Varicose Vein Surgery
Surgery for Varicose Veins
Ligation & Stripping or Ambulatory Phlebectomy
- Patient expectations. Most patients have good results from surgery. Some, however, have inflammation and skin discoloration that lasts for several months afterwards. Patients usually require significant time off work (cf. sclerotherapy).
- Risks from varicose vein surgery. As well as the general anaesthetic risk, postoperative bleeding, infection, permanent nerve injury, scarring, DVT and bruising with pigmentation are more likely with ambulatory phlebectomy than after sclerotherapy. Nerve injury has been documented in up to 12% of phlebectomy cases, many mild or transient, but 1.5% are permanent and can result in numbness or paraesthesia. Phlebectomy in the outer upper leg (common peroneal nerve, causing foot drop) or ankle area (superficial nerves supplying the foot) are important areas. Post phlebectomy infection can result in re-operation, scarring, or worse.
- Recurrence after surgery. This occurs in about 30-40% of cases by 3-4 years following initial successful treatment, more so in women, due to the disease process and the swelling of prior minor tributaries. (Recurrence rate for Duplex Guided Foam Sclerotherapy is the same as for surgery.) Elimination of reflux is not possible with ambulatory phlebectomy alone, if just directed at superficial varicosities.
Currently, no public wait list will accept varicose surgery unless associated with ulceration or superficial thrombophelebitis.
Surgery has been the mainstay of treatment for centuries. It involves any combination of:
- Ligation of the great or small saphenous veins and tributaries in the groin or behind knee.
- Stripping of lengths of the saphenous veins between two small incisions.
- Avulsion of enlarged superficial veins through multiple tiny punctures. Because the veins are close to surface sensory nerves, stripping is limited to the great saphenous between the groin and knee and the small saphenous behind the knee.
Both legs are best not treated at the one operation, as this substantially increases the risk of deep vein thrombosis (DVT), and the legs are best operated on separate occasions with sufficient interval between to allow for maximal ambulation, as a prophylaxis.
What Are the Possible Complications After Surgery?
- Minor bleeding
- Swelling is common due to reaction to the dissections and can last for up to 6 months.
- Numbness is due to damage to surface sensory nerves There can be areas of permanent numbness.
- Complications from anaesthesia. There is risk for any operation requiring an anaesthetic. However, risk from problems associated with severe heart or lung disease is avoided by advising against surgery in such patients. It is important to inform of any allergies that you may have. Severe reactions to the anaesthetic or other medications are rare but any history of bad reactions to anaesthetics should be notified.
- Severe bleeding. This is rare but can occur if a tie slips from a main saphenous vein. If severe bleeding occurs, lie flat, apply gentle pressure and arrange transfer to hospital.
- Infection. Minor infection in the groin is not uncommon but severe infection is rare. If there is excessive pain in the groin with reddening and swelling, you should telephone for early review. However, extensive bruising can cause similar appearances and this does not require active treatment.
- Lymphatic damage. Lymph is a clear fluid that drains from the limbs through very fine lymphatic vessels separate to the blood flow. Lymph can leak from incisions or accumulate under the wound to cause a swelling. Pressure to the site with gauze and a firm bandage usually stops leakage but this can take several weeks. Occasionally, lymphatic damage can lead to permanent swelling of the leg termed lymphoedema.
- Deep vein thrombosis. This most often occurs in people who have an underlying abnormality in the blood clotting mechanisms. Rarely, a deep vein thrombosis can travel to the lungs as a pulmonary embolus and rarely this is life-threatening. A history of past clotting tendencies should be notified. There may be a need to test for the abnormalities and mobilised early after operation to reduce the risk.
- Nerve and arterial injuries. These are extremely rare but deep nerves that activate muscles in the thigh, calf and foot and the major arteries to the legs are close to the operated veins and can be at risk for damage.
- After any operation, there necessitates some scarring at the operation sites, which appears on the skin, varies in prominence, and generally subsides with time. However, in individuals prone to prominent scarring or keloid formation, this may be persistent, and conspicuous.
- Varicose veins, when treated optimally by any method, have a high rate of recurrence. This is in the order of 30-40% after 3-4 years, and is more common in females due to hormonal cause.