Subfascial endoscopic perforator surgery for posterolateral perforators performed in the prone position

Introduction

Subfascial endoscopic perforator surgery (SEPS) is a technique used to sever incompetent perforating veins (IPVs) without using a direct approach in an area with already compromised skin. SEPS has been accepted as an improved treatment modality in the surgical treatment of perforating vein insufficiency, particularly in cases with advanced skin changes.^1–3 However, SEPS has not been widely adopted because of the technical difficulty and burdensome apparatus involved in its performance. In Japan, the two-port system utilizing screw-type ports (EndoTIP^R, Karl Storz, Tuttlingen, Germany) was introduced by Haruta at the beginning of the 21st century, which made the performance of SEPS simpler and easier.^4,5 SEPS was accepted as a national advanced medical system by the Japanese Ministry of Health, Labor and Welfare in May 2009. SEPS is usually performed for the posteromedial perforators in the supine position. We interrupted the posterolateral perforators in the superficial posterior compartment with the patient in the prone position.

Case report

A 51-year-old man presented with varicose veins on the posterior aspect and skin pigmentation around the lateral malleolus of his left lower leg 3 years previously. Eleven months earlier, he suffered from a small ulceration in the area of pigmentation that was resistant to conservative treatment and caused severe pain (Figure 1). He had worn elastic stockings during the daytime for 2 years, but with no improvement. Venous echo showed reflux in the proximal small saphenous vein (SSV), without blood flow toward the medial branch opposite to the skin lesion (6.7 mm in diameter at the SPJ) and three IPVs (5.1, 3.3 and 3.2 mm in diameters) under the area of skin change. Besides the SSV, no other superficial or deep vein insufficiency, or deep vein thrombosis were found. There was no previous history of venous surgery. As most of the patients with stasis ulcer hope so, he hoped to undergo SEPS simultaneously with superficial vein ablation. He underwent stripping of the left SSV and SEPS in the prone position under general anesthesia. SEPS was performed with a two-port system utilizing screw-type ports (EndoTIP^R) as previously described. ⁵ Carbon dioxide insufflation was used to obtain a better working space. IPVs were interrupted using an ultrasonic scalpel under a good visual field (Figure 2). It took 40 min for completion of the SEPS, and total blood loss was 47 g. The patient was discharged on postoperative day (POD) 3 after an uneventful postoperative course without restriction of ambulation, and with an elastic banding. The patient’s pain was completely gone by POD 7. His ulcer healed completely 2 months after the surgery and the skin pigmentation became lighter with time (Figure 3). OPEN IN VIEWER

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Figure 2.

Operative procedure: (A) a 6-mm-caliber EndoTIP cannula used for SEPS and (B) image of the surgery. The left upper corner of the image is the proximal and right lower corner is the distal part of the leg. U: ulcer covered with sterilized film; E: 5-mm caliber endoscope and S: ultrasound scalpel. (C) Endoscopic visualization of the IPVs (arrows). Some adhesions existed between the fascia (upper part of the image) and muscle (lower part of the image).

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Figure 3.

Postoperative course: (A) 1 month, (B) 3 months and (C) 6 months after SEPS showing gradual improvement of the skin lesion.

Discussion

In Japan, the two-port system utilizing screw-type ports (EndoTIP^R, Karl Storz, Tuttlingen, Germany) was introduced by Haruta in the beginning of the 21st century,^4,5 which made SEPS more simple and easier to perform. Briefly, a 7-mm skin incision was made in the healthy upper medial part of the lower leg, from where the first port, a 6-mm EndoTIP^R, was inserted into the subfascial space of the superficial posterior compartment by twisting off subcutaneous tissue and fascia, under the guidance of a 5-mm endoscope inserted through the port. Then, CO₂ at a pressure of 10 mmHg was insufflated into the space through the port and the subfascial space was bluntly dissected by the tip of the endoscope in order to obtain the working space containing the part into which the second port was later inserted. The second port was positioned under the guidance of the endoscope inserted through the first port, and it was inserted into the space in the same way as the first port. One port was used for endoscopic observation, while dissection of soft tissue adhesions and interruption of IPVs were performed by an ultrasonic coagulation system and special dissecting forceps through the other port. The screw-type ports allowed establishment of a multi-directional working space without leakage of insufflated CO₂. Interruption of IPVs by an ultrasonic coagulation system eliminated the necessity for tourniquets. Thus, the time required for performance of SEPS became shorter, and the results became more favorable. With this technique by Haruta, the primary ulcer healing rate was reportedly 97.0%, the ulcer recurrence rate was 9.9% and the provisional ulcer healing rate was 92.1% in 101 C6 legs whose mean follow-up period was 3.95 years. ⁴ Some people believe that IPVs have nothing to do with venous stasis unless positive evidence exists to prove that. But a correct diagnosis by venous echo shows that venous stasis skin lesions are affected by IPVs, as in this case, and as believed by many expert varix surgeons.

According to earlier literature, SEPS is usually performed to sever posteromedial and paratibial IPVs in the superficial posterior medial compartment, with the patient in the supine position.^1–3.

In fact, the superficial posterior compartment in the lower limb ranges beyond the posterior midline, up to the posterolateral aspect of the leg, as described in textbooks of orthopedics. Hence, theoretically, posterolateral IPVs can be severed in the compartment. However, no previous literature has described interruption of posterolateral perforators in the superficial posterior compartment of the leg. The prone position enables interruption of the posterolateral perforators, because gravity-dependent flattening of the muscles enables creation of sufficient subfascial space. Therefore, to facilitate opening of the subfascial space, surgery on posterolateral IPVs should be performed with the patient in the prone position, and posteromedial IPVs should be operated on in the supine position.

In conclusion, we experienced a case with skin ulceration, skin pigmentation and IPVs in the posterolateral aspect of the distal lower limb, in which we performed SEPS in the prone position. Surgery in the prone position facilitated interruption of the posterolateral IPVs without direct incision in an area of already compromised skin, because gravity-dependent flattening of the calf muscles enabled easy access to the IPVs in the superficial posterior compartment. Moreover, SEPS utilizing the screw-type ports is a very useful and simple method,^4,5 allowing good visualization, as was seen in our patient (Figure 3).