RU2205601C2 - Method for low-invasive veinectomy of varicose veins - Google Patents

Abstract

FIELD: medicine, vein surgery. SUBSTANCE: one should isolate the trunk of large subcutaneous vein in area of oval fossa to apply ligature onto large subcutaneous vein. Through oblique-vertical incision one should introduce device for low-invasive removal of varicose veins consisting of working element in the form of unlocked ring. One should insert the major trunk of large subcutaneous vein into the ring of the above-mentioned device to move it along vein in subcutaneous-fatty fiber. Coagulation is carried out along with crossing all the inflows and additional branches along the whole large subcutaneous vein under visual control through device's ocular. Then, beginning from proximal additional branch one should carry out gradual crossing of branches at outflows. One should cross the major trunk of large subcutaneous vein at the site of its outflow at foot. After that it is necessary to remove the device and the whole large subcutaneous vein together with additional branches through oblique-vertical incision in inguinal area. EFFECT: improved cosmetic impact, decreased number of varicosis relapses. 6 dwg

Description

 The invention relates to medicine, namely to surgery.

 Among the diseases of the vessels of the lower extremities, varicose disease takes the first place (Burakovsky V.I., Bokeria L.A., 1989; Savelyev V.S., 1999). Vein diseases are widespread among the population, often causing disability, and sometimes disability. According to H. Dodd, F.B. Cockett, varicose veins (HRV) of the lower extremities are found in every fifth woman. In Russia, approximately half the population suffers from varicose veins, especially after 30 years of life. In hospitals, patients with varicose veins constitute 2-3.3% of the total number of surgical patients. And relapses of varicose veins after surgical treatment reach 75% in general surgical hospitals and 9.6% in specialized departments (Razumeiko A.V., 1997).

 Modern medicine offers a wide range of treatment methods: from local conservative therapy to surgical.

 The main disadvantage of sclerotherapy is its low efficiency with a vein diameter of more than 12-15 mm, and with degeneration of the vein wall, which leads to the disappearance of the ability of the veins to collapse. Poor contact of the sclerosant with the walls of the vein causes a weak inflammatory reaction of the endothelium, insufficient proliferative activity of the connective tissue and, as a result, a rapid relapse of the disease, negating all the efforts of the doctor, and invalidating the treatment method in the eyes of the patient. The most common cosmetic drawback of combination phlebosclerosis therapy is hyperpigmentation of the skin due to sweating of the sclerosant through the vein wall. According to world literature, persistent hyperpigmentation of the skin can persist in 25% of treated patients.

 There is a method when, with the help of an endoscope inserted into the lumen of a vein, sclerosing or coagulation of failed venous inflows is carried out under visual control (V. Bogachev, “Endoscopic technique in phlebology.”, Magazine “Difficult and cardiovascular surgery”, 1994 ., 4, pp. 67-71). But this is an expensive method for which all the shortcomings of sclerotherapy are characteristic, namely, a possible relapse of the disease due to poor contact of the sclerosant with the venous wall and the persistent intervention that is necessary when medications, wearing elastic stockings can no longer help. Modern social conditions and the desire of people to maximize their ability to work with the lowest material costs prompts the search for the most economical, but no less effective methods of treatment than traditional surgical interventions. Medical and technical improvement of vein surgery entails an increase in the requirements for the functional-cosmetic result of surgery for varicose veins. The high relapse rate after the initial successful operation and the frequent formation of a non-treatable leg ulcer caused the need for special surgical methods for vein surgery.

 The basis for the treatment of HRV is “sclerotherapy” as a treatment method based on quick, irreversible damage to a chemical substance of all layers of the venous wall with the development of thrombosis and subsequent permanent and stable connective tissue obliteration of the vein (Belyaev M.V., Outpatient treatment of varicose veins, Novosibirsk 2000 g ., p. 12). Phlebosclerosis is combined with subcutaneous temporary or permanent flashing of the vein, with endoscopic clips on the inconsistent perforating veins of the thigh and lower leg.

 Hyperpigmentation, as well as this method can only be used in patients with the main type of the saphenous vein (BPV) structure, provided that the diameter of the BPV allows an endoscope to be inserted into it, which of course limits the scope of this method.

