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Reprinted with Permission from JOURNAL OF ENDOVASCULAR SURGERY, Volume 3, No. 4, November 1996 Copyright © 1996 by Futura Publishing Company, Inc., Armonk, NY 10504-0418 Endoscopic Technique for Subfascial Perforating Vein Interruption Roy L. Tawes, MD; L. Albert Wetter, MD; George D. Hermann, BSME; and Thomas J. Fogarty, MD Mills Peninsula Hospital, Burlingame, and *Stanford University School of Medicine, Stanford, California, USA Surgical treatment of incompetent perforating veins of the lower leg performed openly carries considerable morbidity associated with wound healing. Newer minimally invasive techniques offer an effective treatment alternative that avoids the lengthy incisions of the classical subfascial ligation techniques. The authors report a simple and quick two-port endoscopic method for clipping incompetent perforating veins of the lower leg using commonly available endoscopic instrumentation. The technique is unique in its use of a balloon dissector to rapidly establish the subfascial working space. J Endovasc Surg 1996;3:414-420 Key words: chronic venous insufficiency, endoscopy, ulceration, subfascial ligation Dr. Fogarty and George Herman have an equity interest in General Surgical Innovations, Cupertino, CA, USA Address for correspondence and reprints: Roy L. Tawes, MD, 1828 El Camino Real, Suite 601, Burlingame, CA 94010. Fax 415-697-5347. Chronic venous insufficiency is a common and debilitating disease, and the management of patients with complications from this condition is challenging and at times frustrating for the vascular surgeon with the rare exception of valve reconstruction1,2 and open subfascial perforator ligation, current surgical approaches to this disease have been limited to the superficial component, in the form of stripping and stab avulsion techniques. Although the contribution of incompetent perforators in the disease process has been acknowledged since Linton's early work3, the open method of surgical exposure of the perforating veins for ligation3-5 has been associated with an unacceptably high rate of wound complications.6 As an alternative, the majority of current treatment modalities are limited to external compression therapy, with varying degrees of effectiveness depending on user compliance and other factors. Recently, however, the wider availability of color duplex ultrasound imaging and the evolution of endoscopic techniques has led to the development of a promising minimally invasive surgical alternative: endoscopic interruption of perforating veins. Although several endoscopic methods have recently been described,7-10 our technique is unique in its use of balloon dissection to create a large working space in the subfascial plane. In our opinion, this method represents an expedient refinement of the endoscopic approach. This technique permits the rapid, direct exposure, identification, and interruption of the perforating vein system through small incisions that are remote from the region of compromised tissue. PATIENT EVALUATION AND SELECTION Patients undergo noninvasive evaluation via color duplex ultrasound imaging of both legs to document the presence of a patent deep system and to confirm incompetence of the perforating veins of the lower leg. The sites of the incompetent veins are marked on the skin for reference at the time of surgery. If indicated, the superficial incompetent system is also marked on the skin for surgical stripping and ligation. Given the accuracy of duplex imaging, venography is not used. Venography is more invasive and, in our hands, is less informative in identifying incompetent perforators. Subfascial vein interruption is offered to patients with preulcerative (lipodermatosclerosis, pain, pigmentation); refractory ulcerative; and active ulcerative venous disease states that do not respond to compression therapy. These disease states correspond to the CEAP (Clinical status - Etiology-Anatomical distribution-Pathophysiology) venous disease classes11 C4, C5, and C6, respectively. SURGICAL INSTRUMENTATION The majority of the instruments used in this procedure are currently used for laparoscopic cholecystectomy. Instrumentation includes an insufflator to introduce carbon dioxide to maintain the working space; a rigid 5- or10 mm endoscope; a three-chip video camera with xenon light source; and a monitor (Fig. 1). The rigid endoscope is introduced into the working space via a 10-mm cannula, but a 5-mm cannula is used for all other equipment. Figure 1 - Instrumentation overview for endoscopic subfascial perforator interruption. Several additional instruments are particularly important for the successful and expedient performance