References

Results of long saphenous stripping under local anaesthesia (700 cases)

Category: Resultats Complications Recidives
Phébologie 1991; 44: 303-312
D. CRETON
EC. Ambroise Paré, rue Ambroise Paré 54100 F-NANCY

This single operation involves complete ablation of the varices by via crossectomy and long invaginated stripping, and all phlebectomies were performed under local anaesthesia, for the first time, in ambulatory mode in 1986. Very quickly convinced by the obvious advantages of this operation, which combines efficacy, comfort and aesthetics, we wanted to look back over the previous three years to examine the inconveniences and sequelae of such an operation.

The study

The study covers 1,475 patients who underwent operations for varices over a two-year period; 1,300 of them underwent long saphenous stripping. Out of these, 700 cases of operations under local anaesthesia, and 500 cases of operations under general anaesthesia were selected, including at least a 10-day follow-up and 60 postoperative days. They were all essential varices without cutaneous lesion. The type of anaesthesia was always freely chosen by the patients, with no anatomical consideration.

Technique

Local anaesthesia uses crural block and Mepivacain or Lidocain

700 operations of this type were performed, 80% of which were women, with age varying from 18 to 77 years, most being between 35 and 40.

The average number of Muller's incisions is 23, with extremes being 6 and 70.

RESULTS

The results were assessed on the basis of comfort, and on the low number of failures and inconveniences caused by the mode of anaesthesia, with regard to the ambulatory treatment or to the technique itself.

The comfort of the operation

The comfort of the operation was judged to be excellent in 95% of cases; indeed, only :

We must recognise that Mepivacain, because of the broader and deeper anaesthesia it induces, makes the operation more comfortable. Finally, permanent intraoperative psychological contact was vital to how the patient felt about the operation.

The ambulatory mode

The ambulatory mode did not cause any post-operative incident. No patient had hematoma, haemorrhage or post-operative malaise.

The failures and inconveniences of local anaesthesia.

No allergic accident was encountered.

e failures and inconveniences of the operative technique (short term results)

The persistence of several varices, still visible 2 months after the operation, and accepted as being a failure, is difficult to analyse, as these cases mainly involve patients with major varicose networks and a number of incisions that can easily be more than 50.

On the other hand, for lesser cases of varices (20 incisions), such failure, caused by insufficient preoperative marking, should be avoided by clinical and Doppler examinations that are performed during preoperative preparation; they should be performed twice in order to avoid functional variations due to fatigue, temperature, or to oestro-progestative variations in women's hormonal cycles.

Aesthetic inconveniences are minor. Indeed, Muller incisions (9,10) totally disappear, and in 10% of cases, varicosity diminishes. On the other hand, they increase in 25% of cases, developing over the external face of the thighs or over the internal face of the knees, in areas that do not correspond to hematomy zones or to operative trauma. Varicosities appear 2 to 3 months after the operation, at the end of hormonal cycles. They do not appear to be related to general operative trauma, but rather to the loss of a cutaneous venous drainage route (appearance of varicosity on the hemi-abdomen (twice) after ligation of the upper branch of the superficial iliac circumflex trunk, or on the external face of the thigh following elimination of an antero-external branch of the thigh) and to the oestrogenoprogestative hormonodependence proper to each patient

The neurological sequelae are of most interest. We observed three types :

TABLE I : Frequency of saphenous nerve injuries per anaesthesic mode General anaesthesia
General anaesthesia Loco regional anaesthesia
  500 200 500
Injury to the saphenous nerve 6 3 0
  1,2 % 1,5 % 0 %
TABLE II : Technique avoiding injury to the saphenous nerve during invaginated stripping Loco regional anaesthesia
Loco regional anaesthesia Painful impassable blockage during invaginated stripping Technique for passing through Neurological injury to the saphenous nerve
200 3 Powerful hypnotic or antalgic 3
500 19 Müller's technique 0
TABLE III : Frequency of neurological complications in strippings under loco regional anaesthesia Neurological complications
Neurological complications
Transitory suspended local anaesthesia 7 %
Sub-malleolar local anaesthesia 2,7 % 0 %
Injury to the saphenous nerve 1,5 % 0 %

DISCUSSION

This retrospective study gives rise to certain points of reflection :

The risk of neurological injury may be decreased by performing classic downward stripping: 27% of risk as opposed to 50% in upward stripping [2,5,11]. The ascension of the stripper head entering the reverse V formed by the divisional branches of the saphenous nerve provokes a definitive extraction of the latter whilst downward stripping provokes partial lesions by friction - stretching; these lesions are certainly more frequent, but they are often transitory and regressive [2,11] (table IV).

