o the level of the tibial tubercle. A small incision a t this point allows the removal of both stripper and vein. Half a minute’s firm fist pressure by an assistant on the vein track in the thigh usually suffices to control oozing. Rernooal of varices: Having dealt with the source(s) of retrograde flow, it only remains to remove the superficial veins, which over the years have become permanently and visibly dilated by the unrestrained effects of increased intraluminal pressure. Since the technique described so far has required only one suturable incision-and this in the groin where once healed it is quite invisible-it would seem logical to complete the operation in a manner which leaves no permanent or visible scars. This is achieved using the method called ‘multiple cosmetic phlebectomy’. ‘Multiple’ because in severe cases of widespread varices one may have to make as many as 25 tiny puncture wounds in the leg, and ‘cosmetic’ in the sense that the tiny scars (made in Langer’s lines, Cox, 1941) disappear, leaving the patients with no visible evidence of previous varices. The technique is as follows. Using a Beaver miniature blade (No. 65), a tiny ‘stab’ not more than 3 mm long is made immediately over the vein (which has been marked preoperatively). With a fine modified Kilner’s mosquito forceps the vein is gently teased out to the surface where it can be more generously grasped with larger forceps and avulsed, using a gentle to and fro rocking movement. In this way it is possible to remove u p to 5 cm, and occasionally (in veins which have not been previously damaged by sclerosant therapy) rather longer lengths, through each stab wound. Bleeding is surprisingly slight owing to the fact that as each segment snaps off, the smooth muscle in the intima contracts to close the lumen. Closure ofwounds: The groin incision is closed with a single subcuticular stitch and the stabs with Micropore. The leg is bandaged with Poroplast lined with
Primary varicose veins
l-ubinette,* the whole forming a neat, non-bulky, snug-fitting dressing which remains untouched for I week. Pos/operaiive course: Patients walk normally, without pain and without a limp, on the day following operation. The groin suture is removed on the third postoperative day, when the patient is discharged home but advised only to undertake light duties. The bandage and Micropore strips are removed on the seventh day and replaced by a ‘throw-away’ support (Tubigrip) which is worn for 1 week only. Patients can drive their car at 1 week after operation, can swim and dance in 14 days and can play tennis etc. within 3 weeks. No further treatment is required. The short saphemus wirr Juxtapopli/eal ligation: Juxtapopliteal ligation of the short saphenous vein is, like juxtafemoral ligation of the long saphenous vein, the sine qua nun of successful varicose vein surgery, but whereas juxtafemoral ligation is, with experience, a relatively straightforward procedure, juxtapopliteal ligation is often fraught with difficulty. The principle underlying the operation is the same: namely, to follow the short saphenous to the saphenopopliteal junction and to carry out a flush ligation at that point. The problem arises in that the medial and lateral popliteal nerves and some of their motor branches also lay claim to the same territory, and in many cases have to be carefully moved aside in order to obtain a reasonable view of the popliteal vein and its environs. A further obstacle to smooth progress lies in the fact that in a number of cases on opening the popliteal fossa the external saphenous vein appears rudimentary or even absent. It is easy to be deceived by this. The short saphenous is always present somewhere in the fossa, and diligent search, very commonly in the lateral border of the fossa or sometimes even distal to the popliteal crease, will always, with practice, be successful in the end.
@
* A snugly fitting gauze-lined bandage, which cannot slip, retains its support, yet is simple to remove after 7 days, is cssential for painless postoperative ambulation. A single layer of thin non-elastic tubular gauze (Tubinette, size H78, Seton Products Ltd) approximately 230 cm in length is applied from groin to toes, leaving the excess 115 cm hanging loose. Firm (bu; not tight) pressure is cffected by 3 rolls of 3-in Poroplast (Scholl Manufacturing Co.), applied from the groin down to the toes in a clockwise manner. The first two turns of bandage i n the groin, directly on the skin, are used to anchor the upper cdge of the tubular gauze. The remaining turns (always clockwise) build up the bandage peripherally over the gauze to the tocs. N o figure of eight turns are used as these can be constricting. Where the bandage does not fit the contours of the limb, the fold is pinched up and cut off flush. The bandage finishes at the base of the toes, and the excess Tubinette is then pulled back over the Poroplast up to the groin, this prevents any ruckling of the bandage in bed. It is important to use flexiblc Poroplast rather than elastic Elastoplast, for the former is not only a far thinner, and hence a more ‘snug’ material, but has the exceptional merit of utilizing a plastic sticky spread which virtually banishes skin allergy (Russell and Thorne, 1955). The author has only met Poroplast allergy in 2 of the last 4000 limbs bandaged either postoperatively or for gravitational leg ulceration.
