Aims of Surgery
The damaged valves in the veins cannot be cured so the best way to cure the problem is to remove the affected superficial veins. The aim of surgery is to take pressure off the skin microcirculation in the leg. This is achieved by disconnecting and removing the varicose veins from the deep veins using a cut in your groin or back of your knee. The removal of varicose veins does not affect blood flow because other veins and especially the deep veins take over this job.
For those with skin changes around the ankles or previous ulceration, reducing the pressure prevents worsening of the skin change and reduces the risk of ulceration. For those who already have an active venous ulcer, treating the VVs may effectively help heal the ulcer. For these patients, the addition of support stockings further protects the skin around the ankles.
Before the treatment
Before undergoing varicose vein surgery, you will need to be seen for a consultation in the outpatient clinic.
During the consultation, Mr A. Abu-Own will conduct a clinical assessment (history and physical examination). A Doppler examination with a handheld Doppler, or a Duplex ultrasound will usually be performed during the same visit. Occasionally, Mr A. Abu-Own may arrange for a further scan to be done in the imaging department.
If a decision is agreed to proceed with treatment, you will undergo a pre-operative assessment. The preop assessment is carried out by a Nurse Specialist in the outpatient department. It may include pre-operative tests such as blood tests, an ECG for some and completing the paperwork. These tests are usually completed at a pre-admission visit to the hospital a short time (1-2 weeks) before your operation. For self-funding patients, the pre-operative assessment is included in your all-inclusive procedure price.
Coming into hospital
Varicose vein surgery can often be performed as a day case procedure. If you are fit, have a family member to take you home, and be with you over night, you will probably qualify. Those having more complex surgery or those who live alone will need to stay in hospital overnight. You should bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also complete your nursing record.
Mr A. Abu-Own will see you immediately before the procedure. He will mark up your veins with a waterproof pen, agreeing with you which veins are to be removed. You should ensure that any varicosities causing you concern are marked. Finally, he will discuss with you further the details of the operation, address any further questions you may have and, if you are willing to proceed, ask you to sign a consent form. During this consenting process, Mr A. Abu-Own will discuss with you the benefits versus risks of the proposed treatment.
The doctor who will give you the anaesthetic will also visit you, and explain the anaesthetic to you.
Varicose vein surgery is performed under general anaesthetic. A tiny needle is placed in the back of your hand. The anaesthetic is injected through the needle and you will be asleep within a few seconds.
While you are asleep, local anaesthetic will be used around the groin incision and the incision on the back of the knee (when used). When you wake up the incisions should be numb.
Sometimes a drip is placed into a vein in your arm (wrist usually) to give you some fluids during and following surgery.
The operation itself
The operation varies a little from case to case, depending on where the leaky valves are. Normally you will have a slanting cut about 3-5cm long running in the skin crease of the groin. Through this incision, the top end of the faulty vein (long saphenous vein) is tied off to stop blood flowing through it - this is known as ligation (SFJ ligation or high tie).
Mr A. Abu-Own's preferred technique for removing the vein is called Inversion PIN Stripping. This involves inserting a pin/wire into the vein and passing it down to knee level. At knee level, a second cut is made and the vein (with the wire running through it) is pulled out inverted inside out. This is considered to be a more gentle approach than conventional vein stripping with less risk of collateral tissue trauma.
The ligation and removal of the long saphenous vein deals with the underlying cause of the varicose veins and should prevent recurrence.
Less frequently, when the principal vein on the back of the knee has a leaking valve, it too needs ligation. This is performed through a horizontal incision about 3cm long on the back of the knee. The short saphenous vein itself is rarely stripped from the leg because it lies close to a nerve and so stripping of this vein could risk damaging this nerve.
Finally, in most cases, the visible varicose veins are removed from the leg through tiny incisions about 2-3mm in length. A special hook is used to fish out the visible varicosities in sections through these tiny incisions. These are called "phlebectomies" or "avulsions". There may be a large number of tiny incisions made if the varicose veins are extensive.
The larger incisions in the groin or behind the knee are closed with an absorbable stitch, which lies beneath the skin and doesn’t need to be removed. The smaller incisions from the avulsions are not stitched, but simply taped with "Steri-strip" - they usually heal very well and are typically not visible at one month follow-up. At the end of the operation, the leg is bandaged firmly from the foot or ankle up to the groin.
After the treatment
You will usually be taken to the theatre recovery area after the operation where you will wake up. When you are fully awake (usually 20-30 minutes) you will be returned to the ward. Most people describe the leg as stinging or burning when they wake up but it is unusual for the leg to be painful. Following this sort of surgery you are very unlikely to feel sick and you should be able to eat and drink again within a few hours.
Some of the smaller incisions may bleed a little over the first 24-48 hours. For this reason, it is best to keep the leg covered with bandages for the first 2-3 days. After this time, the stockings will provide support and reduce bruising and make the leg more comfortable.
