Conventional varicose vein surgery
Mr Paul Hayes MD FRCS
Mr Kevin Varty MD FRCS
Department of Vascular Surgery
Name of procedure: Surgery on the long saphenous varicose veins (in the leg)
Varicose veins are very common, affecting at least 10 to 15% of the adult population in the UK. This condition can be embarrassing and painful and, if untreated, can lead to leg swelling, pigmentation of the skin of the lower leg, and ulcers.
Here, we outline some of the benefits, risks and alternatives to the operation. We want you to have an informed choice to enable you to be involved in the decision-making process. Please ask your surgeon or the specialist nurse about anything you do not fully understand or wish to be explained in more detail.
You will be asked to read this form carefully and you and your doctor (or other appropriate health professional) will sign it to document your consent.
Surgery on the long saphenous varicose veins
The long saphenous vein starts at the groin, runs underneath the skin of the thigh and calf, and ends in the foot. In the groin, the long saphenous vein connects with the femoral vein (in the deep system of veins). At this point, a valve prevents high-pressure blood from the femoral vein entering the long saphenous vein. In varicose veins, this valve has become leaky.
- Depending on the arrangements made for you, you will be admitted to the ward one or two days before the surgery.
- The ward nursing staff will show you to bed and help you settle in. They will explain the preparations for the operating theatre, and show you where everything is.
- You must not have anything to eat or drink for at least six hours before your operation.
- Your surgeon will visit you before your operation to explain the procedure again and to answer any questions. Your surgeon will then mark the position of the veins on your leg using a highlighter pen. At this point you should indicate any veins that you particularly want removing and these will be marked.
- Generally, this procedure involves the use of general anaesthesia, which means you will not be conscious during the surgery. In some circumstances, the operation can be performed under local anaesthetic or regional anaesthesia. Your anaesthetist will discuss the anaesthetic technique with you before the operation.
The first part of the operation is to make an incision (cut) in the skin crease of the groin and find the junction of the long saphenous and femoral veins and then disconnect them.
The long saphenous vein is then stripped (removed) to just below the knee. Research studies have shown that this reduces the chance of the varicose veins growing back (called recurrent varicose veins). Surgeons no longer strip the vein to the ankle because in the lower calf the vein runs very close to a nerve that can be damaged by the procedure and can cause a numb foot. Instead, it is safer to remove any varicose veins in the lower leg by using multiple small incisions (2 to 5mm long) known as avulsions.
The groin wounds are then closed using self-dissolving sutures (stitches), which are inserted underneath the skin so they cannot be seen. The much smaller avulsion wounds usually heal well without any sutures; occasionally, paper ‘Steristrips’ are used to close these wounds. Very occasionally, a suture is required.
At the end of this operation, compression bandages are applied to the leg to prevent bleeding and bruising. The operation usually takes about 30 to 60 minutes for each leg but you might be away from the ward longer because all patients spend a minimum of half an hour in the recovery room while they wake up from the anaesthetic.
After the operation
When you return to the ward you might feel drowsy, but you should not feel any pain or sickness. If you do have any pain or feel sick, please tell the nurse who is looking after you and they will give you a painkiller or something for sickness.
As explained above, your leg will be bandaged firmly. You should remain in bed for the first 4 to 6 hours, and if you require anything, use the nurse-call button.
Later, when the nursing staff are happy with your progress, you may sit up and, later still, get out of bed under supervision. Once you have woken sufficiently, you can start drinking fluids again and have something light to eat.
Discharge from Hospital
The operation can be performed either as a day case or with an overnight stay.
Self-adherent compression bandages, or non-adherent crepe bandages, are removed after 24 to 48 hours.
Once the bandages are removed, you will be given a pair of compression stockings to wear for the next 2 to 4 weeks, or until the legs feel comfortable. The purpose of the stockings is to support the leg, to help blood flow through the deep veins of the leg and to reduce the amount of bruising and tenderness.
At night, the stockings can be removed if this is more comfortable. Bleeding through the bandages or stockings can occur; this is not unusual and is nothing to worry about. If this happens, please elevate the legs, apply continuous pressure to the point of bleeding for 10 to 20 minutes and it should stop. If you are still concerned, please call the daytime number for the hospital given to you on the information sheet, or you can call your GP.