The popliteal fossa is best opened by a transverse incision, some 8cm long, parallel to and 3 cm proximal to the popliteal crease. The dense popliteal fascia lying beneath the subcutaneous tissue should be split vertically and undercut to permit good exposure. On closing the wound the fascia must be carefully approximated, otherwise herniation of the popliteal contents can ensue. Since in the present series incompetent perforating veins have never been found in association with the short saphenous vein, and since stripping the short saphenous vein can not only cause long standing oedema but may also permanently damage the sural nerve, short saphenous stripping has no place in this technique. The operation is completed by multiple cosmetic phlebectomy, as outlined above. Postoperative course: The wounds are closed and the leg bandaged from toes to mid-thigh for 1 week, as for the long saphenous group. The postoperative course is exactly similar apart from the fact that, owing to the presence of the bandage, the popliteal subcuticular suture is left in for 7 days. FOIIOW-UP One of the larger problems in evaluating the results of varicose vein surgery is in deciding what constitutes success or failure. Different authors adopt very different criteria, and these in turn depend upon the demands of their patients. For example, many patients whose legs ache owing to the presence of varicose veins will be delighted if their symptoms cease, even though their varices still remain, and if asked to evaluate the results of their treatment may t e quite happy to class their legs as ‘successful’ or ‘good’. What has actually happened in these cases is that sclerosant therapy or simple ligation has reduced venous back pressure just sufficiently to prevent symptoms, though perhaps not enough to prevent the insidious retrogression towards eczema, ulceration, phlebitis and thrombosis. A better criterion of the effectiveness of treatment is by determining the presence or absence of varicose veins after a stated period of time. If the results of different authors are to be comparable, then a standard definition of a varicose vein must be adopted. As the method of treatment outlined above is based on the timed tourniquet test, which in turn is founded on the definition of a varicose vein as one which refills by retrograde flow in 20 seconds or less after first emptying the legs by elevation, this is the criterion by which the present results have been judged. One final point to be noted is that, as in the Mayo Clinic series (Larson et al., 1974), the results are given in terms of legs rather than patients. This is because varicose veins vary in site of origin and surgical anatomy not only from patient to patient but from leg to leg in the same patient, and it is therefore essential to evaluate each limb and each venous system separately. The follow-up study began in 1971, based upon the potential examination of 2500 consecutive legs with primary varicose veins operated on personally by the 915
Stanley Rivlin Table I: INCIDENCE OF RECURRENCE ACCORDING TO SITE OF VARICES Recurrence ”, No. Site of v a r i c s No. 70 Long saphenous 1708 86 102 Short saphenous 285 14 23 8 Total 1993 100 125 ’I’
TO LENGTH ‘ I : lNCIDENCE OF FOLLOW-UP OF RECURRENCE Length of follow-up (yr)
10 9
8
Recurrence No. of cases
No.