The incisions, although initially visible, will subside to become virtually invisible within 9-12 months.
You may notice extensive bruising in the leg, particularly down the inside of the thigh. This bruising usually lasts for 2-3 weeks, but will gradual clear over the subsequent few weeks. Removal of the skin veins means that blood returns to the heart through the deep veins more efficiently than before the operation.
Most people describe the leg as sore and uncomfortable when they get home.The discomfort usually resolves within 7 days after the operation. Occasionally, when there is phlebitis, there may be more discomfort that can last longer to settle.
Stitches/dressings: Dressings may be removed after 3-5 days. Groin stitches are dissolvable and do not need to be removed. Leg wounds will have plasters on them which wall fall off or you may remove them by the 8th day in the bath or shower.
Bruising: Due to the nature of your operation, bruising is to be expected, particularly down the inside of the thigh. This should fade and disappear in 2-3 weeks.
Medicines: You may be given some mild painkillers such as paracetamol and ibuprofen to take home with you.
Bathing: You may have a shower 48 hours after the operation but soaking of wounds is to be avoided. Bathing or showering immediately after surgery may lead to bleeding from the smaller incisions.
Regular daily exercise: To rest up after the operation raises the risk of developing blood clots in the deep veins (deep vein thrombosis or DVT). Regular exercise reduces this risk, but makes the leg more uncomfortable. Exercise your legs by pointing your toes to the floor and bending and stretching your ankles. Take walks daily if you are able to. This should not be one long walk, but several shorter walks. Elevate and rest your legs after exercise. Do not stand for long periods. Keep marching on the spot if you have to stand. When you are sitting down, keep your legs elevated on a footstool or settee. The higher your legs are raised the better.
Support stockings: these will be provided to you whilst in hospital. Your legs will be measured to make sure you have the right size. If you have bandages on your legs after your surgery, please leave them on for 48 hours. After 48 hours, the bandages are removed and stockings applied. Please wear the stockings for two weeks. You shower as necessary, dry and re-apply the stocking.
Driving: You can drive a car approximately 10-14 days after your operation, when your legs feel comfortable. You should sit in a stationary car and practise an emergency stop before commencing driving. If this is comfortable to do, it should be safe to drive. Avoid long-distance driving for 4–6 weeks.
Returning to work: You will be given two weeks sick leave by the ward doctor or nurse. Occasionally, you may need to have 2-4 weeks off work, depending on your operation and type of employment.
Lifting: There are no limitations in this area.
Mr Abu-Own routinely sees his patients for an outpatient follow-up consultation at least once following varicose vein surgery, around 2-4 weeks after the procedure. For self-funding patients, this is included in your pre-agreed all-inclusive procedure price.
Complications after varicose vein surgery are uncommon.
Chest infections: These can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.
Wound infection: Wounds sometimes become infected and this may need treatment with antibiotics. Serious infections are rare.
Fluid leak from wound: Occasionally the groin incision may leak blood-stained or clear fluid. This may last a few days.
Seroma fluid collection: Sometimes, clear fluid collects under the groin incision. It may be contained beneath the skin as a swelling (cyst). This occurs infrequently mainly following re-operation in the groin.
Nerve injuries: These are uncommon occurring in about 1 in 20 cases. Skin sensory nerves may be damaged leading to reduced sensation anywhere in the leg. The reduced sensation may be very noticeable at first, but normally diminishes with time and is not usually a problem in the longer term.
Deep Vein Thrombosis: DVT complicates any operation from time to time. It also occurs occasionally following varicose vein surgery. Patients with extensive varicose veins associated with skin changes are probably at greatest risk, but this complication is rare. If you are considered at higher risk to develop DVT on risk assessment, you will be given heparin injection(s) (a blood thinner) to reduce the risk.
Recurrent Varicose Veins: Recurrence of varicose veins occurs in about 1 in 15 patients over a ten-year period. Sometimes further treatment may be required. The recurrence rate is reduced by applying appropriate pre-operative assessment and careful surgical technique.
What can I do to help myself?
When you get home, try to return to normal as soon as possible. The more exercise you take, the more sore your leg will be, but the quicker the leg will return to normal.
Suitability for Treatment
Surgery is particularly suitable for people with:
Ulceration, or threat of ulceration resulting from the varicose veins.
Bleeding through the skin caused by varicose veins. This is frightening, and may recur.
Phlebitis (inflammation in the veins and overlying skin)
Large or extensive varicose veins
A bulging / aneurysmal vein, manifesting as a visible swelling in the groin. This is called a Saphena Varix (name is derived from the Arabic for 'ship' i.e. a varicose vein that is clearly visible on the surface).
Many patients opt for the surgical option because they prefer to have the whole treatment completed in one sitting.