Ambulatory Phlebectomy for Varicose Veins Technique

Updated: Jun 23, 2016
  • Author: Albert-Adrien Ramelet, MD; Chief Editor: Dirk M Elston, MD  more...
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Technique

Ambulatory Phlebectomy

Ambulatory phlebectomy for varicose veins requires good lighting and an operating table that allows the patient to be in a Trendelenburg position. Direct intraoperative support is seldom necessary, but a nurse or assistant should be present in the office. Emergency equipment and supplies should be nearby. Only a small number of surgical instruments are required to perform phlebectomy on an ambulatory basis.

Cutaneous incisions are made with the No. 11 scalpel or 18-gauge needle. The incisions should be vertically oriented along the thigh and lower leg and should follow the skin lines at the knee or the ankle. The distance between the incisions ranges from 2 to 15 cm, depending on the experience of the surgeon, the size of the vein, the presence of perforators, any previous episodes of phlebitis, and the results of previous sclerotherapy.

The varicose vein is gently dissected by undermining it with the stem of the phlebectomy hook. Undermining is largely performed along the course of the vein, but it is also slightly extended in a perpendicular direction. When freed of its fibroadipose attachments, the liberated vein can then be grasped by using the harpoon of the hook, and it is easily removed with the mosquito forceps held in the other hand. The surgeon also uses his or her nondominant hand to grip a sterile gauze strip and ensures hemostasis by applying local compression to the already removed venous network. (See the image below.)

Extraction of veins by means of ambulatory phlebec Extraction of veins by means of ambulatory phlebectomy.

The whole varicose vein is progressively extracted from one incision to the next. Incompetent perforators are carefully dissected and eliminated with gentle traction or torsion. Venous ligation is not necessary, because hemostasis is achieved with local compression during and after surgery. Areas in which postoperative compression is most difficult (eg, popliteal folds, thighs, groin, areas with deep and large perforators) are surgically removed first to permit the maximum time for hemostasis while the patient remains supine.

No skin closure is needed if the physician uses minimal incisions (1-3 mm) and good postoperative compression. With experience, removing extensive venous networks on both legs in a single 60- to 120-minute session is usually possible.

Complementary fine-needle sclerotherapy of telangiectasias can be performed immediately before or after the eradication of their nourishing venules. Large telangiectasias may also be destroyed by means of gentle subcutaneous curettage with the harpoon of the hook, whereas debris of venectasias can be removed through tiny incisions.

At the end of the operation, the leg is carefully cleansed with hydrogen peroxide or surgical soap. If oozing persists at any site, it is easily controlled with additional local compression. Elevating the leg for 5-10 minutes may also be helpful. Punctures are not sutured or closed with adhesive strips. Leaving puncture sites open helps with more rapid drainage of tumescent fluid and improves the cosmetic result.

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Postoperative Care

Postoperative bandaging is an essential step in the procedure, and the physician or a well-trained assistant should carefully apply the bandages. The incisions or punctures are left open to allow tumescent anesthesia fluid to drain quickly. Large pads, either gauze or sanitary napkins, are placed along the site of vein removal and covered with an inelastic bandage.

If the physician is experienced with bandaging, a second dressing with a highly elastic (long-stretch) bandage is applied to the leg. This compression dressing prevents postoperative hemorrhage and reduces the likelihood of pain, bruising, seroma formation, and other complications. The long-stretch bandage is applied from the foot up, beginning at the toe joints and including the heel; it is proximally extended to cover all incisions. To avoid a tourniquet effect, an elastic dressing must never be applied over the proximal part of the leg without beginning at the feet.

If the physician is not experienced with elastic bandaging, compression stockings may provide an alternative means of compression. A single pair of 30- to 40-mm Hg compression hose may be used, or two layers of 20- to 30-mm Hg stockings may be applied for additive effects. Use of 30-40 mm Hg hose is recommended. If two layers of stockings are used, the topmost pair may be removed at night and replaced in the morning.

Daily ambulation should be increased as much as possible in the immediate postoperative period. Under no circumstances should a patient be confined to bed rest after venous surgery. Patients may return to work immediately after the operation, but they should not drive an automobile until the next day, because distal motor function may be subtly impaired as a consequence of prolonged anesthesia, particularly after local anesthesia in the popliteal region.

