Surgery has been the mainstay of treatment for centuries. It involves any combination of:
- Ligation of the great or small saphenous veins and tributaries in the groin or behind knee.
- Stripping of lengths of the saphenous veins between two small incisions.
- Avulsion of enlarged superficial veins through multiple tiny punctures.
Because the great saphenous vein is close to a major surface sensory nerve below knee, great saphenous stripping is limited to between the groin and knee. Similarly, the small saphenous vein is associated with its sensory nerve below knee so that stripping of the small saphenous vein is avoided. Ligation alone is associated with far worse results than ligation and stripping. Accordingly, surgery for the small saphenous vein gives poor results and is no longer recommended by our group. More information »
Both legs can be treated at the one operation. Larger incisions are closed with a suture under the surface and small incisions are left open to limit bruising and to give the best appearance. Long-term studies show that there is approximately 30% recurrence after great saphenous vein stripping, but these can be well treated by ultrasound-guided sclerotherapy before they become too large. We no longer advise surgery for the small saphenous vein or repeat surgery for recurrent varicose veins after past surgery as results are too bad and complication rates are too high.
What should you do before surgery?
- Do not apply moisturiser to your legs on the day of treatment.
- Wear slacks or loose trousers and sandals or loose shoes to allow for the thickness of the bandages after discharge.
What happens during the admission for surgery?
- You are admitted to hospital during the morning of the operation.
- You need to fast for 6 hours prior to operation.
- The anaesthetist will assess your general health. You may be given a premedication for sedation before going to theatre.
- The legs are shaved in the ward.
- Veins are marked out by Texta colour immediately before operation.
- The anaesthetic is given in the theatre through a small needle in the hand.
- You will wake in recovery remembering little about the experience.
- An intravenous infusion may be in place in the arm but you should be able to eat and drink soon after. An injection may be required to prevent postoperative nausea and relieve early pain.
- The legs will be firmly bandaged.
- By the following morning, you will be encouraged to walk.
- You must have someone to drive you home after operation for it is not legal to drive a car within 24 hours after general anaesthesia.
What should you do after surgery?
- The main bandages are left intact until the first postoperative visit 3-5 days after operation.
- There are no sutures to remove.
- Home help may be required for the first few days.
- It is best to take at least one week off work.
- Gentle exercise is encouraged but heavy sporting activities should be avoided for three to four weeks.
- Move about and walk as much as is reasonable even if this causes discomfort. When standing, move to exercise the legs.
What can you expect and what are the possible complications after Surgery?
Minor reactions
There are several common minor reactions that do not need to cause concern although they should be reported at the first postoperative visit:
- Minor bleeding. Blood loss during surgery is minimal. Minor bleeding can occur through the bandages but is easily controlled by compression.
- Bruising. Blood can collect under the skin but this has no long-term effects. Firm bandaging or stockings and regular walking allow this to resolve in one to two months.
- Swelling is common due to reaction and can last for up to 6 months but rarely causes any long-term problems. Simple bandaging will make you feel more comfortable.
- Numbness is due to damage to small surface sensory nerves. These grow back but recovery may take up to 6 months. There can be minor areas of permanent numbness.
- Matting can occur at incision sites.
More serious complications after surgery can occur. With good technique, facilities and staff, risk of complications is extremely low. They include:
- Deep vein thrombosis (DVT). The risk is small but probably greater after surgery than other non-surgical techniques. You may be given a heparin injection before operation and this may be continued at home with a daily injection for 7-10 days. You are mobilised early after operation to reduce the risk of DVT.
- Complications from anaesthesia. There is risk for any operation requiring an anaesthetic. However, risk from problems associated with severe heart or lung disease is avoided by advising against surgery. It is important to inform us of any allergies. Severe reactions to medications are rare but any history of bad reactions to anaesthetics should be notified.
- Severe bleeding. This is rare but can occur if a tie slips from a main saphenous vein. If severe bleeding occurs, lie flat, apply gentle pressure and arrange transfer to hospital.
- Infection. Minor infection in the groin is not uncommon but severe infection is rare. If there is excessive pain in the groin with reddening and swelling, you should telephone for early review. However, extensive bruising can cause similar appearances and this does not require active treatment.
- Lymphatic damage. Lymph is clear fluid that drains from the limbs through very fine lymphatic vessels separate to blood vessels. Lymph can leak from incisions or accumulate in the wound to cause swelling. Pressure to the site with gauze and a firm bandage usually stops leakage but this can take several weeks. Occasionally, lymphatic damage leads to permanent swelling termed lymphoedema.
- Nerve and arterial injuries. These are extremely rare but deep nerves that activate muscles in the thigh, calf and foot and the major arteries to the legs are close to the operated veins and can be at risk for damage. Rarely, patients complain of persistent burning pain along the length of the surface sensory nerve.
