Anomalies encountered during varicose vein surgery.

During 5,050 stripping operations for varicose veins, three noticeable deviations from the normal anatomy were encountered. In two patients (0,04%) the long saphenous vein entered the femoral vein completely separate from its branches, which joined to form a common trunk before emptying into the femoral vein. In one patient (0,02%), the femoral vein and artery were transposed in the region of the fossa ovalis. In one patient (0,02%), a long saphenous artery was encountered. It arose from the femoral artery just proximal to the origin of the deep femoral artery and accompanied the long saphenous vein along the medial aspect of the upper thigh. In some patients, a large venous cluster overlying the fossa ovalis was encountered, usually the result of a congenital venous anomaly. Surgical problems can be minimized if the possibility of these congenital anomalies is always considered.

New self-retaining retractor to facilitate surgical exposure.

This new self-retaining retractor has blunt prongs that grip firmly but cause minimal trauma. A widely curved arc permits wide separation of the blades. Because the retractor is relatively long and heavy, it sits snugly within the wound, and the base is out of the surgical field. The extra length of the instrument permits considerable upward retraction of the central blade.

The short saphenous vein.

If an incompetent short saphenous vein is overlooked during an operation, varicosities invariably recur. A flush saphenopopliteal venous ligation is essential, since it is difficult to eliminate marked valvular insufficiency at this site by injections of a sclerosing solution. The prone position affords excellent exposure of the saphenopopliteal junction. Since the anatomy varies greatly, a flexible approach is desirable. If the anatomy is straightforward and the junction is close to the popliteal space, a transverse skin incision affords excellent exposure and heals well. Although it does not heal as well, a vertical or S-shaped incision is advisable in more complicated instances because it provides better exposure. If all valvular insufficiency is corrected at operation and the patient checked annually so that any new varices can be eliminated by injections, the leg should remain free of varicose veins.

Anomalies encountered during varicose vein surgery.

During 5,050 stripping operations for varicose veins, three noticeable deviations from the normal anatomy were encountered. In two patients (0.04%) the long saphenous vein entered the femoral vein completely separate from its branches, which joined to form a common trunk before emptying into the femoral vein. In one patient (0.02%), the femoral vein and artery were transposed in the region of the fossa ovalis. In one patient (0.02%), a long saphenous artery was encountered. It arose from the femoral artery just proximal to the origin of the deep femoral artery and accompanied the long saphenous vein along the medial aspect of the upper thigh. In some patients, a large venous cluster overlying the fossa ovalis was encountered, usually the result of a congenital venous anomaly. Surgical problems can be minimized if the possibility of these congenital anomalies is always considered.

Technique for operation upon recurrent varicose veins.

At the time of a secondary operation, every effort should be made to avoid scar tissue from the previous operation. The procedure is relatively simple, if carried out through clean tissue. If an attempt is made to mobilize an incompetent saphenofemoral junction through scar tissue, the procedure can be time-consuming and exceedingly difficult because of the thick scar tissue and thin, friable recurrent varices. In the majority of secondary operations, it was found that the long saphenous vein had not been ligated flush with the femoral vein. In some patients, the long saphenous vein had been ligated properly, but the short saphenous vein or incompetent perforators had been missed. If all venous insufficiency is eliminated at its source, the surgical result should be excellent. Any postoperative residual varices can be eliminated by injections of sclerosing solution. Annual examinations are essential so that if any new varices appear, they can be obliterated by injections.