Patient Information - Varicose veins The Operation explained

'The information contained in this patient information sheet is not a substitute for medical advice or
treatment, and the Society recommends consultation with your doctor or health care professional'

1. Why do I need the treatment?

• You have varicose veins. There are a number of indications for operation.
• Those with ulceration or threatened ulceration resulting from their varicose veins carry the highest priority. The aim of surgery is to take pressure off the skin veins in the leg, by tying and dividing (and often removing) the principal skin veins in the leg.
• Bleeding through the skin is frightening, and may recur. This problem also carries a high priority for treatment.
• Phlebitis (inflammation in the veins and overlying skin), large varicose veins and aching in the veins is a lesser indication for surgical treatment
• Smaller varicose veins, in the absence of symptoms, don’t need to be treated.
• The aims of surgery are to reduce to normal the pressure in the skin veins. This will prevent existing varicose veins from enlarging further, and will prevent new varicose veins from growing. For those with skin changes around the ankles or previous ulceration, reducing the pressure to normal prevents worsening of the skin change and usually reduces the risk of further ulceration. For this group, the addition of support stockings further protects the skin around the ankles.

2. Before the treatment

• Before varicose vein surgery, there are a number of tests that need to be done. These are of two types: those to assess whether you are suitable for varicose vein surgery, and some immediate pre-operative tests.
• Tests to see whether you are suitable for the operation will have already been done. These will always include examination with handheld Doppler, and may include an ultrasound scan which provides a map of the affected veins and their connections.
• Immediate pre-operative tests include: blood tests and ECG for some, and completing a health questionnaire. These immediate pre-operative tests are usually completed at a pre-admission visit to the hospital a short time before your operation is booked to take place.

3. Coming into hospital

• Varicose vein surgery is often performed as a Day Case. If you are fit, have a family member to take you home, and be with you over night, you will probably qualify.
• Those having more complex surgery and those who live alone, will stay in hospital over night.
• Please bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also complete your nursing record.
• The Surgeon who will be performing your operation will visit you immediately before the procedure. Your veins will be marked with a waterproof pen, at the same time agreeing with you which veins will be removed. You should ensure that all your varicose veins are marked.
• The doctor who will give you the anaesthetic will also visit you, and explain the anaesthetic to you.

4. The treatment

• Varicose vein surgery is usually but not always performed under general anaesthetic.
• A tiny needle is placed in the back of your hand. The anaesthetic is injected through the needle and you will be asleep within a few seconds.
• While you are asleep, local anaesthetic will be used around the groin incision and incision on the back of the knee (when used). When you wake up, the larger incisions  should be numb.
• Sometimes a drip is placed into a vein in your arm (at the wrist usually) to give you some fluids during and following surgery, until you are able to drink fluids freely yourself.

5. The Operation

• The operation varies a little from person to person, depending on where the faulty valves are.
• Normally you will have a cut about 4-6cm long running obliquely in the skin crease of the groin. Through this incision the top end of the principal skin vein (great saphenous vein) is tied off and divided immediately adjacent to its connection with the main deep vein of the leg.
• This vein is then stripped from the leg on a wire. The wire is passed back down the leg in the long saphenous vein to knee level. At knee level a second tiny incision is made to retrieve the vein which contains the wire. The vein is stripped from the leg using this wire.
• Ligation and removal of the great saphenous vein deals with the cause of the varicose veins and should prevent recurrence.
• Less frequently, when the principal vein on the back of he knee has a leaking valve, it too needs ligation. This is performed through a horizontal incision about 3cm long on the back of the knee. The vein is tied and divided immediately adjacent to its connection with the main deep vein of the leg. The short saphenous vein is rarely stripped from the leg because it lies close to a nerve, picking up skin sensation, which may be damaged.
• Finally, in most cases, the visible varicose veins are removed from the leg through tiny incisions about 2-3mm in length. Incisions are placed about 3-5cm apart along the line of the varicose vein. There may be a large number of tiny incisions when the varicose veins are extensive.
• The larger incisions are closed with a stitch, which lies beneath the skin and doesn’t need to be removed. The smaller incisions are not stitched because they heal beautifully.
• The leg is bandaged firmly from toe to groin at the end of the operation.

