Laparoscopy Surgery

PERSONALIZED PATIENT CARE

Minimal Invasive Procedure For Varicose Veins (SEPS) Treatment

The word "varicose" comes from the Latin root "varix," which means "twisted." Any vein may become varicose, but the veins most commonly affected are those in your legs and feet. That's because standing and walking upright increases the pressure in the veins in your lower body.

The veins of the legs are divided into two systems - the deep veins (which run deep to the leathery layer of fascia surrounding the muscles) and the superficial veins (which run in the layer of fat just beneath the skin). The superficial veins are the ones that you can see (for example, on your foot or around the ankle) and they are the ones that can become varicose. It is essential to keep in mind these two different systems - deep and superficial - in order to understand varicose veins and their treatment. In a number of places in the leg, the superficial and deep veins are linked by perforating veins (or 'perforators'). They are called perforators because they perforate the leathery fascial layer surrounding the muscles of the legs. Normally their valves should allow blood to flow only inwards - from the superficial veins to the deep veins. If the valves stop working properly, then blood is pushed out into the superficial veins when the muscles contract: this is one reason for high pressure in the superficial veins, and can be a cause of varicose veins.

The blood in your leg veins must work against gravity to return to your heart. To help move blood back to your heart, your leg muscles squeeze the deep veins of your legs and feet. One-way flaps called valves in your veins keep blood flowing in the right direction. When your leg muscles contract, the valves inside your veins open. When your legs relax, the valves close. This prevents blood from flowing backward. However, when these valves do not function properly, the blood pools, pressure builds up, and the veins become weakened, enlarged, and twisted. This causes varicose veins to develop. Varicose veins develop when one has faulty valves in the veins and weakened vein walls. These veins are twisted, enlarged veins close to the surface of the skin. They usually develop in the legs and ankles.

Varicose veins are a common condition, affecting up to 15 percent of men and up to 25 percent of women. Treatment may involve self-help measures or procedures by your doctor to close or remove veins.

  • Which veins become varicose?
  • The long saphenous vein (LSV)

This vein and its tributaries are the ones that most often form varicose veins. The long saphenous vein is formed from tributaries in the foot, and is visible in many people when they stand, as the vein just in front of the bone on the inner side of the ankle. It runs up the inner side of the calf and the thigh, and at the groin dives to join the main deep vein (the femoral vein).

The short saphenous vein (SSV)

This is the other main vein under the skin of the leg, the tributaries of which can become varicose, but it is affected much less often than the LSV. The SSV starts just behind the bone on the outer side of the ankle, and runs up the middle of the back of the calf. It usually dives to join the main deep vein just above and behind the knee (the popliteal vein), but this varies and before any operation on the SSV it needs to be checked by a scan.

Perforating veins

In almost any part of the leg, a perforating vein can develop incompetent valves. This allows blood to be pumped outwards under pressure into superficial veins, causing them to become stretched and varicose.

Any vein

Any vein under the skin, in any part of the leg, can become varicose, without valve problems in the LSV, SSV or perforating veins. These varicose veins are usually quite small and cause few symptoms.

Some people may be more likely than others to develop varicose veins and spider veins because of inherited characteristics (genetics), the aging process, or hormone changes. Varicose veins may also result from conditions that increase pressure on the leg veins, for example being overweight or pregnant. Though, the most contributing factor is Hereditary. Women are more likely to suffer from abnormal leg veins. Hormonal factors can affect the disease. It is very common for pregnant women to develop varicose veins during the first trimester. Pregnancy causes increase in hormone levels and blood volume, which in turn cause veins to enlarge. In addition, the enlarged uterus causes increased pressure on the veins. Varicose veins due to pregnancy often improve within 3 months after delivery. However, with successive pregnancies, abnormal veins are more likely to remain. Other predisposing factors include aging, standing occupations, obesity and leg injury. Varicose veins are present in 20-25% of adult females and 10-15% of men. This common condition represents a considerable surgical workload.

In varicose veins, symptoms are often worse at the end of the day because more pooling has occurred. Other things which increase pooling and therefore symptoms also include prolonged standing and sitting, exposure to heat (summertime, hot baths) and hormonal factors (pregnancy, around the time of the menses).

