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RECENT ADVANCES
DR.MATHISEKARAN.T
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RECENT ADVANCES IN
MINIMALLY INVASIVE SURGERYFOR VARICOSE VEINS
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INTRODUCTION
VARICOSE VEIN AFFECTS A SIGNIFICANT
PERCENTAGE (40%) OF MIDDLE AGED
POPULATION.
ITS IMPORTANT TO LOCALIZE THE
PROBLEM BEFORE SURGICAL
MANAGEMENT.
CLINICAL EXAMINATION-
90% SENSITIVITY FOR SAPHENOFEMORAL JN
61.5% SENSITIVITY FOR PERFORATOR
INCOMPETENCE
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ENDO-VENOUS THERAPIES KEYHOLE
THERAPYSCLEROSE OR BURN THELEAKY VEIN CLOSE TO VALVE JUNCTIONS.
HEAT SOURCE
LASER RADIOFREQUENCY
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DIVISION OF INCOMPETENT PERFORATING
VEINS REGARDED AS APPROPRIATEAPPROACH FOR TREATMENT OF VENOUS
STASIS ULCERS.
NOW,SEPSSUB FASCIAL ENDOSCOPICSURGERYIMPORTANT PART OF
SURGICAL ARMAMENTARIUM FOR VENOUS
ULCERS.
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PATHOGENESIS
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Pathogenesis
MAIN CAUSE : Persistent chronic ambulatory
venous HTN.
Prevalence of venous ulceration:0.1 0.3%.
Cutaneous venous hypertension occurs as a
consequence of primary valvular incompetence in
60% of patients.
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Clinical features
C 0 NO VISIBLE SIGN OF VENOUS DISEASE
C1 TELANGIECTASES AND/OR RETICULAR
VEINS
C2 VARICOSE VEINS
C3 EDEMA
C4 CHANGES IN SKIN AND SUBCUTANEOUS TISSUE
A PIGMENTATION OR ECZEMA
B LIPODERMATOSCLEROSIS OR ATROPHICBLANCHE
C5 HEALED ULCER
C6 ACTIVE ULCER
Clinical classification is based on CEAP reporting system
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Clinical features
Sensation of heaviness and itching
Cramps and aching
Visible varicosed vein
Cutaneous skin breakdown over medial
malleolus
Complications :
Bleeding
Phlebitis
ulceration
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Indications for surgery
-cosmetic reasons
-chronic venous insufficiency-superficial thrombophlebitis
-bleeding
-anxiety
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Contra-indications
Previous deep vein thrombosis
Major lower limb fracture
Prolonged immobilization
white leg of pregnancy
Arterial insufficiency -relative
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Surgical aspects
Informed consent
Warned of possible complications
Minor hemorrhage
Track thrombophlebitis
Hematomas
Infections
Lymph leak.
Injury to sural or saphenous nv
Permanent lymphoedemaThromboembolism
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Common surgical procedures
Sapheno-femoral ligation
Stripping of long saphenous
vein
Multiple avulsionsSapheno-popliteal ligation
Perforator ligation
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Sapheno-femoral ligation Identification of long saphenous vein Superficial tributaries dissected
Followed back to secondary branches
Divided and ligated
Stripping of long saphenous vein
Reduces rate of recurrence Not universally performed
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Multiple avulsion-Small 3-5 incisions made-vein retrieved with phlebotomy hook
-avulsed.
-avulsions may be closed with steristrips
Sapheno-popliteal ligation
-location of sapheno-popliteal is veryvariable
-pre-operative Doppler or duplex scanning is
important.
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Perforator ligation:-significance of this surgery remains unclear
-surgery designed to divide perforating
veins COCKETT and
LINTONconsiderable morbidity.
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R t Ad
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Recent Advances
Endo-venous therapies(keyhole therapies)
R t Ad
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Recent Advances
Endo-venous therapies(keyhole
therapies) Sclerosing or burning the leaky vein close to valve
junctions.