Dressings are removed after 24 or 48 hours. Typically, the incisions are minimal, and wound dressings are not necessary. However, ongoing compression therapy with elastic bandages or compression stockings is recommended for 7-21 more days, depending on the size of the removed veins and the degree of the reflux treated. Stockings may be removed for showering after postoperative day 4; otherwise, stockings should be worn continuously.

Complementary sclerotherapy of residual varicosities should be delayed several weeks until postoperative healing is well advanced. Many telangiectasias may progressively and spontaneously regress and disappear after varicose veins are removed by means of ambulatory phlebectomy. Patients should avoid early sun exposure because hyperpigmentation may result at the puncture or incision sites.

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Complications

Most minor complications are benign and resolve spontaneously. Typically, varicose veins recur when the source of venous reflux is not treated by means of endovenous ablation techniques (see the image below). Sometimes, the cause may not be apparent until the phlebectomy is performed, particularly when many varicose veins are present.

Before and 2 months after ambulatory phlebectomy. Before and 2 months after ambulatory phlebectomy. Reflux at saphenofemoral junction was treated with radiofrequency endoluminal ablation during same procedure.

The chief complications are as follows:

  • Edema
  • Bleeding
  • Hematoma formation
  • Scarring
  • Trauma-induced telangiectatic matting
  • Blisters due to wound dressings

Other complications, such as occasional nerve injury with sensory disturbances, are relatively unavoidable because a fibrotic nerve may be attached to the removed venous segment. Severe infections have been reported. [14] Very rarely, skin necrosis may occur; this is believed to be related to a high pH caused by adding too much bicarbonate to the anesthetic solution. [15]

Transitory hyperpigmentation usually fades in a few months without any treatment. Blisters secondary to skin shearing due to the use of adhesive tape may induce postbullous depigmentation or transitory hyperpigmentation. Contact dermatitis secondary to the use of antiseptic solutions or adhesives is uncommon, and it usually heals quickly with topical steroid application. Keloids and hypertrophic scars are extremely rare because of the minimal size of the incisions.

Superficial hematomas are common. Hematoma formation depends on individual variations in coagulation and on the effectiveness of the postoperative compression. Hematomas are most common in the popliteal fold, the most difficult area in which to achieve good postoperative compression.

Some patients complain of persistent subcutaneous nodules, which correspond to deep hematomas in the tunnel of the removed vein. When subcutaneous nodules occur, they are reabsorbed over 3-6 months. Significant delayed postoperative oozing may occur. After postoperative dressings are applied, the patients (particularly those with a long journey home) should be asked to walk around for 10 minutes, and the dressing should be reevaluated.

Superficial phlebitis may occur in incompletely removed varicose veins or neighboring veins. Deep venous thrombosis is not yet reported after ambulatory phlebectomy, probably because compression bandages and ambulation are effective forms of prophylaxis.

Lymphatic pseudocysts may be complications of phlebectomy of the ankle or pretibial or popliteal areas. When a subcutaneous nodule develops rapidly, the lymph collection may be punctured and drained. The best treatment is increased compression along with periodic gentle circular massage. In resistant cases, lymphatic drainage may be required. [16]

Neotelangiectasia (ie, telangiectatic matting) is the most annoying potential complication of phlebectomy. This complication is observed after classic stripping, as well as after sclerotherapy, and the etiology is unclear. In some cases, it seems to be related to a sudden local increase in venous pressure or to an area of persistent reflux that remains to be corrected. In others, it may be an angiogenic response to tissue injury that is part of the normal healing process. Some authors have noted an association with exogenous estrogens, but this association has not been confirmed.

Usually, telangiectatic matting spontaneously fades away after several months. In some cases, matting may be treated with sclerotherapy of the tiniest vessels; however, in other cases, every attempt to sclerose the vessels results in a new blush of recurrent matting. Pulsed dye laser or intense pulsed-light therapy could also be considered.

Injury to small cutaneous sensory nerves is common when veins are removed under general or regional anesthesia. However, sensory nerve injury is much less common when local anesthesia is used, because intraoperative manipulation of a sensory nerve is painful. If the surgeon stops immediately when the patient reports pain, sensory branches are typically left intact.

Small-nerve injury is possible in patients previously treated with sclerotherapy because inflammatory fibrous reaction and surrounding tissue adhesions bind the vein to the adjacent sensory nerves. Hyperanesthesia, hypoanesthesia, or total anesthesia secondary to nerve injury usually resolves within weeks or months. Neuroma is an extremely rare complication of peripheral nerve injury.

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