The small avulsion wounds on your leg(s) will usually be closed with tape rather than sutures. The main wound at the top of the leg will be closed by dissolvable sutures underneath the skin. Try to keep these wounds dry for three days. After that, you may take a shower but try to avoid soaking the wounds in a bath until after 5 days. In water, the tape will come off the leg wounds but do not worry about this. Rarely, there might be some sutures to remove, and the ward nursing staff will arrange for this to be performed.
Returning to work and normal activities
- You will probably need 7 to 14 days off work. Please return when you feel comfortable.
- Avoid driving until you are pain-free and in full control of the vehicle (usually about 7 days).
- Walk as much as possible to keep the blood circulating in the leg. Avoid standing for any long period of time, avoid crossing your legs and elevate the legs when resting.
- You may resume sex when it is comfortable.
Intended benefits of the procedure
To remove the uncomfortable / unsightly veins from your leg, and prevent their growth or recurrence.
Some veins may remain at the end of the operation. Small thread veins can be injected to improve the cosmetic appearance of the leg.
Serious or frequently occurring risks
Removing varicose veins always produces some bruising and soreness. The severity of this depends on how many veins are removed. Sometimes, it can take several weeks for all the bruising to settle completely.
Because the main wound is in the groin, this area can become infected. If the wound becomes painful and red this can indicate infection, which can usually be treated by a course of antibiotics. The same applies to other wounds on the leg (avulsions).
Small nerves lying next to the veins can be disturbed, which can lead to patches of numbness in the lower leg and foot in 10 to 20% of patients. This usually resolves over the first year after surgery but occasionally, it is permanent.
Rarely, a deep vein thrombosis (blood clot; DVT) can occur in the deeper veins of the leg and, occasionally, this can lead to a pulmonary embolus (blood clot to the lung). Blood clots on the lung can be fatal. Thrombosis occurs in less than 1% of patients.
Varicose veins can grow back (recur), usually by regrowth of the veins. After 5 years, 10% of patients can have this recurrence.
Generally this operation is performed under general anaesthesia. A general anaesthetic allows you to be in a state of controlled sleep whilst your surgery proceeds. You will be unaware of your surgery and will feel no pain.
1. Your preoperative visit
- After your admission to hospital, the anaesthetist will come to see you and ask you questions about your health and may also examine you. You will be asked about your general health, any previous illnesses or operations, medications, allergies or adverse drug reactions, any problems with neck movement and mouth opening and whether you have any crowns on your teeth.
- Minor illnesses can cause problems for anaesthesia. If you have a cough, cold or other illness please let the anaesthetist know, as it may be better for you to recover from this prior to your surgery.
- It is very important that you follow the instructions you are given regarding eating and drinking. You are asked not to eat and drink anything for six hours before the operation, except for a glass of water up to two hours before the operation. This allows your stomach to empty by the time you already for surgery. With an empty stomach there is less likelihood of vomiting during or after your anaesthetic. You should let your anaesthetist know if you have a problem with hiatus hernia or acid reflux. You may also take some water to swallow your medication tablets.
2. Your anaesthetic
- You will be connected to a monitor and a small needle will be placed in the back of your hand. Drugs to start anaesthesia will be put through this needle.
- Once asleep, a tube will be placed into your breathing pipe and your breathing controlled. The insertion of this tube can often be difficult when neck movement is limited and it is sometimes necessary to use a special telescope to do this. You will be advised if this will be necessary at the preoperative visit.
- You will remain unconscious for the duration of your operation and you will be continuously monitored throughout this time.
- You will be given appropriate pain relieving drugs and fluids during your operation. At the end of your operation anaesthesia will be reversed and you will wake up in the operating theatre and then be taken to the recovery room.
3. Post Operative Care
- You will continue to be closely monitored in the recovery room to ensure that your vital signs are stable and that your pain relief if adequate.
- Pain relief is important, not only for your comfort, but also to allow you to move around in bed, breath deeply and cough. This is vital if you are to avoid problems of chest infections. If your pain is not well controlled, you must tell a member of staff.
4. What are the risks of anaesthesia?
- An anaesthetist is a doctor whose role is to care for all aspects of your health and safety over the period of your operation and immediately post operatively. Risks depend on your overall health, the nature of your operation and its seriousness. There can be complications, but serious complications are very rare indeed.
- An increased risk due to your personal health and circumstances will be discussed with you at the pre-operative visit.