References

Varicose surgery : loco-regional anaesthesia as a pain reducer

J. Pathol Digest, 1995 ; 5 : 20-21
D. CRETON
EC Ambroise Paré, rue Ambroise Paré F- 54100 NANCY

INTRODUCTION

Since 1953 [1] the reduction of pain in varicose surgery has evolved in parallel with the development of loco-regional anaesthesia [2] ]3]. We believe that loco-regional anaesthesia, regularly used since 1986, has helped improve the results of varicose surgery. We feel that the reduction in pain is a vital factor in the development of ambulatory surgery.

METHOD

In order to assess postoperative pain, we reviewed the follow-up of 480 consecutive patients who underwent operations in 1995, and to whom no particular follow-up instructions had been given; we also studied the return to work of another group of 1,340 patients, operated on in 1994 and 1995.

Used in the operations, loco-regional anaesthesia was performed by femoral block with search by electrostimulation using Lidocaine Hcl (XYLOCAINE) 1%. The anaesthesia was prepared between 30 minutes and 1 hour before the operation. On average, it lasted between 3 and 6 hours. Verbal contact was maintained throughout the operation. Monitoring essentially concentrated on oxymetry and arterial pressure.

RESULTS

Out of a total of 2,848 femoral blocks performed between 1987 and 1994, we never had any traumatic complications from needle injection into the femoral nerve. Some patients described a sensation of cold running liquid on the inside face of the thigh, but these sensations disappeared after a few months. Despite the absence of theoretical contact between the injecting needle and the femoral nerve during the block with marking by electrostimulation, we had two patients who, several years after the operation, had violent episodic pains when they made certain hip movements, which might suggest the existence of a post-traumatic neuroma; the electromyogram was normal, but the Carbamazépine (TEGRETOL) proved to be effective.

  • Postoperative comfort was assessed by a postoperative survey carried out on the 30th day on 1,340 patients (Table I). 74.5% of these patients said that they had returned to normal domestic life the day after the operation. 15% on the 5th day and 10.5% more than one week later.
  • Out of 450 patients who underwent ambulatory operations for varices (Table II) 2 patients saw their consulting physician on the 8th day for a problem of postoperative pain, 14 patients (3%) telephoned the surgeon between the 2nd and 15th days (average 8th day) for a problem of postoperative pain: none of the calls before the 30th day justified surgical consultation. On the 30th day, the clinical aspect of the limb was judged to be normal, and without neurological complication. Two hematoma and one hypodermic inflammation retrospectively explained these postoperative pains. Out of this same series of patients (Table III), 46 other patients (10%) called their surgeons for other problems (mainly dressings and postoperative compression), 8 patients (1.7%) came to see the surgeon before the end of 30 days for reasons other than pain (compression, tights, dressing, scarring problems, postoperative oedema). 45 patients (10%) saw their consulting physician for administrative problems, prescriptions or postoperative advice that had nothing to do with pain.

In total: out of all the patients who left the clinic the day of the operation, with no instructions regarding postoperative telephone or consultation follow-up, 75% had no need of advice before the 30th day. 25% did ask for advice, half of them directly contacting their consulting physician, and the other half telephoning their surgeon. Out of the 450 patients, only 3.5% needed help with regard to a problem of postoperative pain.

DISCUSSION

Whilst, by definition, general anaesthesia eliminates intraoperative pain and all memory of the operation, certain details of loco-regional anaesthesia also allow us to reduce intraoperative pain.

