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 ¤ Results
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 Table of Contents     
ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 3  |  Page : 208-212
 

Subfascial Endoscopic Perforator Surgery: A safe and novel minimal invasive procedure in treating varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence


Department of General Surgery, Sriram Chandra Bhanj Medical College, Cuttack, Odisha, India

Date of Submission10-Jun-2017
Date of Acceptance29-Aug-2017
Date of Web Publication6-Jun-2018

Correspondence Address:
Dr. Manash Ranjan Sahoo
Department of General Surgery, Sriram Chandra Bhanj Medical College, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_107_17

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 ¤ Abstract 

Aim: Aim of this study is to evaluate the results of Subfascial Endoscopic Perforator Surgery(SEPS) in treating varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence.
Materials and Methods: A case series was undertaken at our institute from the period January 2010 to January 2014 on 45 pregnant women. Pregnant women with failed conservative management for varicose veins were subjected to SEPS in 2nd trimester Perioperative parameters like operative time, intraoperative complications, post-operative complications, hospital stay, pain relief, ulcer healing duration and recurrence rate were studied. All the patients were reviewed and followed up for a minimum period of 3 years.
Results: During the study period.total of 45 pregnant women were enrolled in the study. The median age of the patients was 26 years (range 22 years - 30 years). The mean operative time was 90±10 minutes. The post-operative hospital stay was 1-2days. There were no intraoperative complications like bleeding or gas embolism. There were no post-operative complications like seroma or abscess, port site infection, deep vein thrombosis and gas embolism. Mean healing duration of ulcers following surgery was 7-8 weeks.No patient complained of temporary or permanent paraesthesia. Every patient was subjected to follow up for a minimum period of 3 years. 5(11.1%) patients with recurrence were documented in the study.
Conclusion: SEPS is a safe, cost effective and novel minimal invasive procedure in treatment of varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence.


Keywords: 2nd trimester of pregnancy, below knee perforator incompetence, harmonic scalpel, subfascial endoscopic perforator surgery


How to cite this article:
Sahoo MR, Misra L, Deshpande S, Mohanty SK, Mohanty SK. Subfascial Endoscopic Perforator Surgery: A safe and novel minimal invasive procedure in treating varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence. J Min Access Surg 2018;14:208-12

How to cite this URL:
Sahoo MR, Misra L, Deshpande S, Mohanty SK, Mohanty SK. Subfascial Endoscopic Perforator Surgery: A safe and novel minimal invasive procedure in treating varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence. J Min Access Surg [serial online] 2018 [cited 2021 Oct 17];14:208-12. Available from: https://www.journalofmas.com/text.asp?2018/14/3/208/217060



 ¤ Introduction Top


Varicose veins are abnormally dilated and tortuous veins of lower limb. There are three categories of venous insufficiency i.e., congenital, primary and secondary.[1] Primary venous insufficiency is an acquired idiopathic entity. There are three main anatomic categories of primary venous insufficiency-telangiectasias, reticular veins and varicose veins.[1] The precise pathophysiology of venous insufficiency has yet to be elucidated. They are mechanical abnormalities, cellular abnormalities and molecular abnormalities. Risk factors for the development of varicose veins include advancing age, female gender, heredity and history of trauma to extremity.[1] Venous function is undoubtedly influenced by hormonal changes, particularly progesterone liberated by the corpus luteum.[1] It produces relaxation of the smooth muscle fibers.[1] Patients with symptomatic varicose veins commonly report with heaviness, discomfort and extremity fatigue.[1] Cutaneous burning and pruritus can also occur. The diagnosis is made by history taking, physical examination and various diagnostic modalities such as Doppler study, phlebography, venography and magnetic resonance venous imaging (MRVI).[1] Treatment modalities include conservative management and surgical management. Surgical management includes phlebectomy, stripping, endovenous therapy for failed conservative management of varicose veins.[1] We hypothesised that subfascial endoscopic perforator surgery (SEPS) is a safe and novel minimal invasive procedure in treating varicose veins in the 2nd trimester of pregnancy for below knee perforator incompetence.