The heat for burning the vein is provided by laser orradio frequency.
Less painful procedure.
The results are good and better than surgery.
The endovenous thermal ablation restores the normalblood flow towards the deep system.
The success rate is 93 -95%
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Subfascial endoscopic surgery(SEPS)
Procedure:
The patient in supine position
Esmarch bandage is tightly applied and a
sterile tourniquet is inflated high up on the
thigh.The esmarch is then removed.
A 10 mm endoscope is laid on the leg
A 13 mm skin incision is made 3cm from
the medial margin of tibia.
10mm opticview port with the scope is
inserted.
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It is rotated to reach the white fascia
Then the underlying muscles are exposed. At this point, the subfascial space has been
entered.
It is angled towards the patients foot and
advanced into this space. The scope and the inner cannula are removed
And CO2 insufflated to 30mm/hg pressure.
The scope is then reinserted into the port.
The second port is placed 5-10cm from the first
and approximately the same level.
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The endoscissors are inserted through 2nd port and
subfascial space opened. After creating the optical cavity, larger perforating
vein is clipped and divided.
Space is opened from medial tibial border to midline
posteriorly From the level of port to as far distally as dissection
can comfortably proceed
Paratibial fossa should be opened sharply so that
additional perforating veins can be divided in deepposterior compartment.
Cautionto avoid injury to postr tibial art,vn and tibial
nerve
DISCUSSION
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DISCUSSION
CLASSICALY VASCULAR SURGERY REMAINED
RELATIVELY AWAY FROM ENDOSCOPICTECHNIQUES
SEPS represents a safe,easily mastered technique for
vascular practitioner to enter ENDOSCOPIC world.
LINTON PROPOSED:
Patients with perforator incompetence treated directly by
dividing offending perforators.
Long incision had to be made85% patients enjoyed ulcerfree recurrence in long term.
Complicationsinfection, flap necrosis, delayed healing.
Minimally invasive surgeryre-evaluation of the procedure
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HAUER IN GERMANYmechanical system for
endoscopic subfascial surgeryto date has thegreatest experience.
ODONNELL OF USAemployed saline infusion
adequate optical space.
GLOVICZKI OF USAemployed CO2 insufflation
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APPROPRIATE PATIENTS FOR SEPS:
Active ulcersRecurrent ulcers
Healed ulcer present >4months.
It is advisable to synchonously treat superficial reflux by
stripping while also perrforming SEPS,if perforater
competence was documented.
Underlying pathophysiological process is
best documented by color flow duplex
scanning
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LASER/RADIOFREQUENCY
ABLATION SYSTEMS
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ELVeS Endo Laser Vein System is a
minimally-invasive laser treatment forIncompetent Saphenous and Accessory Veins a
problem which often leads to the formation of
varicose veins. ELVeS takes approximately 30
minutes and requires only local anesthesia allowing
patients to walk home after treatment. With virtuallyinstant relief from Venous Reflux and Venous
Hypertension, patients can return to their normal
lifestyle and activities immediately following
treatment.
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Benefits of ELVeS for varicose veins
& spiderveins:
Endovenous Laser Therapy ELVeS is a minimally
invasive laser vein treatment for damaged incompetent
veins. ELVeS requires no incisions, leaves no visible
scarring and with minimal postoperative pain recoveryperiods are quick and minimal.
Treatment in less than an hour in office with no general anesthesia or hospitalization.
Up to 98% success rate.
Immediate relief of symptoms.
Return to normal activity immediately with little or no
pain.
No scars.
CONCLUSION
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CONCLUSION
-minimal morbidity.
-out patient basis.
SEPS represents a promising new
approach to ulcer management in
patients with perforator
incompetence
NASEPS committee is warranting continued
evaluation, focusing in incidence of
recurrent ulceration and ultimately standard
evaluation of ulcer therapy
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THANKYOU