6. After the Treatment

• You will usually be taken to the Recovery area after the operation, where you will slowly wake up. When you are fully awake (usually 20-30 minutes) you will return to the ward.
• Most people describe the feeling in the leg as stinging or burning when they wake up. It is unusual for the leg to be painful.
• Following this sort of surgery you are very unlikely to feel sick, and you should be able to eat and drink again within a few hours.
• Some of the smaller incisions may bleed a little over the first 24-48 hours. For this reason, it is best to keep the leg covered with bandages or stockings for the first 48 hours.
• After this time, the stockings may provide support to the bruising making the leg more comfortable. They may be worn for up to 10 days, but do not usually help beyond this time.
• The incisions, although initially very visible, will subside to become virtually invisible within 9-12 months.
• There is usually extensive bruising in the leg, particularly down the inside of the thigh. This bruising usually lasts for 3-4 weeks.
• Removal of the skin veins means that post-operatively blood returns to the heart through the deep veins more efficiently than before the operation.

7. Going home

• Most people describe the leg as sore and uncomfortable when they get home. These feelings increase steadily from the second postoperative day and are usually at their worst on the 8th-10th postoperative day. The discomfort usually resolves 12-14 days after the operation.
• Often no painkillers are required at all.
• Occasionally, usually when there is phlebitis, the leg will be painful. The pain may last for up to three weeks in this situation.
• Regular daily exercise such as going for a walk or using an exercise bike gently to provide a gradual return to normal activity is recommended.
• To rest up after the operation raises the risk of developing blood clots in the deep veins (deep vein thrombosis or DVT). Regular exercise reduces this risk, but makes the leg more uncomfortable.
• Driving: You will be able to drive within 48 hours of the operation provided the leg is not too uncomfortable.
• Bathing: You can bath or shower within 48 hours of operation. Sometimes bathing or showering immediately after surgery may lead to bleeding from the smaller incisions.
• Work: If this applies to you, you should be able to return to work within 1-3 weeks of surgery depending on your job. Your GP will advise you of this when you see him/her for your sick-note.
• Lifting: There are no limitations in this area.
• Medicines: You will usually be sent home with some painkillers. You will be advised on their use before you leave hospital.

8. Complications

• Complications after varicose vein surgery are uncommon.
• Chest infections: These can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.
• Wound infection: Wounds sometimes become infected and this may need treatment with antibiotics. This is more common with redo varicose vein operations in the groin. Bad infections are rare.
• Fluid leak from wound: Occasionally the groin incision may leak blood stained or clear fluid. Usually this lasts a few days when it is bloodstained. Sometimes, clear fluid collects under the groin incision. It may be contained beneath the skin or it may leak through the incision. It is called a lymphocele. This occurs infrequently mainly following re-operation on the groin. If there is leakage from the groin, it may take up to 6 weeks to settle.
• Nerve injuries: These are uncommon occurring in about 1 in 20 cases. Two skin nerves are particularly at risk. The first picks up sensation from the top of the foot, and the second from the outer border of the foot. Other unnamed nerves may also sometimes be damaged leading to reduced sensation anywhere in the leg. The reduced sensation may be very noticeable at first, but normally diminishes with time, and is not usually a problem in the longer term.
• Deep Vein Thrombosis: DVT complicates any operation from time to time. It also occurs occasionally following varicose vein surgery. Patients with extensive varicose veins associated with skin changes are probably at the greatest risk, but the complication is rare.
• Recurrent Varicose Veins: Recurrence of varicose veins occurs in about 1 in 15 patients over a ten-year period. Sometimes further treatment may be required.

9. What can I do to help myself?

• When you get home, try to return to normal as soon as possible. The more exercise you take, the more sore your leg will be, but the quicker the leg will return to normal.

10. Further Questions

• If you have further questions, please do not hesitate to ask either your Consultant or one of his team, or the Nurses who are looking after you on the ward.

The Vascular Society is grateful to Mr Simon Parvin and members of the Audit and Research Committee for writing this information leaflet.

March 2006