319 387
22 28
396
24
”/,
6
author in the years 1961-5, thus giving a maximum of 10 years’ and a minimum of 5 years’ follow-up. In the event, the practicalities of tracing patients and arranging for a physical examination by the author proved far greater than anticipated and took 2 years. Despite the problems involved, 1993 (79 per cent) legs have been assessed. Results Of the 1993 legs, 1708 (86 per cent) had been operated upon for varices of the long saphenous, and 285 (14 per cent) for incompetence of the short saphenous vein. The recurrence rate was 6 per cent (102 legs) in the long saphenous system and 8 per cent (23 legs) in the short saphenous group (Table I ) . The most interesting finding was that thepercentage ofrecurrence was constant within narrow limits irrespective of the length of time of the follow-up. This is shown in Table II where the overall recurrence rate is shown for each follow-up period. Causes of recurreme Of the total of 125 limbs with recurrent varices, 79 of the 102 with long saphenous varices and 21 of the 23 with short saphenous incompetence submitted themselves to further surgery, not only to remove the new varices by multiple cosmetic phlebectomy but also, by exploration of the groin or popliteal areas, to elucidate if possible the cause of the recurrence. In the short saphenous group the answer was always the same. In every instance the new varices were being fed either by a connection with the popliteal vein in the popliteal fossa which had not been noticed at the original operation (10 cases), or by theshort saphenous vein itself which had been totally missed and in fact recorded as ‘absent’ or ‘rudimentary’ in the operation notes (11 cases). The popliteal fossa, with its many motor nerves criss-crossing the operative field, is a difficult surgical area, and on occasion the position of the large medial and lateral popliteal nerves renders it hazardous to expose the popliteal vein quite as thoroughly as one would wish. Thus on occasions where a rudimentary short saphenous vein with no deep venous connections is found passing straight through the fossa up into the posterior thigh it is 916
tempting, particularly where the position of the motor nerves is especially perilous, to assume that one is dealing with an anatomical anomaly and to treat the varices on an ad hoc basis by multiple phlebectomy. Under similar circumstances one would tend to behave in the same manner where the short saphenous vein was apparently completely absent. However, as a result of exploring these recurrent cases the author has no hesitation in saying that a true short saphenous vein is always present somewhere in the fossa and will virtually always be found by diligent and careful search. Occasionally this will require a second and distal incision just below the popliteal crease to pick u p a short saphenous vein which has perforated the deep fascia rather earlier in its course than is usual. In most other instances it will be found to have taken a lateral instead of a midline route in the fossa and will be discovered very deep in the lateral angle of the incision. The findings on exploring the 79 cases in the long saphenous group were very different. In no instance was there a reflux from the saphenofemoral junction. The technique of thorough juxtafemoral ligation described earlier in this study appears to have eliminated this previously most common cause of recurrent varices. In 12 instances the recurrence was due to the fact that the internal saphenous vein had not (as had been supposed) been stripped, the stripper having passed along a vein lying adjacent and parallel to the true long saphenous vein, leaving the original thigh perforators untouched and able to pass their reflux. In the remaining 67 cases the varices were arising from uncommonly sited perforating veins not connected with the long saphenous vein but feeding their own little group of superficial varices. Eight of the perforating veins were present in the medial thigh within 10 cm of the groin, 7 lay just 3 cm posterior to the usual site of the tibia1 tubercle perforator and the remaining 52 arose at various points along the medial side of the thigh. Conclusion The surgery of varicose veins is a strict discipline involving careful clinical preoperative examination by the timed tourniquet test to demonstrate accurately the source of the venous reflux. Operation at the saphenofemoral or saphenopopliteal junction is a meticulous procedure requiring hard-won experience if good results are to be obtained. The current vogue for sclerosant therapy is based upon a meaningless comparison of inadequate surgery with outpatient injections. The suggestion that varicose veins are due to a local congenital valvular anomaly rather than a chronic progressive degenerative process is supported by the steadiness of the long term results which are unaffected by the length of the follow-up. The overall recurrence rate of 7 per cent can be improved by particular attention being paid to the popliteal fossa, but even allowing for this, it would seem that there is a hard core of 5 per cent of patients who will have recurrent varices despite the most careful preoperative assessment. However, these cases can easily be dealt
Primary varicose veins with by stab phlebectomy accompanied, if necessary, by simple local ligation of the offending perforating vein.
Acknowledgement I am grateful to Sister June Geddes for her invaluable assistance in persuading patients to attend for followUP. References (1955) The pathology and treatment of venous ulcers of the leg. Br. J . Surg. 43,260-278. cox H. T. (1941) The cleavage lines of the skin. Br. J . Surg. 29, 234-240. DODD H. and COCKETT F. B. (1956) The Pathology and Surgery of Veins of the Lower Limb. Edinburgh, Livingstone. COCKETT F. B.
K.( I 960) Varicose Veitis. A Practical Manual, 3rd ed. Bristol, Wright. HAEGER K . (1961) Technique of high ligation of the long saphenous vein. An analysis of 54 reoperation cases. Acta Chir. Scand. 122, 85-92. LARSON R. H . , LOFGREN E. P., MYERS T. T. and LOFGREN K. A. (1974) Long term results after vein surgery. Study of 1000 cases after 10 years. Mayo Chi. Proc. 49, 114-1 17. PIACHAUD D. and WEDDELL J . M. (1972) The cost of treating varicose veins. Lancet 2, 1191-1 192. RivLiN s. ( 1 951) Treatment of Varicose Veins and their Complications. London, Heinemann, pp. I 1-1 6. RIVLIN s. (1966) Recurrent varicose veins. Med. J . Aust. 1, 1097-1 102. RUSSELL B. and THORNE N. A. (1955) Skin reactions beneath adhesive plasters. Lancet 1, 67-70. FOOTE K.