TABLE IV : Frequency of the saphenous nerve injuries according to the type of stripping Injury to the saphenous nerve during stripping
Injury to the saphenous nerve during stripping
Upward Babcock type stripping 50 % (Cox)
Downward Babcock type stripping 27 % (Cox)
Invaginated stripping under general anaesthesia 1,2 %
Downward stripping by telescoping 0,5 % (Degni)
ated stripping under loco regional anaesthesia 0 %

 

Invaginated stripping performed under general anaesthesia allows us to considerably reduce this risk, as it is found in 1.2% of the 500 cases of general anaesthesia, and in 1.5% of the first 200 cases of local anaesthesia where we retrospectively had the impression that we had injured the nerve through our lack of experience. This stretching does not correspond to any particular zone of adherence [8] but to a collateral branch being put under tension and strangling the nerve or one of its collateral branches (always between 10 or 20 cm under the knee interlineation). We came across such blockage in the stripping (due to intertwining) 19 times in the following 500 cases; this painful blockage could be freed by section of a venous collateral of the saphena.

Between upward stripping of the Babcock type [1] with external sharp oliva, and invaginated stripping, the stripping by telescoping with a rigorously intravenous oliva would appear to be an intermediate solution that is much easier to perform and far less traumatic. Degni [3] reports 0.5% of neurological complications out of 2,000 cases with strippings of this type. It is thus logical to assume that the traumatic risk mainly depends on the size of the oliva used for the stripping (table IV).

One classic criticism of invaginated stripping is that it leaves in place flaps of adventitia which might participate, by neovascularisation, in the reconstitution of a venous fragment or to the connection of a perforate with subcutaneous veins. This neovascularisation [6,7] is the result of a certainly under-estimated phenomenon in the ethiology of long-term recidivation. We were unable to prove the repermeabilisation of a saphenous path after an invaginated stripping.

The evolution of our experiment allowed us to decrease the contraindications to local anaesthesia, which are now of a psychological order only. Certainly, obesity is always a problem [12] but the use of the block by electro-stimulation makes the anaesthesia more efficient. The importance and the number of varices may be an argument in favour of local anaesthesia due to the low level of intraopoerative bleeding, which makes the operation more comfortable. Finally, the spread of varices over the limb is also an argument in favour of local anaesthesia because patient mobilisation is then much easier.

CONCLUSION

At the end of this study, we can say :

REFERENCES

  1. Babcock W.W A new operation for the extirpation of varicous vein of the leg . Med. J. N. York.1907 ; 86 : 153-156
  2. Cox SJ., Welwood J.M., Martin A. Saphenous nerve injury caused by stripping of the long saphenous vein . Br. Med. J. , 1974 ; 1 : 415-417
  3. Degni M. Un nouveau type d'extirpateur de veine saphène interne ou externe. Phlébologie 83. A. Davy., J. Van Der Stricht 1989. Ars Medici Congress Series , 825-830.
  4. Fullarton G.M., Calvert M.H. Intraluminal long saphenous vein stripping : a new technique minimizing perivenous tissue trauma. Br. J. Surg. 1987; 74: 255
  5. Garnjobst W.Injuries of saphenous nerve following operations of varicose veins .Surg. Gynecol. Obstet. ,1964 ; 119 : 359-361
  6. Glass G.M. Neovascularization in recurrence of the varicose great saphenous vein. Following transection . Phlebology , 1987 ; 2 : 81-91.
  7. Glass G.M., Prevention recurrent saphenofemoral incompetence after surgery of varicose veins. Br. J. Surg. 1989 ; 76 : 1210
  8. Holme J.B.,Holme K., Sorensen L.S. The anatomic relationship between the long saphenous vein and the saphenous nerve. Acta Chir Scand 1988; 154 : 631-633
  9. Muller R. La Phlébectomie Ambulatoire . Phlébologie , 1978 ; 31 : 273-278
  10. Muller R. La Phlébectomie Ambulatoire. Helv. Chir. Acta, 1987 ; 54 : 555-558
  11. Ramasastry S.S., Dick G.O., Futrell J.W. Anatomy of the saphenous nerve : relance to saphenous vein stripping . Am. Surgeon. 1987 ; 53 : 274-277
  12. Rettori R. L'obésité modifie-t-elle les techniques chirurgicales ? Phlébologie , 1988; 41 : 576-584
  13. Van Der Stricht J., Goldstein M., Van Hoorn M., Delcroix G. Etude des indications et des résultats des saphènenectomies et des scléroses /in : crossectomie et stripping ,pp. 123-129 Paris, Expension Scientifique 1962
  14. Van Der Stricht J. La saphènenectomie par invagination sur fil. Presse Med. 1963 ; 71 : 1081-1082.