Videoendoscopic dissection of perforating veins of the leg in the treatment of varicose vein disease

The dissertation is devoted to the surgical treatment of varicose vein disease of the lower extremities with an emphasis on interventions on the perforating veins of the leg. The work examines the prevalence of the disease, the severity of its complications, including trophic ulcers, as well as the limitations of the classical Linton–Felder operation associated with a high frequency of pyonecrotic complications and persistent sensory disturbances. The author conducted a comparative study of videoendoscopic dissection of perforating veins, open subfascial ligation, and an original technique of closed dissection. The analysis covers the duration of operations, the terms of hospitalization and rehabilitation, the character and frequency of complications, the possibilities of applying the method in patients with high operative and anesthetic risk, as well as the performance of combined minimally invasive interventions.

The aim of the research is to improve the outcomes of treatment of patients with varicose vein disease of the lower extremities by evaluating and refining videoendoscopic and minimally invasive approaches to dissection of the perforating veins of the leg.

The prevalence of varicose vein disease of the lower extremities is extremely high. According to various statistical data, this disease in one form or another occurs in 20-25% of the working-age population of industrially developed countries (Savelyev V.S., 1982; Vedensky A.N., 1983; Savelyev V.S., 1997; Feqan J., 1967; Roddie I., 1969; Olenire T., 1986; Grondin L., 1992). Among women the disease occurs in 26-38%, with an annual increase in new cases of 2.6%, and among men in 10-20%, with an increase of 1.9% per year (data of a meeting of expert phlebologists, Moscow, 2000). The situation with varicose vein disease of the lower extremities in Russia is even more serious, which is due to the predominance of late seeking of medical care and late detection of the disease.

V.S. Savelyev (1997) considers that about 50% of the adult population of our country suffers from varicose vein disease. Of these, no less than 20% have prolonged loss of working capacity or disability (Romanovsky A.V., 2004). According to A.I. Kirienko (1998), a significant proportion of cases (up to 20%) falls on advanced forms. In 40% of cases, varicose vein disease of the lower extremities is complicated by various trophic disorders of the skin and subcutaneous adipose tissue (Savelyev V.S., 1996; Kirienko A.I., 1997; Basanquet N., 1996). The most severe of these complications are trophic ulcers.

In economically developed countries, 1-2% of the adult population suffers from ulcers of venous etiology (Franks P.J., 1994; Basanquet N., 1996; Rucklej C.V., 1997), and among elderly persons this figure reaches 4-5%. For Russia this indicator is even more serious — more than 2% of cases (Savelyev V.S., 2001; Romanovsky A.V., 1999).

At the same time, despite the obvious progress in the diagnosis and treatment of chronic venous insufficiency, the frequency of trophic ulcers is a kind of constant identified by numerous epidemiological studies over the past 20 years. Taking demographic indicators into account, it may be stated that in Russia no less than 5 million people suffer from trophic ulcers of venous etiology (V.Ya. Vasyutkov, V.Yu. Bogachev, 1999).

A certain significance in this circumstance belongs to the imperfection of the existing surgical techniques aimed at dissection of perforating veins and elimination of pathological veno-venous shunting. Despite the enormous role of the Linton–Felder operation, its substantial drawbacks are obvious, both in its classical variant and in its modifications. These are primarily pyonecrotic complications in the early postoperative period, occurring in 20-30% of cases, as well as persistent impairment of cutaneous sensitivity noted in 50% of patients (Kirienko A.I., 1997). In patients with trophic ulcers, complications after the Linton operation may reach 46-60% (Robinson J., 1992).

The development and introduction into everyday clinical practice of new methods of surgical treatment of varicose vein disease, including those on the perforating veins of the leg, which do not require prolonged hospitalization and are accompanied by good functional and aesthetic results, is a topical task.

The aim of the present study is improvement of the results of treatment of patients with varicose vein disease of the lower extremities.

To achieve this aim the following tasks were set:

1. To determine the place of videoendoscopic dissection of perforating veins of the leg in patients with varicose vein disease of the lower extremities;

2. To assess the capabilities of videoendoscopic intervention on the perforating veins of the leg in varicose vein disease of the lower extremities in different forms of the disease and degrees of chronic venous insufficiency;

3. To assess the capabilities of videoendoscopic intervention on the perforating veins of the leg in varicose vein disease of the lower extremities in patients with a high degree of operative and anesthetic risk;

4. To study the character of the postoperative period and the frequency of intraoperative and postoperative complications after videoendoscopic and traditional interventions on the perforating veins of the leg in varicose vein disease of the lower extremities;

5. To study the possibility of performing combined minimally invasive interventions in varicose vein disease of the lower extremities and concomitant surgical diseases.

Scientific novelty:

1. It is proved that the use of videoendoscopic technique considerably reduces the severity of the postoperative course and the frequency of local complications. A qualitative difference in the postoperative period is shown depending on the character of the intervention performed. In patients who underwent videoendoscopic dissection of perforating veins, the intensity of the pain syndrome was significantly lower, and the terms of postoperative rehabilitation were reliably shorter (p<0.05).

2. A minimally invasive method of closed dissection of perforating veins of the leg has been developed and introduced, and the results of the intervention have been evaluated.

3. The possibility and expediency of simultaneous performance of minimally invasive interventions in the combination of varicose vein disease and other surgical diseases have been demonstrated and substantiated.

4. It is confirmed that the performance of videoendoscopic dissection of perforating veins of the leg improves the results of treatment of patients with a high degree of operative and anesthetic risk, including elderly patients, those with severe concomitant diseases, and those with obesity.

5. It is proved that, unlike the stage of the disease and the degree of chronic venous insufficiency, the prevalence of varicosity has no substantial influence on the results of treatment of patients.

Practical significance:

It is demonstrated that the performance of videoendoscopic intervention on the perforating veins of the leg is possible on one side as well as simultaneously on both sides. It is proved that bilateral intervention does not lead to prolongation of the terms of postoperative treatment and rehabilitation.

In the present study it is shown that such a serious postoperative complication in interventions on perforating veins as persistent impairment of sensitivity of the leg due to trauma of subcutaneous nerves was noted in 4.8% of patients operated on endoscopically, and in 42% of patients who underwent the traditional operation.

The first experience of closed dissection of perforating veins of the leg proved the fundamental possibility of performing the intervention with observance of the principles of minimal invasiveness and without the use of expensive equipment.

It is shown that the complications noted in patients who underwent the traditional intervention were not only frequent, but also varied and sufficiently serious (suppuration of the wound, lymphorrhea, erysipelas), requiring additional treatment, in particular prolongation of antibiotic therapy for 5-8 days after the intervention, as well as the application of secondary sutures.

The operative trauma inflicted by modern videoendoscopic interventions is insignificant. It is proved that the combined performance of videoendoscopic dissection of perforating veins of the leg and other minimally invasive interventions practically does not increase the terms of rehabilitation.