 A known method of endoscopic subfascial dissection of perforating veins, when using special instruments introduced into the projection of pathologically changed veins under the control of a rigid endoscope, perforating veins are extracted and intersected in a small area accessible from a single skin incision (approximately 20 cm long). Skin incisions are performed in the projection of pathologically altered veins, since there are several changes, then the incisions are made according to their number. Vienna is not removed. This toolkit includes: direct-vision optics with a working shaft, thin and wide split Manhares bipolar forceps, split Manhares scissors, tools for gentle preparation of vessels according to Dr. Fischer (hand tools with olive, with a spike, with a blunt spatula and hook) . / "Varikosis und chronische Venenmsuffizienz in der Praxis", Sigva - ris, 2. Auflage 1994, by Ganzoni & Cie AG, St. Gallen / Switzerlend, s. 22-23 /.

 The disadvantage of this method is the high invasiveness of exposure to subcutaneous structures, as well as a large number of skin incisions that significantly reduce the cosmetic effect. This method can be applied in case of insolvency of single perforating veins, provided that the BPV valve apparatus is viable, and has a narrow scope.

 Closest to the claimed is the generally recognized surgical treatment of CVT according to the Troyanov-Trendelenburg-Bebkok method, when an oblique vertical skin incision of 3-4 cm is made into the groin in the projection of the mouth of the great saphenous vein, the trunk of the UCV in the oval fossa is highlighted, the ligature is applied to the UV at the place of its entry into the femoral vein, the BPV itself is cut off and taken to the turnstile, and the oval fossa is sutured, then, through one or more incisions into the lumen of the varicose vein, a venextractor probe is inserted, with which the available distance is the isolation and ligation of the BPV trunk, as well as the ligation of its tributaries, removal of a vein from the subcutaneous tissue. From individual accesses, a ligation of insufficient perforating veins is performed (A. Shalimov, I. I. Sukharev, “Vein Surgery.” Kiev, Zdorovya, 1984, pp. 177-179).

 The probe is a veneractor that starts blindly, and often instead of the main trunk, it enters the additional branch of the large saphenous vein (BPV). The small inflows of the ventilator lobes are cut off, insolvent and perforating veins remain unligated, and the distal segments of the ventilatory dysfunction on the lower leg remain not removed. All these shortcomings are the cause of relapse of the disease. The use of the probe requires additional skin incisions, which affects the cosmetic effect of the operation. Removing veins with a probe is possible with the main structure of the vein, and is difficult if there is a pronounced expansion of it, which limits the application of this method.

OBJECT OF THE INVENTION
Increasing the effectiveness of surgical treatment of BPH and reducing the number of relapses, increasing the cosmetic effect of the operation, the possibility of surgical minimally invasive treatment of BPH with a diameter of dilated veins of 10 or more millimeters.

 The task is achieved by the fact that through a oblique vertical incision, a venectomy device is introduced and it is carried out externally along a vein in subcutaneous fat, under its visual control, coagulation and intersection of all tributaries along the entire BPV and its additional branches at the place of their inflow are carried out, and additional branches are distinguished to the place of their source and coagulate there, but do not cross until the main trunk of the BPV is completely isolated and released from tributaries, and only then, starting from the proximal additional branch, they are transformed cross-section at the source, at least intersect the main trunk of the great saphenous vein at the site of its source on the foot, the device and all of the great saphenous vein with additional branches are removed through a skin wound.

NOVELTY OF THE INVENTION
1. Isolation and removal of varicose veins is performed using a device that is advanced externally along a vein in subcutaneous fat throughout its length.

 2. Carry out coagulation and intersection of all tributaries at the places of their confluence along the entire BPV and its additional branches.

 3. Additional branches of the BPV are isolated to the place of their source and coagulate there, but do not cross. Coagulate the source of BPV on the foot.

 4. Starting from the proximal additional branch, make a sequential intersection of all branches at the source, then cross the main trunk of the BPV at the place of the source on the foot.

 5. The device and all the selected BPV with additional branches are removed through an oblique vertical section.

 The invention is illustrated by drawings, which depicts the steps of the operation to remove varicose veins: figure 1, 2, 3 shows the allocation, passage and intersection of the tributaries of the vents; figure 4, 5 shows the allocation and bypassing additional branches of the BPV. Figure 6 shows a device developed by us for minimally invasive removal of HRV (application 2001105462/005533 with priority dated 6.02.01 has been filed). The electrical connector of the device is connected to the output of the general surgical device EHF (Olympus OES PSD), set to 5 units of scale in mixed mode. And the device itself is connected to a standard illuminator (Olympus CLE-10), the device has a working element in the form of an open ring and a monopolar electrode in the form of tongs.

