Extra-fascial ligation of incompetent perforators via mini-incisions, under local anaesthesia

ABSTRACT

Reflux of the venous blood outwards through incompetent perforators may be primary or secondary [post-thrombotic], with resultant liposclerosis, eczematization, pigmentation, edema and ulceration. The main objective of managing these cases is preventing the transmission of deep venous pressure to affected skin areas by perforator interruption. Initially this was achieved by long incisions whether medial lateral or posterior and direct perforator ligation subfascially. Pre-operative color duplex localization and skin marking of the incompetent perforators, followed by assessement of the efficacy, convenience and wound complications of a simplified method to ligate them extrafacially through mini incisions under local anaesthesia. Eight hundred incompetent perforators in 184 limbs in 102 patients with chronic venous insufficiency with ulceration. Inclusion criteria was the presence of non liposclerotic skin at the skin mark or within 2 cm of it. Local infiltration of the chosen skin site with Xylocaine 2%, 2-2.5 cm incision is made in the skin. Using small retractors with gentle dissection to find the perforator, aided by gentle finger dissection. Following the perforator down to the fascia to make sure it has no other branches. Ligation and division of the perforator. A compression bandage is applied from toes up to knee level. Follow up of the patient for 12 month post operative for ulcer healing and for wound complications. It was observed that the site of incompetent perforators in 22.3% of limbs did not match the location of ulcer in the same compartment. Such a phenomenon may result from its connection with another muscular vein branch [a deep communicator] with a remote surface emergence in another compartment. Early procedure complications were incision wound break down [5.38%], and sepsis [7, 88%]. It was observed that there is an individual variability in patient's tolerance to venous congestion sequalae, also edma, after ligation of all incompetent perforators, may be responsible for incomplete ulcer healing without any new perforator incompetence. Extra-fascial ligation of incompetent perforators under local anaesthesia has the advantage of; patient satisfaction is high, post operative ambulation is fast and most of them could resume daily activity within 3-4 days. It is also economic and a large number of cases can be done within a short time