917
The surgical cure of primary varicose veins STANLEY RIVLlN* SUMMARY
A prime requisite of successful varicose cein surgery is a detailed clinical examination. This reveals a new test for short saphenous incompetence and shows that 14 per cent of’ varices stem from a saphenopopliteal reflux. The intimate details oj juxtajemoral and juxtapopliteal ligation are emphasized and the common causes of failure pointed out. The technique of ‘scarless’ varicose irein surgery is described. A 6-10-year follow-up of some 2000 patients reveals an overall recurrence rate o f 7 per cent.
EXCURSIONS into the literature of varicose vein surgery reveal a variety of surgical opinions. Many treatments have been propounded, and all have been followed by varying degrees of recurrence. In fact, many surgeons feel that since varicose veins are so difficult to cure they hardly justify the use of surgical beds for their treatment, when such cases might be better temporarily sclerosed as outpatients and thus take up less of the National Health Service’s time and money (Piachaud and Weddell, 1972). A method is described here whose beginnings date back to 1951 (Rivlin, 1951), and which has now been developed to the point where a 10-year follow-up demonstrates an overall recurrence rate of not more than 7 per cent. This paper is concerned only with primary varicose veins (which account for 85 per cent of varicose vein sufferers), that is, varices arising directly as a result of local, probably congenital, superficial-deep valve failure. It is not a study of the numerically far smaller problem of secondary varices, whose valvular incompetence is spread widely up and down the limb as a result of deep vein thrombosis. Examination The long saphenous system The examination of varicose veins is based upon one simple fact: namely, that if a leg bearing normal veins is emptied by elevation, when the subject stands up the veins take 25-30 seconds to refill (from below), whereas, depending upon the degree of varicosity, and this always correlates with the patient’s symptoms, varicose veins will refill from above in 0-20 seconds after emptying the leg. However, if the retrograde flow is prevented by the application of a venous tourniquet placed distal to the source of the reflux, then the filling time will return to normal, the veins slowly filling in 30 seconds from the arterial side (as opposed to rapidly from the venous side) of the circulation. Hence, by moving the venous tourniquet down the leg in steps and noting the improvement in the filling time
67*
towards normality, it becomes, with experience, a relatively straightforward matter to determine the point sources of reflux in the lower limb. This method of examination has previously been described in detail (Rivlin, 1951), and the technique has stood the test of time. The number of sources of reflux in the lower limb below the knee has been exaggerated in the past, no doubt to explain away past surgical failures. In the long saphenous system there are, for all practical purposes, four point sources of reflux only: the saphenofemoral junction (most common and most important), the mid-thigh perforator, the lower thigh perforator and the tibia1 tubercle level perforator. The surgery of primary varicose veins has been much influenced in recent years by insistence upon the importance of the so-called ‘ankle blow-out perforators’ (Cockett, 1955). These, in fact, only become of note in secondary varices due to deep vein thrombosis, and even then are merely part of a massive and widespread failure of most of the perforating veins in the lower limb. They can be safely ignored in the 5 million cases of primary varicose veins at risk at any given moment in Great Britain. The shorf saphenous system In 1 out of every 7 cases (14 per cent) of varicose veins, application of the venous tourniquet to the upper thigh has the paradoxical effect of increasing the strength of the reflux, as shown by a faster instead of slower filling time. This sign, which has not been described before, is pathognomonic of varices of the short saphenous system. The mechanics of this phenomenon are quite simple, for in these cases of short saphenous insufficiency, application of the upper thigh tourniquet blocks off the normal internal saphenous system which is carrying most of the superficial venous return, and thus throws into greater prominence the retrograde leak from the saphenopopliteal junction. Final definitive proof of short saphenous incompetence is obtained by temporarily blocking the saphenopopliteal junction with thumb pressure. The proximal portion of the short saphenous vein, although quite impalpable in the erect posture with a straight leg, can easily be found just lateral to the midline of the popliteal crease when the knee is slightly flexed. Jt should be marked with a pen with the patient standing, and then as soon as the veins are emptied by leg elevation, firm thumb pressure can be applied to the spot whilst the patient stands. The varices will remain empty until 25 seconds
* 99 Harley
House. 1.ontlon.