Varicose veins may be associated with a sensation of heaviness and itching and, in the presence of deep and superficial reflux, cramps and aching. However, all too often generalised aches and pains in the leg may be attributed to visible varicose veins. Left unchecked, they tend to increase in size and often lead to progressive skin and tissue damage resulting in eczema, lipodermatosclerosis and, in advanced cases, venous ulcers. Lipodermatosclerosis is the medical term that describes damage both to the skin and to the fatty layer beneath it '

Ulcers, when they occur, most often afflict the elderly, blighting their lives with frequent visits to their local surgeries or hospital out-patient departments. Many sufferers complain of aching of the legs, skin itching, ankle swelling, restless legs, night cramps and sleep disturbance.

Varicose veins are arguably the most frequently referred general surgical malady presenting to hospitals. Varicose veins are often caused by an underlying problem in leg vein.

First your physician asks you questions about your general health, medical history, and symptoms. In addition, your physician conducts a physical exam. Together these are known as a patient history and exam. Your physician will examine the texture and color of any prominent veins. He or she may apply a tourniquet or direct hand pressure to observe how your veins fill with blood. So the diagnosis is based primarily on the characteristic appearance of the legs when the patient is standing or is seated with the legs dangling.

At times a physician may order a duplex ultrasound exam of extremity to see blood flow and characterize the vessels, and to rule out other disorders of the legs. Duplex ultrasound uses high-frequency waves higher than human hearing can detect. Your physician uses duplex ultrasound to measure the speed of blood flow and to see the structure of your leg veins. The test can take approximately 20 minutes for each leg.


Angiography

Rarely, an angiography of the legs may be performed to rule out other disorders.

The surgeon first assesses the patient, with a detailed history and physical examination, and confirms the diagnosis and extent by relevant investigations. Not every person with a varicose needs surgery. One needs to discuss the reasons for operating and understand the risks involved. A large proportion of patients may wish surgery for cosmetic reasons or due to anxiety that their disease may progress to chronic venous insufficiency and ulceration. It should be emphasized that varicose vein surgery is not curative, and early surgery in uncomplicated veins will not prevent development of future varicosities. However, it has been shown, that quality of life is reduced in patients with varicose veins compared with the general population, and that this is improved by surgery.

Non-surgical methods

Varicose veins may sometimes worsen without treatment. Your physician will first try methods that don't require surgery to relieve your symptoms. If you have mild to moderate varicose veins, elevating your legs can help reduce leg swelling and relieve other symptoms. Your physician may instruct you to prop your feet up above the level of your heart 3 or 4 times a day for about 15 minutes at a time. When you need to stand for a long period of time, you can flex your legs occasionally to allow the venous pump to keep blood moving toward your heart. Besides these treatments like compression stockings, sclerotherapy, laser treatments are offered which are non-surgical and the first line of action.

Compression Stockings

For more severe varicose veins, your physician may prescribe compression stockings. Compression stockings are elastic stockings that squeeze your veins and stop excess blood from flowing backward. Compression stockings also can help heal skin sores and prevent them from returning.

This form of treatment is a non-surgical procedure in which a solution is injected into the problem varicose veins or spider veins in order to cause its disappearance.

A chemical irritant can be injected into veins, although large veins are difficult to treat using this method, as the chemical has to physically come in contact with the lining of the target vein for long enough to destroy it. Sclerotherapy works by burning the lining of the vein, which causes the vessel to spasm and block off with clot. The idea is to make the vein shrivel away by scarring. Unfortunately, the clot often clears away, allowing the scarred vessel to open up again.

EVLT works by heating the inside of the vein, which causes it to seal shut and disappear. This treatment requires that a very thin laser fiber be inserted into the damaged underlying vein. Tiny electrodes at the tip of the catheter heat the walls of your varicose vein and destroy the vein tissue. As with chemical sclerotherapy, your vein is then no longer able to carry blood, breaks up naturally, and is absorbed by your body.

This method treats the vein by heating them, causing the vein to contract and then close.

This form of vein therapy involves a light beam that is pulsed onto the veins in order to seal them off, causing them to dissolve. Successful light-based treatment requires adequate heating of the veins. Several treatments are usually needed for optimal results.

This procedure involves making tiny punctures or incisions through which the varicose veins are removed. The incisions are so small no stitches are required.

The most common operation performed for varicose veins is high long saphenous ligation and stripping involving a groin crease incision.

