A Peroperative Study on the Anatomical Variation at the Saphenofemoral Junction

ABSTRACT

Introduction: The term varicose is derived from the Latin word meaning – “dilated.” Varicose veins are defined as dilated, usually tortuous, subcutaneous veins 3 mm in diameter measured in the upright position with demonstrable reflux .Although varicose veins were identified prehistorically, only in the present century, considerable knowledge has been gained concerning the anatomy of venous system of the leg, the physiological mechanism of venous return to heart against gravity, and pathology of the disorder, which has led to many newer treatment modalities. One of the pitfalls in venous surgery lies in inadequate knowledge of the venous physiology and anatomy. In contrast to the anatomy of the arteries, the anatomy of veins is characterized by numerous variations.Hence, a thorough and precise knowledge of the anatomical variations of the great saphenous vein (GSV) and SFJ determines the successful outcome of surgery. Materials and Methods: A descriptive study was carried out on 90 patients who were operated for varicose veins in the Surgery Department, Sree Gokulam Medical College and Research Foundation, Venjarmoodu, Trivandrum, during the period of October 2012– April 2014. All patients were examined clinically after taking a detailed history. They were investigated by ultrasonography venous Doppler to confirm the diagnosis. They were subsequently posted for surgery, the intraoperative findings of which were recorded by measurement and photographs. Patients with recurrent varicose veins and perforator incompetence without saphenofemoral incompetence were not included in the study. For those patients posted for surgery, written informed consent was obtained from each patient and basic patient data were recorded in the pro forma. During surgery, documentation of the following intraoperative findings was done • Measurement of the SFJ from the pubic tubercle. • Description of the tributaries that drain into GSV. • Presence or absence of duplex veins. All details regarding SFJ and tributaries were documented through photography and further analysis was done using standard statistic techniques. Results: During the study period, 90 cases of varicose veins were enrolled in the study, of which 35 were male and 55 were female. These patients were evaluated by clinical examination, investigations, and peroperative recording of the findings in the pro forma and the following interpretations were made and compared with other studies. Conclusions: The purpose of the present study was to assess the position of the SFJ in relation to the pubic tubercle and identify the various tributaries draining into the terminal part of GSV. During the allotted period, 90 cases of varicose veins of the lower limb were studied in detail. Analysis of the findings recorded has enabled this study to arrive at the following conclusions: • The position of SFJ junction is highly variable and should always be marked preoperatively using Doppler. The average measurement of the SFJ from the pubic tubercle was 2.1 cm below and 4.4 cm lateral to the pubic tubercle. There was considerable variation in the number and anatomical course of the tributaries draining into the terminal part of GSV. The most common tributary identified in the study was the superficial epigastric vein and the least identified tributary was the posteromedial vein. Duplication of varicose veins was observed in 9% of the cases. In conclusion, adequate knowledge of the anatomy of the tributaries at the SFJ and ligating them in combination with GSV stripping is associated with a lower rate of the recurrence of varicose veins and a better quality of life. It is always imperative to explore the first 5 cm of GSV precisely to identify all tributaries at the SFJ (about four tributaries by average) to ensure appropriate surgical technique