913
Stanley Rivlin have elapsed o r will refill immediately the thumb pressure is removed, whichever happens first. It should be stressed that there are. for all practical purposes, no other incompetent perforating veins in the short saphenous system. Consequently it is quite unnecessary, and in the author’s view harmful, to ‘strip’ the external saphenous vein. Treatment Once the routine of a careful clinical examination has been established, treatment should be axiomatic: a faulty long saphenous system requires juxtafemoral ligation combined with ablation of the incompetent thigh and knee perforating veins and removal of varices, whilst an incompetent short saphenous system demands juxtapopliteal ligation alone, plus extirpation of varices.
The long saphenoris system Jiixtafernoral ligation : The term ‘juxtafemoral ligation’ is one to which more lip service than surgical skill is generally applied. Should this seem a sweeping statement, it is supported by the fact that of the last 5500 patients personally seen and examined by the author, 1453 had been subjected to previous unsuccessful surgery. At reoperation n o less than 72 per cent were found to be recurring as a result of failure to carry out a true juxtafemoral ligation (Rivlin, 1966). This is in line with other previously published studies. Haeger (1961) found saphenofemoral recurrent reflux in 77 per cent of 54 legs, whilst Dodd and Cockett (1956) found 73 per cent in 33 legs. Attempts have been made to list the variations in so-called ‘normal’ venous anatomy a t the saphenofemoral junction. In fact there is no ‘normal’. The arrangements of venous tributaries are seemingly infinite, and the ways in which they join the long saphenous or femoral vein seem to be decided only by the laws of chance. So forget the tributaries by name and treat them as they deserve by dividing each and every one as it stands in your path whilst you make your way towards your goal-the saphenofemoral junction. This at least is constant. The long saphenous vein always joins the femoral vein within the femoral sheath medial to the femoral artery and within 1 or 2 cm of the groin crease. It is at this point, flush with the femoral vein, within the femoral sheath that it must be ligated. At the same time the femoral vein must be exposed on its anterior, lateral and medial aspects for at least 3 cm proximal and distal to the saphenofemoral junction in order to facilitate the division of further tributaries, found in over 50 per cent of cases, which join the femoral vein direct, and will if left lead to recurrence. Ablation oj incompetetit perforating zieins: Having secured the major source of reflux, the next step is to deal with the incompetent perforating veins, and this is the point at which the stripper comes into its own. When Foote ( 1 960) popularized the stripping technique he did a great service. Unfortunately, the attractions of removing an entire internal saphenous vein in one manceuvre so overshadowed the surgery of varicose 914
veins that the importance of juxtafemoral ligation tended to be overlooked. The operation for varices became known as ‘stripping’. The long term results were as poor as the short term effects were dramatic, and contributed not a little to the gloomy view of varicose vein surgery held by many members of the profession and the public. The stripper is, however, still a very valuable tool (provided that it is not allowed to take oker the operation!), for it enables the long saphenous vein, together with the incompetent perforators which join it, to be removed. Since, as pointed out earlier, the most distal incompetent perforating vein is within a centimetre o r two of the level of the tibial tubercle, there is n o longer any need for the old-fashioned ankle-length stripper, and in fact the stainless steel piano-wire strippers made by Down Bros have a standard length of 73 cm. The stripper is inserted into the upper end of the divided internal saphenous vein and passed down the main channel (avoiding ‘lay-bys’ and minor tributaries) until it can be felt lying one finger’s breadth medial t o the medial border of the tibia about 4 c m distal t o the level of the tibial tubercle. A small incision a t this point allows the removal of both stripper and vein. Half a minute’s firm fist pressure by an assistant on the vein track in the thigh usually suffices to control oozing. Rernooal of varices: Having dealt with the source(s) of retrograde flow, it only remains to remove the superficial veins, which over the years have become permanently and visibly dilated by the unrestrained effects of increased intraluminal pressure. Since the technique described so far has required only one suturable incision-and this in the groin where once healed it is quite invisible-it