of the operation. One is the balloon dissector (General Surgical Innovations, Cupertino, CA, USA). Although dissection of the subfascial plane can be accomplished manually via endoscopic instruments, the balloon dissector significantly expedites the dissection process and helps create a large, unencumbered operative working space. The balloon dissector used in this technique (Fig. 2) consists of a 300-cc-capacity balloon with a protective removable cover; a guide rod to aid in introduction and placement; and a 10-mm laparoscopic cannula with skin seal. Figure 2 - Balloon dissector for subfascial perforator interruption: (A) fully assembled; (B) with cover removed and balloon inflated; and (C) with balloon and obturator removed, leaving the 10-mm cannula A second important instrument is the 5-mm roticulating endograsper (US Surgical, Norwalk, CT, USA) (Fig 3A), whose combination of tip articulation and rotation offers a high degree of maneuverability. The 5-mm clip applier (Ethicon Endosurgery, Cincinnati, OH, USA) (Fig. 3B) needs only a 5-mm port. Its small size also affords greater maneuverability and visibility when working in the tunnel-like confines of the endoscopic working space. The applier delivers an 8-mm-long (medium/large) clip in a convenient multifire configuration. TECHNIQUE The procedure is performed under general or spinal anesthesia with the patient supine and in the Trendelenburg position with the knee slightly flexed and elevated. In anticipation of concomitant superficial stripping, the entire extremity is prepped circumferentially. A 10-mm incision is made through the skin 4 cm medial to the tibia and 10 to 12 cm below the popliteal crease. After dissecting the subcutaneous tissue, the posterior compartment is identified, and a 10-mm transverse incision is made into the fascia. The subfascial space is identified and held open with Army-Navy-type narrow blade retractors. Figure 3 - Five-millimeter instrumentation for subfascial perforator interruption. (A) Roticulating grasper facilitates exposure of perforating veins. (B) Clip applier delivers 8-mm-long clip for interruption of perforators.   A B Figure 4 - The balloon dissection technique. (A) Introduction and advancement along the subfascial plane. (B) The balloon cover is removed, and the dissection balloon is filled with saline. The balloon dissector is then introduced into the fascial incision and directed toward the medial malleolus (Fig. 4A). After removal of the peel-away balloon cover sheath, the dissection balloon is inflated with saline to a volume of 200 to 300 cc. The balloon is constructed in such a way that radial expansion occurs initially, followed by distal propagation toward the malleolus (Fig.4B), as the balloon everts distally. Dissection by the balloon occurs along planes of least resistance; thus, the perforating veins are not disrupted in the process. Once the dissection is accomplished, the balloon is deflated and removed, and the rotating seal of the integral 10-mm trocar is secured to the fascial incision. The cannula is introduced into the dissected space, and the guide rod and obturator are removed. The skin seal is rotated into the fascial incision to provide a gas seal. CO2 at a pressure of 15 mmHg is then insufflated to create the working space. A zero-degree, 10-mm rigid laparoscope with attached video camera and light cable are introduced (Fig. 5A), and the subfascial space is visualized on the video monitor. A 5-mm laparoscopic working port is then inserted in the mid calf under direct endoscopic vision. It is important to place this trocar as posteriorly as possible to make a wide working axis. This trocar arrangement aids visualization of the working instrument and facilitates manipulation of the instruments (endograsp dissector or clip applier) in the confines of the calf (Fig. 5B). A B Figure 5 - The endoscopic instrument technique. (A) After balloon removal, the video endoscope is inserted into insufflated subfascial working space. (B) Perforating veins are clipped via a secondary 5-mm port. The perforating veins may be visible immediately (Fig. 6A), or a modest amount of blunt dissection and exploration may be required. Skin markings from the duplex venous studies are useful in guiding the surgeon to the location of the perforators. Once identified, each perforating vein is double clipped with the 8-mm titanium clips from the 5-mm clip applier (Figs. 6B and 6C). In general, all perforating veins that can be identified are clipped. Because perforator continuity is interruped by the clips, the veins are not usually divided. However, division of the perforator between the clips can be performed, when desired, with endoscopic shears to