The subfascial interruption of incompetent medial calf communicating veins

          • This shows the lower leg with a group of large varicosities in the pos­teromedial aspect of the calf and an intraluminal stripper in the long saphenous vein. If only the long saphenous vein is removed, these varicosities will persist because they have developed as a result of the incompetence of the communicat­ing veins in this region and not primarily because the main saphenous vein is incompetent. For this reason, an oblique incision is made as shown. It is impos­sible to pinpoint the exact location of the communicating veins or to know for certain how many will be found. The keynote to success is to find all the incom­petent veins and to interrupt them beneath the deep fascia. The subfascial ap­proach and interruption make it possible to perform this much more effectively and completely than ligation superficial to the deep fascia; in fact, it would be impossible to find all those superficial to the fascia.
          • Blunt dissection with the forefinger of the left hand between the deep fascia and the calf muscles is readily carried out because there is only loose areolar tis­sue and the communicating veins between them. As this cleavage plane is developed, the enlarged incompetent communicating veins are readily located. The dissection can easily be carried to the midline posteriorly. The only structure to be avoided is the sural nerve, or the median component of it. Many surgeons persist in calling these perforating veins, presumably because they pass through the deep fascia. The term is otherwise meaningless, and the term “communicating vein” is much more significant since it indicates that the veins connect the deep and superficial systems. When the communicating veins become incompetent they play an exceedingly important role in the etiology of varicose veins and the pathological changes that develop in the leg. Furthermore, without the eradication of these veins the varicosities and the stasis dermatitis and ulcers will persist. Instead of diagnosing them as recurrent varicose veins, they should be called persistent when they are observed a year or longer postoperatively. Their presence under these conditions is evidence that an incomplete operation had been performed.

One comment

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