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|Posted By : Dr.Deepraj Bhandarkar, MS, MAMS, FRCS, FICS, FACS, FAIS, FIAGES, FALS, FACG, Dipl. Lap. Surg (France)|
|Posted On : 18 Oct 2007 (Total Views : 8747)|
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The heart pumps blood to supply oxygen and nutrients to all parts of the body. Arteries carry blood from the heart towards the various body parts and veins carry the blood back to the heart. The veins have one-way valves to prevent the blood from flowing backwards. For example, when a person is standing or walking, blood in the veins in the legs does not flow back towards the ankles but is only pumped upwards towards the heart.
If the one-way valves in the veins become weak or faulty some of the blood can stay back in the veins. This pressure causes the veins to enlarge and dilate abnormally. These veins which appear to be bulging under the skin are called varicose veins.
They can be found anywhere in the legs from the groin to the ankle. Also, the tiny capillary branches of the veins can also become filled with blood, producing multiple spider veins and causing discolouration of the skin around the ankles.
Weakness of the valves in the veins may be inherited in some people. The valves may also be stretched and caused to leak by obesity and pregnancy. People who stand for prolonged periods of time, e.g. policeman, salesman etc are more likely to notice their veins and their symptoms. In people who have a tendency to develop varicose veins, they cannot be prevented by taking any specific precautions.
In patients with varicose veins, the fault with the valves in the veins can be present in one of the three areas:
a) In the groin where the long saphenous vein carrying the blood from the leg joins a deep vein,
b) At the back of the knee where the short saphenous vein carrying the blood from the lower leg joins a deep vein or
c) In the perforating veins which connect the superficial veins to the deep veins. These perforating veins are present both above and below the knee.
What are the symptoms of varicose veins?
The symptoms of varicose veins may appear before the veins become apparent. The common symptoms include:
- Swelling and heaviness in the legs, particularly towards the end of the day or after standing for a long time.
- Presence of dilated, visible veins along the thigh or the leg
- Pain, tenderness or redness developing along segments of prominent veins because of inflammation (phlebitis)
- Brownish discolouration, itching, thickening of the skin around the ankle
- Ulceration (wound) developing around the ankle which does not heal easily
For any of the above problems if an operation is to be carried out successfully, it is essential that the anatomy of the abnormal varicose veins is understood and that the sites of any faulty, "leaky" valves are identified precisely. These faulty areas can be tackled by surgery and the problem corrected.
The surgeon first performs a careful clinical examination to establish the cause and plan the treatment of the varicose veins. This is usually supplemented by a detailed ultrasound examination (duplex or doppler scan) before making a decision on the details of any necessary surgery. A duplex scan gives the surgeon accurate information about which of the valves is at fault and helps in planning surgery.
1. Wearing well-fitting stockings which extend at least upto the knees. These have to be worn throughout the day, i.e., all the time that the person is on his feet. It is important to acquire a pair of properly fitting stockings of good quality so that they are comfortable to wear. These stockings should be cleaned and washed on a regular basis to prolong their life.
2. Persons with varicose veins are generally advised to avoid standing for prolonged period of time. Every two or three hours, they should sit down and keep the legs up on a chair or a stool.
3. Taking regular exercise in the form of walking to maintain circulation in the veins of the legs.
A decision not to undergo an operation may have to be reviewed in the future if the situation changes.
An operation may be appropriate when a patient has any one of the following:
- Symptoms - such as aching, throbbing or tenderness of the veins
- He / she is concerned about the cosmetic appearance because of the prominent veins
- When complications such as bleeding from the veins, eczema or ulceration around the ankle develop
When a patient is offered surgery, the surgeon always explains and the patient should understand clearly the reasons for which surgery is being undertaken and the expected benefits of any surgery.
The aims of an operation in patients with varicose veins are:
a) To stop the leak of blood from the valves within the veins which have been identified to be faulty and
b) Remove the veins which are cosmetically disfiguring
The operation differs slightly in each patient depending on which of three possible ?leaky areas? mentioned above are at fault. Most varicose vein operations will include a combination of the following elements:
- A surgical exploration to deal with the "leaking valves?: This most commonly involves a 3-4 cm incision in the groin and/or behind the knee.
- Removal of any long, straight segments of superficial veins suspected of containing further faulty valves. This is done by stripping the diseased segment of the vein and is most usually carried out in conjunction with an exploration of the groin. Removal of superficial veins in the thigh can ensure more thorough disconnection of varicose veins lower in the calf and reduce the risk of future recurrence.
- Surgical removal of some of the larger varicose veins which will have been marked on the skin surface prior to the operation. This is usually carried out by making multiple tiny incisions over the marked veins and pulling out sections of vein with fine forceps.
How are the leaky perforator veins treated?
Traditionally, treatment of the faulty / leaky perforator veins which are situated along the inner aspect of leg from the ankle to just below the knee required a long (20 ? 30 cm) incision. In patients with varicose veins as the skin around the ankle is often thickened, such a long incision extending in to the unhealthy area commonly results in poor healing and incision-related problems.
What is the endoscopic surgery for varicose veins?
To avoid the abovementioned problems when dealing with leaky perforating veins, a new technique called subfascial endoscopic perforator surgery (SEPS) has been developed. This is carried out by making two tiny incisions just below the knee. Through one of the incision a telescope attached to a camera is passed to visualize the perforating veins. Through the other incision, special long instruments are introduced for dissecting out and clipping the perforating veins. As the incisions are tiny, the pain is minimal and recovery after the operation is rapid. Most importantly, as the incisions are far away from the thickened skin around the ankle, they generally heal without any problem.
In the hospital
After varicose vein surgery, the patient returns to the ward with a firm bandage applied from the foot to the mid-thigh. The patient is allowed to take fluids by mouth and eat within a few hours of surgery and is generally discharged the day after surgery. Some elderly patients and those with other medical problems like heart disease or diabetes may have to stay in the hospital a little longer. The pain after varicose vein surgery is generally mild and patients are given painkiller tablets to keep the discomfort to a minimum. All patients are encouraged to be as active as they feel comfortable to be.
On returning home
On returning home from the hospital, the patient should plan for 3 or 4 days of quiet rest at home. The activity should be limited to walking around a little and spending most of the time resting with the leg elevated on cushions. After 3 or 4 days, the activity can be increased. In most cases, fairly normal activity and return to work with only slight residual discomfort should be expected after about 10 ? 14 days.
The bandages are usually removed after about a week when the patient visits the doctor for removal of sutures. Areas of superficial bruising and swelling in the surgical wounds and where veins have been stripped and avulsed are not uncommon. These slowly resolve without any specific treatment. It may sometime take upto 3 to 4 months before the leg returns to normalcy and the final result of the operation can be assessed.
As patients who have varicose veins are prone to develop them again even after a successful operation, they are advised to follow a regimen consisting of three ?E?s
a) Exercise: Regular leg exercises ensure that the circulation in the veins is maintained,
b) Elevation: of the legs whenever possible reduces the pooling of blood in the legs, and
c) Elastic stockings: provide support to the legs.
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