BACKGROUND OF THE INVENTION
1. The device used has a working body in the form of an open ring, allowing you to enter it subcutaneously and advance along the entire vein, isolating it from subcutaneous fat. It allows you to visually control the process. Cross the tributaries, the size of which reaches 5 mm at the place of their confluence and their coagulation. The design of the working body allows you to skip the mouth of the additional branches, the size of which is more than 5 mm, and pass along them, highlighting them and cutting off the tributaries, less than 5 mm from the place where the additional branches flow into the BPV to their source. Then the device returns to the place where the additional branch flows into the BPV and again moves along the BPV to the next branch, which is processed similarly to the first branch, and so on to the source of the BPV in the foot.

 2. Coagulation and intersection of all tributaries up to 5 mm in size is carried out along the entire BPV and along all its additional branches having a size of more than 5 mm, this is done in order to prevent blood from entering the BPV and to isolate the trunk of the BPV together with additional branches.

 3. Additional branches of the BPV coagulate at the source, but do not cross in order to prevent blood from entering the BPV and return the device to the main trunk of the BPV.

 4. Coagulate the source of the BPV on the foot, but do not cross, since the device returns to the additional branches along the trunk of the BPV.

 5. Begin the intersection of the sources of the additional branches, moving from the proximal branch so that the cut off branches do not interfere with the further advancement of the device.

 6. Cross the main trunk of the BPV at the place of its source on the foot, this is done in the last turn, since the trunk itself serves to conduct the device along it at all stages of the operation.

 7. The venous trunk is removed through a single incision on the thigh, because the trunk and veins are separated from the subcutaneous fat throughout due to the repeated passage of the working organ along them, the tributaries are coagulated and cut off at the places of flowing, additional branches are coagulated and crossed at the source, the main BPV is coagulated and cut off at the source on the foot. All this allows you to very cleanly and easily remove a vein from a single cut in the foot, preventing breakages and leaving fragments of BPV in the subcutaneous fat, as well as reduce intraoperative blood loss. The proposed method allows to significantly increase the efficiency of the operation to remove varicose veins due to the complete isolation and removal of BPV with all its additional branches, which is achieved by preparation of the BPV system under clear visual control while passing the ring of the working element of the device along the removed vein in the subcutaneous fat, which is dull It divides the surrounding tissue, as well as due to the separation of the superficial and deep vein systems using electrocoagulation, which is the basis for the prevention of relapse.

DESCRIPTION OF THE METHOD OF OPERATION
In the projection of the mouth of the great saphenous vein into the groin, an oblique vertical section of the skin is made 3-4 cm long. Next, the site is prepared for the introduction of the instrument. The BPV trunk is distinguished in the region of the oval fossa, a ligature is placed on the BPV at the place of its inflow into the femoral vein, the BPV itself is cut off and taken to the turnstile, and the oval fossa is sutured: through the oblique vertical incision with the finger, the BPV trunk is ligated and intersects all the tributaries that Reachable from dermal access. Then, the distal part of the device, 2, is inserted into the wound, and the main BPV trunk is inserted into the ring of the working part 5 through the slot (Fig. 1). In places where the device is in contact with the edges of the skin, it is isolated from it with gauze napkins, smeared with an inert ointment, to create a seal and prevent injury to the edges of the wound when the apparatus is advanced. The edges of the wound, also to create a hermetic, are stitched with separate seams, the knots are tied to a bow. The limbs are given an elevated position at an angle of 30 degrees so that the blood flows to the injection site of the device and does not interfere with the examination of the surgical field. Further advancement of the apparatus is carried out progressively with the help of hands under visual control through the eyepiece of the device, thereby achieving the isolation of the main BPV trunk from surrounding tissues. When appearing in the field of view of the inflows of the vents with the help of screws - 10 and the apparatus rotates along the axis, this vein is installed against the instrumental channel and captured by instrument - 6 (Fig. 2), to which a mixed mode current of 5 units of the EHF apparatus scale is applied at that moment (Olympus OES PSD), which provides effective coagulation with simultaneous intersection of the vein (Fig. 3, the current strength was empirically selected). When additional BPV branches appear in the field of view (their diameter is more than 7 mm), the ring - 5 is installed in the place of their discharge so that the slot is on the side opposite to the branch location (Fig. 4). Then the apparatus is given translational movement, due to which only an additional branch remains in the ring (Fig. 5), and then the process described above is repeated until the source of this branch appears in the field of view, where the branch coagulates, but does not intersect. The device is displayed on the main trunk of the BPV, where again the intersection of the tributaries to the source of the BPV on the lower leg is performed. At this point, the source of BPV is coagulated for 10 mm. Then the device returns to the source locations of the additional branches of the BPV and, starting with the proximal, they intersect in the "cutting" mode. Lastly, the main trunk of the BPV crosses at its source on the foot. The apparatus can be promoted by directing its distal part with your hand, directly through the skin. When the entire BPV is isolated and crossed, it is removed along with the apparatus through the skin wound, and bandaging of the lower limb is performed simultaneously, starting from the foot. The seams on the skin open and gauze wipes are removed along with blood clots. A wound toilet is made with a 1% hydrogen peroxide solution. Stitches are tightened on the skin. A sterile cloth is applied.

