Varicose veins are defined as dilated palpable subcutaneous veins, generally larger than 4mm in the upright position. Severity of the disease may vary from telangiectatic veins to venous ulceration. Subfascial endoscopic perforator surgery (SEPS) is a new, minimally invasive technique performed in patients with advanced chronic venous insufficiency, enables surgeons to address perforator vein incompetence less invasively, with small upper calf incisions remote from severely diseased skin in the distal leg, with less surgical complications compared to open subfascial perforator ligation.
Aim: The aim of the study is to compare the outcomes and complications of open subfascial perforator ligation versus endoscopic perforator surgery (SEPS) for treatment of varicose veins in terms of postoperative recovery by studying factors such as stay duration, postoperative pain, hematoma formation, wound site infection, Post-Operative edema, ulcer healing individually.
Materials and Methods: Data is collected from patients satisfying the inclusion and exclusion criteria, chosen from the in-patients of Surgery Department, J.S.S. Hospital, Mysuru during the study period of August 2013 to September 2015. 40 diagnosed cases of perforator incompetence with or without long saphaneous vein varicosity were included in the study. 20 patients were included in SEPS and 20 patients were included in open subfascial perforator surgery group.
Treatment Protocol and Methodology: All patients irrespective of treatment group underwent Trendelenburg procedure (flush ligation of Sapheno femoral junction) with stripping of GSV up to knee. For below knee varicose veins alternate patient has been selected for subfascial endoscopic perforator ligation, fulfilling the inclusion and exclusion criteria and willing to undergo surgical intervention. During Post-Operative recovery period study factors were compared among two groups like pain, hematoma formation, wound site infection, Post-Operative edema, and ulcer healing time was compared during follow up period.
Results: In the present study, mean age distribution among the two groups was comparable with open group having mean age of 44.3 +/-15.8 SD, and in SEPS group having mean age of 41.5 +/- 14.6 SD. Among the open group 2 patients had 2 incompetent perforators (10%), three perforators in 16 patients (80%), and four perforators in 2 patients (10%) and in SEPS group 12 patients had 2 incompetent perforators on Doppler study, additional one perforator was identified during the surgery and was ligated, 8 patients had 3 incompetent on Doppler study, additional one perforator was identified and ligated during surgery. Therefore total number of perforators ligated in SEPS group were more compared to open group which was statistically significant with p value 0.046. The mean duration of stay in hospital in open group is 7.3 +/- 0.6 days and 5.2+/- 0.9 days in SEPS group which is statistically significant with p value<0.0001.Comparison of pain Post-Operatively was done using VAS scale, VAS scoring was 3 +/-0.7 on Post-Operative day 1 in open group and 2 in SEPS group which is statistically significant with p value <0.0001, on Post-Operative day 3 VAS scoring was 2.2+/-0.5 and 1.2 +/-0.4 in SEPS group in open group which is statistically significant with p value <0.0001 and on Post-Operative day 7 was 1.0+/-0.4 in open group and 0.4 +/-0.5 in SEPS group which is statistically significant with p value <0.0001Post-Operatively wound site hematoma was seen in 2 patients in open group on Post-Operative day 1 which disappeared after Post-Operative day 5 and no patient developed wound site hematoma in SEPS group. In our study, 12 patients had ulcers in open surgery group, among them 1 patient had complete ulcer healing by 2 weeks Post-Operatively, 9 patients had complete ulcer healing by 1 month Post-Operatively, 2 patient had complete ulcer healing by 3 months Post-Operatively and 7 patients had ulcers in SEPS group, 5 patients had complete ulcer healing by 1 month Post-Operatively, and 2 patients had complete ulcer by 3 months Post-Operatively. In our study mean preoperative ulcer size in open group was 8.15±5.48 cm2, on postoperatively 2 weeks ulcer size decreased to 5.78±1.32 cm2, and on postoperatively 1 month ulcer size decreased to 3.28±0.1 cm2 and complete ulcer healing was observed by Post-Operatively 3 months, in SEPS group, mean preoperative ulcer size was 8.75± 5.70 cm2, on postoperatively 2 weeks, ulcer size decreased to 3.45±1.49 cm2, on Post-Operatively 1 month ulcer size was 2.86±0.31 cm2, and complete ulcer healing was observed by postoperatively 3 months, however this observation was not significant statistically. No patients in both groups had wound site infection, saphenous nerve injury, ulcer recurrence during follow up period.
Conclusion: This study has shown the superiority of SEPS over open technique because of shorter mean hospital stay, lesser post-operative pain, the number of perforators ligated in SEPS was more as compared to the open subfascial ligation group as some perforators missed on Doppler localization were identified during surgery and ligated, which may be a cause of future recurrence in varicose veins in the open surgery. Early relief of symptoms in terms of ulcer healing was better in the SEPS group, however both groups had no wound complications except for 2 patients in open group had hematoma formation.