  • Mepivacaine (CARBOCAINE) is a faster and more powerful local anaesthetic. It can be used just as effectively as Lidocaine (XYLOCAINE) with 0.5 dilution. Femoral blocks with Mepivacaine provide the patient with a deeper and more comfortable proprioceptive anaesthesia. The duration of the block is identical to that under Lidocaine.
  • Cold storage of anaesthetic products and the dilution of acidic products (LIDOCAINE Hcl) with sodium bicarbonate makes injections less painful.
  • ful sensation is mainly limited by contact with the patient. The use of a cerebral theta wave synchronisation apparatus, by visual and auditory stimulation, is a very useful technique for improving operative comfort. Finally, anxiety-relieving products such as Midasolan (Hypnovel), and antalgesics of Alfintanyl chlorohydrate type (Rapifen), when injected beyond a certain dosage during the operation upon request by the patient, have a useful retrograde amnesic effect with regard to the operation.
  • Loco-regional anaesthesia obliges one to reduce operative trauma as much as possible, with a limited inguinal incision, off centre at the top and inside, using a Muller phlebectomy and systematic invagination for the stripping, and using a needle to unhook the posterior femoral saphenous branches which come out of the zone of anaesthesia.
  • The fact that this operation is ambulatory in 90% of cases [4] illustrates the major reduction in pain under loco-regional anaesthesia and with the use of certain technical devices. Since 1987 there has been a regular increase (from 60% to 90%) in ambulatory surgery for varices, which demonstrates a steady improvement in postoperative comfort.
  • The number of painful postoperative hematoma depends on drainage and postoperative compression, but is also strongly related to postoperative bleeding. Surgery under pure local anaesthesia does not involve any vasomotor paralysis, which is common under general anaesthesia and peridural. Similarly, femoral block is rarely accompanied by vasomotor paralysis by sympathetic block. This rare sympathetic block sometimes only involves a branch of the femoral nerve, thus leading to cutaneous redness and a sensation of heat in the area of this branch. The general absence of vasomotor paralysis during the femoral block minimises bleeding, hematoma and postoperative pain. Unlike the femoral block, the sciatic block is always accompanied by a sympathetic block and by vasomotor paralysis in the zone, which is why we do not use it for posterior anaesthesia of the leg.
  • Painful complications and sequellae in varicose surgery are mainly due to neurological complications [5], painful anaesthesia, neuroma. They are reported relatively frequently in varicose surgery under general anaesthesia [6, 7, 8, 9]. Anaesthesia by femoral block does not eliminate the specific feeling triggered by putting the saphenous nerve under tension during long stripping. We have shown that in 1.2% of cases [10] during long invagination, the saphenous nerve is stretched at the 1/3 middle 1/3 upper leg junction. The sensation or pain that patients describe as a cramp, relates to the saphenous nerve being put under tension at the return loop of the stripping. This "cramp signal" allows one to avoid tearing the nerve. At the beginning of our experiment [10] the forcing of this "cramp signal" with the aid of powerful antalgesics was always followed by painful postoperative anaesthesia of the inside face of the lower third of the leg, relating to the tearing of the saphenous nerve. This prevention of saphenous neurological complications can only be effected under loco-regional anaesthesia.

CONCLUSION

  • Precocious postoperative pain in varicose surgery mainly stems from cutaneous sensitivity; it is limited by non-aggressive surgical procedure, and is reduced by the homogenous postoperative compression created by elastic tights.
  • Lasting postoperative pain is mainly caused by sub-cutaneous hematoma, and is limited by loco-regional anaesthesia by femoral block
  • Definitive postoperative pain, or "sequel pain" is always due to neurological injury from stripping of from a Muller hook. This can be avoided by careful surgery, guided by proprioceptive vigilance, for patients operated on under loco-regional anaesthesia, by femoral block

REFERENCES

  1. Nabatoff RA. A complete stripping of varicose veins under local anesthesia : New York State J Med 1953 ; 53 : 1445-8
  2. Taylor E W , Fielding JW, Keighley MR, Alexander-Williams J. Long saphenous vein stripping under local anesthesia . Ann Roy Coll Surg Engl 1981;63 : 206-207
  3. Goren G. Yellin A.E. Invaginated axial stripping and stab avulsion (hook) Phlebectomy : a definitive out patient procedure for primary varicose veins. Ambulatory surgery 1994 ; 2 : 27-35
  4. Creton D. Study of the limits of local anaesthesia in one-day surgery in the case of 1500 stripping of the great saphenous vein. Ambulatory Surgery 1993 ; 1 : 132-135
  5. Staelens I., Van der Stricht J- Complication rate of long stripping of the greater saphenous vein. Phlebology 1992 ; 7 : 67-70
  6. Holme J.B., Home K., Sorensen L.S. -The anatomic relationship between the long saphenous vein and the saphenous nerve. Acta chir Scand. 1988; 154 : 631-633
  7. Garnjobst W. - Injuries of the saphenous nerve following operations for varicose veins Surg. Gynecol. Obstet., 1964 ; 119 : 359-361
  8. Ramasastry S.S, Dick G.O., Futrell J.W. -Anatomy of the saphenous nerve : relevance to saphenous vein stripping. Am . Surgeon. , 1987 ; 53 : 274-277
  9. Cox S. J. Welwood J.M., Martin A. - Saphenous nerve injury caused by stripping of the long saphenous vein . Brit . Med . J., 1974 ; 1 : 415-417
  10. Creton D. Résultats des strippings saphène interne sous anesthésie locale ambulatoire ( 700 cas) . Phlébologie 1991 ; 44 : 303-311
Table I Normal domestic life : 1340 LRA 1994-1995
First Day 74,5 %
5th Day 15 %
>= 8th Day
10,5 %
Table II Problem of post operative pain: 450 LRA 1995 3.5%
14 Phone the surgeon (2-15 j) 3,5 %
2 Consultation to the general practitioner
Table III Problem of dressing or post operative compression: 450 LRA 1995 22%
46 Phone the surgeon 22 %
8 Consultation to the surgeon
45 Consultation to the general practitioner
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