facilitate distal exposure. When interruption of the perforators is completed, the trocars are removed, and the skin incisions are closed with interrupted mattress stitches using monofilament sutures. In patients with superficial venous insufficiency, superficial ligation and stripping can be performed in the standard fashion. All wounds are covered with nonadherent dressing, and the treated leg is wrapped with a compression bandage extending from the forefoot to the upper calf or leg as indicated. Patients are discharged the day of surgery and followed routinely as an outpatient 1 week after surgery. DISCUSSION Treatment of incompetent perforating veins using the Linton or Cockett subfascial ligation techniques has been reserved for patients with intractable disease because both of these open procedures carry considerable morbidity. The option to address the perforator system using minimally invasive techniques provides a significant advance in treatment of these difficult patients. By approaching the veins subfascially from remotely placed ports, morbidity from wound complications is virtually eliminated. Clipping or dividing the perforators achieves hemodynamic results equivalent to the open operations. Refinements in port placement and technique have reduced our typical endoscopic operative time to 20 minutes. This is due in large part to the balloon dissector, which quickly creates a large operative working space that, when expanded with gas, facilitates rapid identification and exposure of the perforating veins. A B C Figure 6 - Endoscopic view of subfascial working space created with balloon dissection. Note vein on right margin of dissected space perforating the fascia above (A) immediately after balloon dissection; (B) during clipping; and (C) with clipping complete. We have used this technique in patients with severe lipodermatosclerosis or ulceration (active or recurrent) due to incompetent perforators, and it has been particularly useful in cases where distal perforators in the vicinity of the ankle have been difficult to visualize and control by other endoscopic approaches.8 We have experienced no difficulty in visualizing incompetent veins identified by duplex or successfully clipping the veins endoscopically. However, we have seen additional perforating veins not detected on ultrasound in several patients, which leads us to believe that exploration of the entire subfascial plane under direct endoscopic visualization provides a more thorough identification of perforating veins than can be obtained with duplex imaging. Bleeding has not been a problem at the time of surgery or in the postoperative period, nor have we encountered compartment syndrome of the leg. Clinical improvement of symptoms with prompt wound healing is usually seen in 4 to 8 weeks. Our early results using this refined endoscopic approach for the treatment of chronic venous insufficiency are encouraging. Further clinical investigation with longer term monitoring of the clinical outcomes will determine the ultimate role of this particular approach for the treatment of chronic venous insufficiency. REFERENCES 1. Raju S. Valvuloplasty and valve transfer. Int Angiol 1985;4:419-424. 2. Listener R. Surgical technique of venous valve repair. The Straub Proceedings 1990;55:15-16. 3. Linton R. The communicating veins of the lower leg and the operative technique for their ligation. Ann Surg 1938;107:582-593. 4. Cockett F, Jones B. The ankle blow-out syndrome: A new approach to the varicose ulcer problem. Lancet 1953;1:17-23. 5. Raju S, Fredericks R. Venous obstruction: An analysis of one hundred thirty-seven cases with hemodynamics, venographic and clinical correlations. J Vasc Surg 1991;14:305-313. 6. Cikrit D, Nichols W, Silver D. Surgical management of refractory venous stasis ulceration. J Vasc Surg 1988;7:473-478. 7. O'Donnell TF. Surgical treatment of incompetent communicating veins. In: Bergan JJ, Kistner RL, eds. Atlas of Venous Surgery. Philadelphia, WB Saunders, 1992:11-124. 8. Gloviczki P, Cambria RA, Rhee RY, et al. Surgical technique and preliminary results of endoscopic subfascial division of perforating vein. J Vasc Surg 1996;23:517-523. 9. Wittens CHA, Pierik RGL, van Urk H. The surgical treatment of incompetent perforating veins. Eur J Vasc Endovasc Surg 1995;9:19-23. 10. Jugenheimer M, Junginger T. Endoscopic subfascial sectioning of incompetent perforating veins in treatment of primary varicosis. World J Surg 1992;16:971-975. 11. Executive Committee of the American Venous Forum. Classification and grading disease in the lower limbs: A consensus statement. In:Gloviczki P, Yao JT, eds. Handbook of Venous Disorders.London, Chapman & Hall Medical, 1996:652-660.