How ambulatory phlebectomies are performed?
As explained before, it is very uncommon that phlebectomies are performed by themselves. Very occasionally, duplex ultrasonography shows that there are isolated varicose veins dilated and just under the surface of the skin that are not being fed by any other refluxing veins and that do need treatment by phlebectomies alone. However this is really quite uncommon, and is usually followed by a course of sclerotherapy for surrounding veins.
Therefore for the majority of people undergoing phlebectomies, they are either having another endovenous procedure performed at the same procedure or, may have had a local anaesthetic endovenous procedure performed previously and have returned for local anaesthetic ambulatory phlebectomies.
As with all good vein surgery nowadays, phlebectomies are performed under local anaesthetic on an outpatient basis.
The patient is stood up and lumpy varicose veins are marked on the skin. Even with all our latest technology, at the end of the day it is still important to identify exactly which veins bulge on standing and to ensure that these are removed as part of the procedure. Simply standing the patient and marking the veins with an indelible pen is still one of the most effective ways of achieving this.
In many cases, the patient is then also scanned with a duplex ultrasound to make sure that any other veins that may be close to bulging when the patient is standing are also marked for removal.
The patient’s leg is cleaned and a sterile operating field is made.
- Once the underlying cause of the reflux has been fixed, the varicosities (dilated varicose veins) need to be removed.
If they aren’t they will clot, causing thrombophlebitis (hard painful lumps that can leave brown stains on the skin)
The surgeon or assistant then injects local anaesthetic solution around all of the marked veins using a very large volume of solution. Many vein clinics now use pumps to do this as they tend to be gentler and cause less pain. This solution usually contains local anaesthetic to numb the area and also a vasoconstrictor such as adrenaline or epinephrine which causes the veins to contract and reduces bleeding and bruising. There are several different solutions that can be used, but one of the most popular is the “Klein solution”. When local anaesthetic solutions are injected around the veins, it is often called “tumescent anaesthesia” as the fluid usually makes the skin and underlying tissue quite turgid.
To further reduce any bleeding or bruising, the operating table is then tipped “head down” so the patient’s head is lower than their ankles. In this position, blood drains out of the leg veins by gravity.
- Phlebectomies start with a 1-2mm incision with a small blade
Once this has been done, very fine blades can be used to make tiny holes in the skin, each usually less than 3 mm in length. Hooks are then put through these incisions and the target veins are “hooked” up and out of these little holes. When the vein emerges, it is seen to be pearly white. Most people tend to think of veins as blue or green. However, when they have no blood in them, veins are in fact bright white.
Fine clips are then used to tease the vein out through the incision, removing as long a length of vein as possible.
- During phlebectomies of varicose veins, a dilated vein is removed with a small hook through a tiny incision
Once all of the target veins have been removed, the multiple tiny incisions can be closed with a small sticking plaster each – the incisions being too small to need stitches. A bandage is placed on the legs which is usually only needed overnight to make sure there is no bleeding onto the bed sheets. Patients are usually discharged wearing compression stockings which can be worn for a variable amount of time depending on comfort.
Next page: Alternatives to phlebectomiesThis website was last updated on 11/10/16.