Varicose vein surgery

Etiopathogenesis and rationale for surgical treatment

Varicose veins of the lower extremities predominantly affect the basins of the great (v. saphena magna) and small (v. saphena parva) saphenous veins.

The pathogenesis is based on venous valve incompetence. Due to the inability of the valves to prevent backflow, pronounced venous stasis occurs, especially in the lower parts of the leg. This stasis inevitably leads to severe tissue trophic disorders, the final stage of which is the formation of slow-healing trophic ulcers.

An extremely important factor in disease progression is the incompetence of the valve apparatus of perforating veins—vessels connecting the superficial and deep venous networks. Normally, blood flows through them strictly from outside to inside. When valves fail, a pathological shunt (reflux) of blood occurs from the deep veins back into the superficial ones, which repeatedly increases the load on the superficial network and stretches the vascular wall.

Interventions on superficial trunks

To date, operative surgery distinguishes historical and modern radical approaches to eliminating varicose trunks.

Trendelenburg operation (Trojanov—Trendelenburg procedure) This intervention is of predominantly historical significance. The essence of the method boiled down to simple ligation of the great saphenous vein directly at its junction with the femoral vein. Clinical practice has shown that isolated junctional ligation without removing the trunk itself proved ineffective and often led to recurrences.

Babcock operation It is considered the most radical and classic method. Its essence lies in the complete physical removal (extraction) of v. saphena magna using a special instrument—a flexible metal rod (stripper).

Technique of the Babcock operation:

1. The surgeon makes a small incision in the upper third of the thigh, just below the inguinal ligament, locating the saphenous opening.
2. A flexible guide equipped with a smooth bulbous head is inserted into the vessel lumen. The instrument is advanced down along the course of the vein up to the level of the knee joint.
3. A second small incision is made in the knee area, through which venesection is performed. The end of the guide is brought outward.
4. The bulbous head on the upper end of the rod is replaced with a working element—the vein extractor (a metal cone with sharp cutting edges).
5. The surgeon begins to forcefully pull the rod by the lower end (brought out at the knee) or vice versa, depending on the modification, dragging the cone through the subcutaneous channel.
6. The sharp edges of the vein extractor cut the tributaries, and the vein is literally torn out of the subcutaneous adipose tissue, gathering like an accordion on the rod.
7. The remaining distal part of the vein on the lower leg is removed in a similar manner if necessary.

Methods for perforating vein ligation

Eliminating pathological blood shunting through perforating veins is an obligatory stage of comprehensive treatment. There are two classic open surgical approaches:

• Cockett operation. The access is epifascial. The surgeon performs all manipulations strictly within the subcutaneous adipose tissue, superficially. The deep fascia of the lower leg is not incised in this process. Incompetent perforators are isolated in the tissue and ligated.
• Linton operation. A subfascial access is used. To reach the perforating veins, the surgeon longitudinally incises the deep fascia of the lower leg. Vessel ligation is performed in a deeper layer—the subfascial space.

Modern alternative: Currently, the classic wide incisions according to Cockett and Linton are increasingly replaced by video-endoscopic dissection. Introducing an endoscope into the subfascial space allows visualizing, clipping, and transecting perforating veins through minimal punctures, which radically reduces the invasiveness of the surgery and accelerates rehabilitation.

Class and exam questions

What else to study on this topic

• Topographic anatomy of the deep fascia of the lower leg and perforating vein channels
• Topographic features of the saphenofemoral junction
• Design and modifications of phlebovein extractors
• Technique of endoscopic perforator vein dissection

Other topics in the "Lower Limb" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.