would seem logical to complete the operation in a manner which leaves no permanent or visible scars. This is achieved using the method called ‘multiple cosmetic phlebectomy’. ‘Multiple’ because in severe cases of widespread varices one may have to make as many as 25 tiny puncture wounds in the leg, and ‘cosmetic’ in the sense that the tiny scars (made in Langer’s lines, Cox, 1941) disappear, leaving the patients with no visible evidence of previous varices. The technique is as follows. Using a Beaver miniature blade (No. 65), a tiny ‘stab’ not more than 3 mm long is made immediately over the vein (which has been marked preoperatively). With a fine modified Kilner’s mosquito forceps the vein is gently teased out to the surface where it can be more generously grasped with larger forceps and avulsed, using a gentle to and fro rocking movement. In this way it is possible to remove u p to 5 cm, and occasionally (in veins which have not been previously damaged by sclerosant therapy) rather longer lengths, through each stab wound. Bleeding is surprisingly slight owing to the fact that as each segment snaps off, the smooth muscle in the intima contracts to close the lumen. Closure ofwounds: The groin incision is closed with a single subcuticular stitch and the stabs with Micropore. The leg is bandaged with Poroplast lined with
Primary varicose veins
l-ubinette,* the whole forming a neat, non-bulky, snug-fitting dressing which remains untouched for I week. Pos/operaiive course: Patients walk normally, without pain and without a limp, on the day following operation. The groin suture is removed on the third postoperative day, when the patient is discharged home but advised only to undertake light duties. The bandage and Micropore strips are removed on the seventh day and replaced by a ‘throw-away’ support (Tubigrip) which is worn for 1 week only. Patients can drive their car at 1 week after operation, can swim and dance in 14 days and can play tennis etc. within 3 weeks. No further treatment is required. The short saphemus wirr Juxtapopli/eal ligation: Juxtapopliteal ligation of the short saphenous vein is, like juxtafemoral ligation of the long saphenous vein, the sine qua nun of successful varicose vein surgery, but whereas juxtafemoral ligation is, with experience, a relatively straightforward procedure, juxtapopliteal ligation is often fraught with difficulty. The principle underlying the operation is the same: namely, to follow the short saphenous to the saphenopopliteal junction and to carry out a flush ligation at that point. The problem arises in that the medial and lateral popliteal nerves and some of their motor branches also lay claim to the same territory, and in many cases have to be carefully moved aside in order to obtain a reasonable view of the popliteal vein and its environs. A further obstacle to smooth progress lies in the fact that in a number of cases on opening the popliteal fossa the external saphenous vein appears rudimentary or even absent. It is easy to be deceived by this. The short saphenous is always present somewhere in the fossa, and diligent search, very commonly in the lateral border of the fossa or sometimes even distal to the popliteal crease, will always, with practice, be successful in the end.
@
* A snugly fitting gauze-lined bandage, which cannot slip, retains its support, yet is simple to remove after 7 days, is cssential for painless postoperative ambulation. A single layer of thin non-elastic tubular gauze (Tubinette, size H78, Seton Products Ltd) approximately 230 cm in length is applied from groin to toes, leaving the excess 115 cm hanging loose. Firm (bu; not tight) pressure is cffected by 3 rolls of 3-in Poroplast (Scholl Manufacturing Co.), applied from the groin down to the toes in a clockwise manner. The first two turns of bandage i n the groin, directly on the skin, are used to anchor the upper cdge of the tubular gauze. The remaining turns (always clockwise) build up the bandage peripherally over the gauze to the tocs. N o figure of eight turns are used as these can be constricting. Where the bandage does not fit the contours of the limb, the fold is pinched up and cut off flush. The bandage finishes at the base of the toes, and the excess Tubinette is then pulled back over the Poroplast up to the groin, this prevents any ruckling of the bandage in bed. It is important to use flexiblc Poroplast rather than elastic Elastoplast, for the former is not only a far thinner, and hence a more ‘snug’ material, but has the exceptional merit of utilizing a plastic sticky spread which virtually banishes skin allergy (Russell and Thorne, 1955). The author has only met Poroplast allergy in 2 of the last 4000 limbs bandaged either postoperatively or for gravitational leg ulceration.