 ¤ Materials and Methods Top


A case series was undertaken on 45 pregnant women from January 2010 to January 2014 at our institute. Patients presented with discomfort, bleeding and ulceration. Some were clinically silent. Patients were subjected to physical examination and diagnostic tests like Doppler to determine the aetiology and locate the site of venous incompetence. Deep venous thrombosis was ruled out. Ultrasound of the abdomen was performed to rule out other abdominal causes for varicose veins. Routine blood tests were performed. Patients were subjected to pre-anaesthetic evaluation and were posted for the procedure after obtaining fitness for surgery. Perioperative parameters such as operative time, post-operative complications, hospital stay, duration of healing, pain relief and recurrence rate were studied. Every patient was subjected to follow-up and reviewed for minimum 3 years by Doppler study.

Operative technique

The patient was put on the operating table in supine position. Under regional anaesthesia and under aseptic precautions, a 10 mm trocar was placed subfascially at inferomedial aspect, 4 cm below the knee joint [Figure 1]. With the help of pneumo, space was created [Figure 2]. Dissection of subfascial plane was done. A 5 mm trocar was placed suitably [Figure 3]. Harmonic scalpel was used to divide the perforators [Figure 4] and [Figure 5]. All the perforators were identified and divided [Figure 6] and [Figure 7]. Haemostasis was achieved and ports were closed [Figure 8]. Tight compression dressing was given using crepe bandage and leg end was elevated postoperatively. Early ambulation was encouraged for the patients.
Figure 1: A 10 mm trocar was placed subfascially at inferomedial aspect, 4 cm below the knee joint

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Figure 2: With the help of pneumo, space was created

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Figure 3: A 5 mm trocar was placed suitably

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Figure 4: Harmonic scalpel was used to divide the perforators

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Figure 5: Harmonic scalpel was used to divide the perforators

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Figure 6: All the perforators were identified and divided

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Figure 7: All the perforators were identified and divided

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Figure 8: Haemostasis was achieved and ports were closed

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 ¤ Results Top


During the study, a total of 45 pregnant women were included in the study. The median age of the patients was 26 years (range 22–30 years). Five (11.1%) patients were clinically silent, 18 (40%) patients presented with discomfort, 14 (31.1%) patients presented with ulceration, and 8 (17.77%) patients presented with bleeding. Patients were subjected to SEPS following physical examination and other diagnostic modalities. The mean operative time was 90 ± 10 min. The post-operative hospital stay was 1–2 days. There was no intraoperative complication such as bleeding or gas embolism. There were no post-operative complications such as seroma or abscess, port site infection, deep vein thrombosis and gas embolism. Mean healing duration of ulcers following surgery was 7–8 weeks. There was significant pain relief in all the patients. No patient complained of temporary or permanent paraesthesia. Every patient was subjected to follow-up for minimum 3 years. Five (11.1%) patients with recurrence were documented in the study.


