Abstract
Ikponmwosa et al. 1 describe the use of preoperative ultrasound to enhance the accuracy of venous surgery. Hobbs 2 previously used intraoperative venography to facilitate sapheno-popliteal ligation. Intraoperative ultrasound (IUS) is a further extension of both techniques and removes the requirement for preoperative marking.
IUS can be used to identify the saphenofemoral (SFJ) and saphenopopliteal (SPJ) junctions, the greater saphenous vein (GSV) and the small saphenous vein (SSV). IUS permits the introduction of tumescent anaesthesia (TA) along the GSV/SSV before stripping. The anaesthetized patient should be slightly head up to facilitate identification of the GSV/SSV. IUS is then used to identify the proximal portion of the SSV/GSV, and the line of the vein marked and approximate depth noted. The exact level of the SFJ and the SPJ is also noted and the junctions can be marked in longitudinal and transverse planes. A small incision is made just below the relevant junction. Incisions are minimized as they are always made directly over the relevant veins. The GSV/SSV is dissected out and the junction identified. The vein is not divided at this stage but clear identification and dissection before the introduction of TA facilitates ligation later. Early division of the vein makes it more difficult to identify the GSV/SSV for TA as the vein becomes smaller.
IUS is then used to guide the introduction of TA around the GSV/SSV to create a halo of fluid around the vein. I use 300 mL of fluid per leg comprising 20 mL of 1% lignocaine with adrenaline diluted in saline. If the vein becomes superficial it is important to introduce fluid between the skin and the vein. TA does seem to attenuate the slight tachycardic response of patients frequently noticed by anaesthetists at the time of stripping, but also tamponades the space left by the stripped GSV/SSV. Once TA has been introduced the patient is placed head down. The junction has already been dissected and so it is simply a matter of dividing between clips and any additional dissection towards the junction is facilitated. The junction is ligated, the stripper passed retrogradely down the GSV/SSV, retrieved at an appropriate site and a reverse strip performed.
Having used this technique over the last two years it is noticeable how by tumescing the strip track the bleeding is markedly reduced and frequently there is no bleeding. The larger the volume of TA, the better the effect, presumably due to the tamponading effect of the fluid. Blanching of the skin occurs after TA so there may also be a vasoconstrictor action. TA was a technique introduced for endovenous ablation under local anaesthesia but is equally well suited to surgical patients. Modifying surgical techniques and adopting IUS facilitates the precision of intervention and produces significant and noticeable improvements in bleeding and subsequent bruising along the track of stripped veins. IUS should be routinely available and in the armamentarium of every venous surgeon.