To perform vein stripping, your physician disconnects and ties off all major varicose vein branches associated with the saphenous vein, the main superficial vein in your leg. Your physician then removes the saphenous vein from your leg. A procedure, called small incision avulsion, can be done alone or together with vein stripping. Small incision avulsion allows your physician to remove varicose veins from your leg.

In a similar procedure called TIPP (Transilluminated Powered Phlebectomy), your physician shines an intense light on your leg to show your veins. Once your physician locates a varicose vein, he or she passes a suction device through a tiny incision and suctions out the vein. Although these procedures sound painful, they cause relatively little pain and are generally well tolerated. Your vascular surgeon will advise you regarding which procedure is the best for your particular situation..

Introduction
A few years ago, long incisions had to be made in the calf to gain access to these difficult veins. The dissection was extensive, the complication rates high and recovery prolonged, which may go a long way to explaining the continued reluctance of many surgeons to treat perforators at all. Perforators can now be treated using a camera. These are exciting refinements that have yielded excellent results in this series. SEPS stands for Subfascial Endoscopic Perforator Surgery. SEPS was introduced more than 15 years ago as a minimally invasive alternative to open perforator ligature. This is a specialized minimally invasive procedure performed on patients who suffer with leg ulcers due to incompetent perforator veins. Using tiny incisions and an operating scope, perforator veins are tied off. This results in ulcer healing in the vast majority of patients.

SEPS provides excellent visualization of the anatomy of the subfascial plane. Subfascial means under the fibrous tissue beneath the skin, and endoscopic refers to the narrow instrument used to examine the inside of a cavity in the body. It enables introduction of the instruments through skin incisions that are distant from the site of skin changes and carries a low rate of complications. Hence, SEPS is the procedure of choice in the treatment of patients with chronic venous insufficiency.

Procedure
Subfacial Endoscopic Perforator Surgery (SEPS) is a minimally invasive surgical procedure which the doctors use to treat the underlying condition that causes venous ulcers. During the procedure they disconnect the abnormal perforator veins, which cause ulceration because of improperly functioning valves. By disconnecting these veins, they redirect the blood flow to healthy veins. Circulation in the leg is improved, and the ulcer is healed.

SEPS is usually performed with two ports of entry into the leg. A special instrument is inserted deep to the fascia of the leg and a large balloon is inflated with water to create a working space. The balloon is then emptied and the space is insufflated with air. The camera is inserted and the perforator veins can be seen in the space passing from superficial to deep layers. Another small incision is made in the calf for passage of another instrument. The perforator veins are carefully dissected, clips are applied and the veins are divided if necessary. Perforating veins are then divided with endoscopic scissors. Metal clips are placed on the cut ends of the vein to avoid bleeding. Another option to interrupt the vein is to use a harmonic scalpel, an instrument that uses ultrasonic waves to seal the cut end of the veins to avoid bleeding. All trocars are then removed and the wounds are closed. The leg is dressed with an ACE wrap.

After surgery
After surgery, the limb is elevated at 30 degrees for 3 hours, after which walking is allowed. Patients are discharged from the hospital either the same day or the morning after the procedure. After 10 days to 2 weeks, patients may return to work.

Recovery
The patient is generally sent home the same day of surgery and the ACE wrap can be removed in 48 hours. Recovery from this procedure is rapid with a return to normal function within a week. Walking is permitted throughout this recovery period and pain associated with this procedure is minimal. For those patients who present with leg ulcers, healing of these ulcers is markedly accelerated with the reduction of venous pressure subjected to the skin and ulcer area.

Benefits and drawbacks
Subfascial endoscopic perforating vein surgery (SEPS) is the treatment of choice. The healing time with SEPS is substantially decreased when compared with conventional treatment and carries low complication and recurrence rates. Conventional surgery of perforating veins requires long skin incisions in order to ligate incompetent perforating veins. As the overlying skin is often atrophic, poorly nourished and frequently affected with skin necrosis, impaired wound healing and wound infection pose considerable problem.

Ulcer healing is rapid, and half of the ulcers can be expected to heal within 8 weeks. The wound complication rate is only 5%. At 2 years, 80% of the ulcers stay healed in patients who never had blood clots in the leg but only 54% of those who had blood clots in the leg veins before surgery have no ulcers. And above all minimal hospital stay is required following SEPS.