The popliteal fossa is best opened by a transverse incision, some 8cm long, parallel to and 3 cm proximal to the popliteal crease. The dense popliteal fascia lying beneath the subcutaneous tissue should be split vertically and undercut to permit good exposure. On closing the wound the fascia must be carefully approximated, otherwise herniation of the popliteal contents can ensue. Since in the present series incompetent perforating veins have never been found in association with the short saphenous vein, and since stripping the short saphenous vein can not only cause long standing oedema but may also permanently damage the sural nerve, short saphenous stripping has no place in this technique. The operation is completed by multiple cosmetic phlebectomy, as outlined above. Postoperative course: The wounds are closed and the leg bandaged from toes to mid-thigh for 1 week, as for the long saphenous group. The postoperative course is exactly similar apart from the fact that, owing to the presence of the bandage, the popliteal subcuticular suture is left in for 7 days. FOIIOW-UP One of the larger problems in evaluating the results of varicose vein surgery is in deciding what constitutes success or failure. Different authors adopt very different criteria, and these in turn depend upon the demands of their patients. For example, many patients whose legs ache owing to the presence of varicose veins will be delighted if their symptoms cease, even though their varices still remain, and if asked to evaluate the results of their treatment may t e quite happy to class their legs as ‘successful’ or ‘good’. What has actually happened in these cases is that sclerosant therapy or simple ligation has reduced venous back pressure just sufficiently to prevent symptoms, though perhaps not enough to prevent the insidious retrogression towards eczema, ulceration, phlebitis and thrombosis. A better criterion of the effectiveness of treatment is by determining the presence or absence of varicose veins after a stated period of time. If the results of different authors are to be comparable, then a standard definition of a varicose vein must be adopted. As the method of treatment outlined above is based on the timed tourniquet test, which in turn is founded on the definition of a varicose vein as one which refills by retrograde flow in 20 seconds or less after first emptying the legs by elevation, this is the criterion by which the present results have been judged. One final point to be noted is that, as in the Mayo Clinic series (Larson et al., 1974), the results are given in terms of legs rather than patients. This is because varicose veins vary in site of origin and surgical anatomy not only from patient to patient but from leg to leg in the same patient, and it is therefore essential to evaluate each limb and each venous system separately. The follow-up study began in 1971, based upon the potential examination of 2500 consecutive legs with primary varicose veins operated on personally by the 915
Stanley Rivlin Table I: INCIDENCE OF RECURRENCE ACCORDING TO SITE OF VARICES Recurrence ”, No. Site of v a r i c s No. 70 Long saphenous 1708 86 102 Short saphenous 285 14 23 8 Total 1993 100 125 ’I’
TO LENGTH ‘ I : lNCIDENCE OF FOLLOW-UP OF RECURRENCE Length of follow-up (yr)
10 9
8
Recurrence No. of cases
No.
319 387
22 28
396
24
”/,
6
author in the years 1961-5, thus giving a maximum of 10 years’ and a minimum of 5 years’ follow-up. In the event, the practicalities of tracing patients and arranging for a physical examination by the author proved far greater than anticipated and took 2 years. Despite the problems involved, 1993 (79 per cent) legs have been assessed. Results Of the 1993 legs, 1708 (86 per cent) had been operated upon for varices of the long saphenous, and 285 (14 per cent) for incompetence of the short saphenous vein. The recurrence rate was 6 per cent (102 legs) in the long saphenous system and 8 per cent (23 legs) in the short saphenous group (Table I ) . The most interesting finding was that thepercentage ofrecurrence was constant within narrow limits irrespective of the length of time of the follow-up. This is shown in Table II where the overall recurrence rate is shown for each follow-up period. Causes of recurreme Of the total of 125 limbs with recurrent varices, 79 of the 102 with long saphenous varices and 21 of the 23 with short saphenous incompetence submitted themselves to further surgery, not only to remove the new varices by multiple cosmetic phlebectomy but also, by exploration of the groin or popliteal areas, to elucidate if possible the cause of the recurrence. In the short saphenous group the answer was always the same. In every instance the new varices were being fed either by a connection with the popliteal vein in the popliteal fossa which had not been noticed at the original operation (10 cases), or by theshort saphenous vein itself which had been totally missed and in fact recorded as ‘absent’ or ‘rudimentary’ in the operation notes (11 cases). The popliteal fossa, with its many motor nerves criss-crossing the operative field, is a difficult surgical area, and on occasion the position of the large medial and lateral popliteal nerves renders it hazardous to expose the popliteal vein quite as thoroughly as one would wish. Thus on occasions where a rudimentary short saphenous vein with no deep venous connections is found passing straight through the fossa up into the posterior thigh it is 916