CLINICAL EXAMPLE
Patient S., 48 years old, serving, suffers from varicose veins for 10 years. From the anamnesis: in 1997, sclerosis of the BPV of the right lower limb was performed, 11 months after this, the patient again had the same complaints. In February 2001, she was operated on with a device for minimally invasive venectomy under general anesthesia. The duration of the operation was 1 hour 15 minutes. The patient’s BPV was represented by the main trunk with a diameter of about 11 mm, and two additional branches 12 and 7 cm long, along the main trunk 31 inflows were coagulated and crossed, on the additional branches 4 and 2. Through the oblique vertical incision, the trunk was highlighted in the groin BPV in the region of the oval fossa, then 5 inflows of BPV reached from the skin incision were identified, ligated, and crossed, a ligature was placed on the main trunk of the BPV at the site of its inflow into the femoral vein, the trunk of the BPV was taken to the turnstile and cut off. A venectomy device was inserted subcutaneously through the incision, and then the operation was performed using this device under its visual control through the eyepiece: with the translational movement of the device, the ring of its working part separated the BPV trunk from the surrounding tissues, while 3 inflows were coagulated and crossed when the device was started at a distance of 20 cm, the first additional branch appeared, the device was transferred to the branch itself, while advancing the device along the additional branch, 4 tributaries coagulated, at 32 cm the branch was coagulated for Preventing blood flow in the GSV, but we have not crossed for the device to be returned to the main trunk of the GSV. Before the appearance of the second additional branch in the field of view, 2 tributaries coagulated. The second additional branch is highlighted for 7 cm, coagulated, but not crossed, the device is returned to the main trunk of the BPV. After passing the device along the main trunk of the BPV, 16 more tributaries were coagulated and crossed. The main BPV trunk at the source location on the foot is coagulated, then the device was returned to the source location of the proximal additional branch and made its intersection, the device was transferred to the main trunk, along it went to the source of the second additional branch, which crossed at this place. Lastly, they crossed the main trunk of the BPV at the site of its source on the foot, the device and the entire BPV with additional branches were removed through the skin wound. Blood clots were removed from the wound canal. The edges of the wound are reduced by skin sutures. Aseptic dressing.

 The postoperative period was uneventful, the postoperative sutures were removed on the 7th day, on the 8th day the patient was discharged from the hospital and wore an elastic bandage for two months. Examined 3 months after the operation: the patient does not note any complaints, recurrence of varicose veins is not noted.

 Using our method, we operated on 5 patients with varying degrees of HRV, the maximum follow-up period was 6 months, and no one recurred the disease.

 Thus, the proposed method of venectomy using a tool for minimally invasive venectomy allows sparing and radical treatment of HRV in patients who are not amenable to sclerotherapy, as well as with relapses after it, and all patients who are indicated for surgical treatment. We also see the possibility of using this method of venextraction in obese patients, when dissection of deep perforating veins is difficult, and in patients with allergies to sclerosing agents, when sclerotherapy cannot be performed. The number of relapses after the proposed method of operation is significantly reduced, since the entire BPV is completely removed along with its large branches, and the perforating veins are coagulated and intersect. The cosmetic effect of the method is maximum due to a single cut in the groin.

Claims (1)

 A method for minimally invasive venectomy of varicose veins, including an oblique vertical incision in the groin, isolation of the trunk of a large saphenous vein in the oval fossa and ligation of its tributaries, ligation of the large saphenous vein, its intersection at the site of flow into the femoral vein and at the source, characterized in that through the specified oblique vertical incision, a device for minimally invasive removal of varicose veins with a working element in the form of an open ring is inserted, the main trunk of the large saphenous vein is inserted cut a cut into the ring of the specified device, advance it along the vein in the subcutaneous fat, coagulate and intersect all the tributaries and additional branches along the entire large saphenous vein under visual control through the eyepiece of the device, and the additional branches are isolated to the place of their source and are not coagulated there crossing, coagulate the source of the great saphenous vein on the foot, then, starting from the proximal additional branch, sequentially intersect the branches at the source, cross the main trunk of the large saphenous veins at the place of its source on the foot, after which the device and the entire large saphenous vein with additional branches are removed through the indicated oblique vertical incision.

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