 ¤ Discussion Top


Varicose veins are abnormally dilated and tortuous veins of lower limb. There are three categories of venous insufficiency i.e., congenital, primary and secondary.[1] Congenital causes include anatomic variants, venous ectasias, absence of venous valves and Klippel-Trenaunay syndrome.[1] Primary venous insufficiency is an acquired idiopathic entity. There are three main anatomic categories of primary venous insufficiency-telangiectasias, reticular veins and varicose veins.[1] Secondary causes may be due to intra-abdominal tumours, pregnancy, loaded colon, ascites, retroperitoneal fibrosis and arteriovenous fistula. The precise pathophysiology of venous insufficiency has yet to be elucidated.[1] They are mechanical abnormalities, cellular abnormalities and molecular abnormalities. Mechanical abnormalities may involve superficial system or deep ones or perforators may be the sole cause.[1] Failure of valve which protects the tributary from pressures may lead to varicosities. Cellular abnormalities contributing to pathophysiology of varicosities are monocytic and macrocytic infiltration.[1] In chronic advanced venous insufficiency there is advanced lipodermatosclerosis, capillary proliferation and extensive capillary permeability. In molecular abnormality, there is reduced elastin and collagen.[1] Risk factors for the development of varicose veins include advancing age, female gender, heredity and history of trauma to extremity.[1] Venous function is undoubtedly influenced by hormonal changes, particularly by progesterone liberated by the corpus luteum.[1] It produces relaxation of the smooth muscle fibers. Patients with symptomatic varicose veins commonly report with heaviness, discomfort and extremity fatigue.[1] Cutaneous burning and pruritus can also occur. Signs of chronic venous insufficiency are hyperpigmentation in gaiter area (secondary to deposition of hemosiderin) and lipodermatosclerosis. On physical examination, there may be palpable great saphenous vein and palpable cords. The diagnosis is made by history taking, physical examination which includes  Brodie-Trendelenburg test More Details, Perthe's test, Schwartz test, Pratt's test, Morrissey's cough impulse test and Fegan's method to indicate the sites of perforators. Diagnostic modalities such as Doppler study, phlebography, venography and magnetic resonance venous imaging (MRVI) detect the aetiology of varicosities and locate the site of abnormality. Doppler is used more to detect incompetent veins.[1] The duplex technology detects refluxing veins precisely. Phlebography is not much helpful in case of primary venous insufficiency.[1] It is more of use in secondary venous insufficiency. MRVI detects pelvic and abdominal venous vascularity.[1] It may be congenital malformation, chronic and acute venous thrombosis. Treatment modalities include conservative management and surgical management. Surgical management includes phlebectomy, stripping and endovenous therapy. Conservative management's objective is to improve the symptoms. These include elastic compression, leg end elevation, exercise, triple layer compression dressing. The indications for intervention are refractoriness to conservative therapy, recurrent superficial thrombophlebitis, variceal bleed, venous stasis ulceration.[1] Injection sclerotherapy is used for venules with dimensions >1 mm and <3 mm.[1] Complications include hyperpigmentation, venous matting, post-sclerotherapy necrosis and allergic reaction.[1] Recurrence is found within 8–12 months.[1] Foam sclerotherapy is used for spider veins and perforators.[1] Its dreaded complication is paradoxical embolism.[1] For axial venous incompetence ambulatory phlebectomy and powered phlebectomy is used as a surgical procedure.[1] Complications of ambulatory phlebectomy are bleeding, infection, temporary/permanent paraesthesia, phlebitis from retained vein.[1] Powered phlebectomy is used to treat extensive secondary branch varicosities.[1] Complications include haematoma, bleeding, phlebitis, temporary/permanent paraesthesia.[1] Stripping in early decades was considered as gold standard. It reduces risk of re-operation. Complications include prolonged rest, neovascularisation and nerve injury. Endovenous therapy includes radiofrequency ablation and endovenous ablation.[1] Its advantages being percutaneous procedures and performed on outdoor basis.[1] Complications include deep vein thrombosis, pulmonary embolism, skin burn, thrombophlebitis, paraesthesia and recurrence.[1] SEPS is a minimal invasive surgical procedure, aims to eliminate major cause of chronic venous insufficiency and venous leg ulceration.[2] SEPS helps to visualise all the perforators which may be missed on Doppler or by other surgical methods.[3] Dividing them all minimises the risk of residual perforators and recurrence. It enables to improve visual control of perforator interruption.[4] SEPS reduces post-operative hospital stay and encourages early ambulation. SEPS causes early healing of leg ulcers, less wound complications.[3] SEPS creates a virtual space which avoids further damage to scarred tissue around ulcers reducing the risk of wound complications.[2] It eliminates the risk of permanent paraesthesia and nerve damage. Significant pain relief is observed with SEPS. Complications such as deep vein thrombosis, pulmonary embolism, skin burn and thrombophlebitis are also minimised by SEPS.


 ¤ Conclusion Top


In general, SEPS is a safe, cost-effective and novel minimal invasive surgical treatment modality for varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence.

Acknowledgement

We would like thank Anaesthetists and all our operation theatre and nursing staff.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Courtney M. Townsend JR, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 19th ed., Vol. II, Ch. 49, Sec. 10. India Gurgaon: Saunders, an imprint of Elsvier Inc.; 2014. p. 1801-18.  Back to cited text no. 1
    
2.
Ravikumar S. Subfascial endoscopic perforator surgery in perforator vein insufficiency: Review article. WJOLS 2011;4:117-122.  Back to cited text no. 2
    
3.
Vashist MG, Vijay M, Nitin S. Role of subfascial endoscopic perforator surgery (SEPS) in management of perforator incompetence in varicose veins: A prospective randomized study. Indian J Surg. 2014;76:117-23.  Back to cited text no. 3
    
4.
Kushwaha JK, Sonkar AA, Singh KR, Anand A. Endoscopic treatment of chronic venous insufficiency by interrupting below knee perforating veins: A prospective study. JMSCR 2016;4:8878-85.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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