tempting, particularly where the position of the motor nerves is especially perilous, to assume that one is dealing with an anatomical anomaly and to treat the varices on an ad hoc basis by multiple phlebectomy. Under similar circumstances one would tend to behave in the same manner where the short saphenous vein was apparently completely absent. However, as a result of exploring these recurrent cases the author has no hesitation in saying that a true short saphenous vein is always present somewhere in the fossa and will virtually always be found by diligent and careful search. Occasionally this will require a second and distal incision just below the popliteal crease to pick u p a short saphenous vein which has perforated the deep fascia rather earlier in its course than is usual. In most other instances it will be found to have taken a lateral instead of a midline route in the fossa and will be discovered very deep in the lateral angle of the incision. The findings on exploring the 79 cases in the long saphenous group were very different. In no instance was there a reflux from the saphenofemoral junction. The technique of thorough juxtafemoral ligation described earlier in this study appears to have eliminated this previously most common cause of recurrent varices. In 12 instances the recurrence was due to the fact that the internal saphenous vein had not (as had been supposed) been stripped, the stripper having passed along a vein lying adjacent and parallel to the true long saphenous vein, leaving the original thigh perforators untouched and able to pass their reflux. In the remaining 67 cases the varices were arising from uncommonly sited perforating veins not connected with the long saphenous vein but feeding their own little group of superficial varices. Eight of the perforating veins were present in the medial thigh within 10 cm of the groin, 7 lay just 3 cm posterior to the usual site of the tibia1 tubercle perforator and the remaining 52 arose at various points along the medial side of the thigh. Conclusion The surgery of varicose veins is a strict discipline involving careful clinical preoperative examination by the timed tourniquet test to demonstrate accurately the source of the venous reflux. Operation at the saphenofemoral or saphenopopliteal junction is a meticulous procedure requiring hard-won experience if good results are to be obtained. The current vogue for sclerosant therapy is based upon a meaningless comparison of inadequate surgery with outpatient injections. The suggestion that varicose veins are due to a local congenital valvular anomaly rather than a chronic progressive degenerative process is supported by the steadiness of the long term results which are unaffected by the length of the follow-up. The overall recurrence rate of 7 per cent can be improved by particular attention being paid to the popliteal fossa, but even allowing for this, it would seem that there is a hard core of 5 per cent of patients who will have recurrent varices despite the most careful preoperative assessment. However, these cases can easily be dealt
Primary varicose veins with by stab phlebectomy accompanied, if necessary, by simple local ligation of the offending perforating vein.
Acknowledgement I am grateful to Sister June Geddes for her invaluable assistance in persuading patients to attend for followUP. References (1955) The pathology and treatment of venous ulcers of the leg. Br. J . Surg. 43,260-278. cox H. T. (1941) The cleavage lines of the skin. Br. J . Surg. 29, 234-240. DODD H. and COCKETT F. B. (1956) The Pathology and Surgery of Veins of the Lower Limb. Edinburgh, Livingstone. COCKETT F. B.
K.( I 960) Varicose Veitis. A Practical Manual, 3rd ed. Bristol, Wright. HAEGER K . (1961) Technique of high ligation of the long saphenous vein. An analysis of 54 reoperation cases. Acta Chir. Scand. 122, 85-92. LARSON R. H . , LOFGREN E. P., MYERS T. T. and LOFGREN K. A. (1974) Long term results after vein surgery. Study of 1000 cases after 10 years. Mayo Chi. Proc. 49, 114-1 17. PIACHAUD D. and WEDDELL J . M. (1972) The cost of treating varicose veins. Lancet 2, 1191-1 192. RivLiN s. ( 1 951) Treatment of Varicose Veins and their Complications. London, Heinemann, pp. I 1-1 6. RIVLIN s. (1966) Recurrent varicose veins. Med. J . Aust. 1, 1097-1 102. RUSSELL B. and THORNE N. A. (1955) Skin reactions beneath adhesive plasters. Lancet 1, 67-70. FOOTE K.
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