Das Schicksal der Vena saphena – The fate of Vena Saphena

Das Schicksal der Vena saphena in der Geschichte der Venenchirurgie

The fate of Vena saphena in history of venous surgery

Presentation at the 1st. Northern European Endovenous Forum 2018 – 

PD. Dr. med. Wolfgang Lahl, Dr. med. Ulf Th.Zierau

Almost in focus Vena Saphena. Almost exactly 50 years ago, PD Dr. Wolfgang Lahl entered the Surgical Clinic as a training assistant. He was immediately entrusted with the care of varicose vein patients. The same story can tell Dr. U.Zierau – 20 years later.
At that time, the patients were mainly treated as inpatients. The hospital stay was approximately 7 days.

PD Dr. Wolfgang Lahl

The old-timers were glad that they no longer had to worry about the unspectacular clinical picture, the operations were without exception at the end of the surgery program. The boss appeared regularly in the room to ask what keeps me so long with the patient. He said: „It is a disease and not cosmetics“. He was most disturbed by small incisions.

At this time, the saying still applied: „Major incisions, major surgeons. minor incisions, minor surgeons.

However, We have to add that the majority of patients were patients with pronounced chronic venous insufficiencies, often in combination with ulcer cruris. Cosmetic aspects were actually not in the foreground at that time. Even today, We remember the first operation reports, which were stereotypical: Skin incision hand wide below the groin, searching for the Vena Saphena and severing between ligatures…Then a button cannula was bound in and retrograde instillation of a calorose solution, a 60% invert sugar, took place. The patient lying under local anesthesia had to indicate as soon as he noticed a feeling of warmth in the ankle area. This completed the procedure and compression bandaging was performed.

Ultimately, this procedure corresponded to the procedure proposed by Moszkovicz in 1927.

Looking back, We have to ask ourself whether we were among the pioneers of chemical endovenous therapy at the time, or whether the treatment was based on an antiquated procedure.

Unfortunately, revascularization of the truncal vein and thrombosis due to the transfer of the high percentage solution into the deep vein system were possible complications.

We therefore dedicated ourself to the stripping procedure after a short time. The existing, approx. 60Cm (23.6 inches) long original Babcock probes were, however, only conditionally suitable. They were too rigid as well as too short and the vein material often slipped over the probe olive. At that time, we were still far away from an invaginating or stage-appropriate stripping, the exhairese up to the malleolus was the rule. Stripper probes could not be acquired in the former GDR. Necessity is the mother of invention, we obtained flexible piano sides from the Hochschule für Musik „Hanns Eisler“, Berlin, and manufactured slide-on cylinders of various diameters.

Historical view of therapy Vena Saphena varicoses

If you try to get an overview of the historical development of the
varicose vein treatment, after a short time you agree with the 1862 of Minkiewicz,  „Comparative studies of all surgical procedures recommended against varices“ that

„the quantity of some healing methods proposed in surgical and therapeutic practice against certain diseases either proves that the former have not yet been sufficiently researched or that the actual healing method is yet to be discovered. This applies to a large extent to varices and the usual „operation methods“.

In order to be able to appreciate the changes in dealing with the insufficient Vena Saphena, which have taken place over the course of centuries, We have to take a look back into the more distant past.

Descriptions and illustrations of varicose veins and their complications are already available from pre – christian times as well as the following centuries. However, therapeutic measures consisted mostly only of relieving interferences with complications.
Only with the introduction of anaesthesia, anti- and asepsis in the middle of the 19th. century you come across an almost unmanageable number of different treatment proposals to eliminate the pathologically dilated saphenous septum and the varicose side branches.

Ferdinand Sauerbruch

Surgeons against surgery for a long time

For a long time though, leading surgeons generally spoke out against surgical intervention.

Johann Friedrich Dieffenbach, who held a chair at the Charité until his death in 1847, formulated this as follows:

„These in many cases doubtful, rarely only by the urge of circumstances
varicose vein surgery is performed according to the various methods that have been recommended to be easier than to protect the patient from the adverse consequences of the same“.

Theodor Billroth also pointed out in his book in 1863,  „General Surgical Pathology and Therapy.“

„We have to explain ourselves incompetently in the treatment of varicose veins, because we do not know of any means that would be able to destroy the disposition to these venous diseases… If we also removed one or more of these diseased veins, other paths would soon develop. For this only reason, I reject operations that have the purpose of removing one or more varicose nodules from the lower leg. Remember that the individual varicose veins themselves make almost no complaint at all, that any operation on the veins can become life-threatening through complication with thrombosis and embolism. So, I must consider the varicose vein operation to be completely unmotivated. Nevertheless, these operations are carried out especially in France and often with fatal outcomes.“

Modern view of pathophysiology

It is certainly justified to date the modern pathophysiology of venous insufficiency to Friedrich Trendelenburg (1844-1924) (5). He introduced the concept of the „private cycle“ and thus founded the solitary ligature of the Vena Saphena to eliminate reflux. In 1891 he described his procedure in Brun’s contributions to clinical surgery under the title:

„On the prevention of the saphenous vein magna in lower leg varicosities“.

At that time Trendelenburg was in Bonn, but had also worked at the University of Rostock from 1875- 1882.

Neither an extirpation of the truncal varicose veins nor a crossectomy was associated with this procedure.

Friedrich Trendelenburg

Rostock can boast of another vein pioneer. In 1884, the Ordinarius Madelung presented his method at the 13th. Congress of the German Society of Surgery, in which the varicose veins and perforators were extirpated from two skin incisions on the upper and lower leg as well as after back- preparation of both skin flaps in addition to the truncal veins. This method was practiced well into the 20th. century.

Also worth mentioning are the spiral incision of the Stendal surgeon Rindfleisch 1906  and the resection of the Utrecht surgeon Narath 1908, often called „finger stripping“. He mobilized and removed the truncal Vena Saphena subcutaneously via several small skin incisions.

The instrumental removal of the stem vein began with a kind of invagination of short vein segments by the American Keller in 1905.

In 1906, Charles Mayo succeeded in the first promising saphenous extirpation in Rochester with a ring-curette developed by him, with which he triggered the extraluminal stem vein.

In 1907, William Wayne Babcock was able to introduce the intravascular procedure with his stripper probe, which is still practiced today. However, the Mayo method, described in 1916 in Boston by John Homans with a combination of crossectomy, stripping and ulcer excision as radical surgery, remained the preferred method for many years.

Radical treatment – radical reaction

The radical use of Vena Saphena and the associated complications, admittedly, led to a limited spread of the stripping method in Germany in the first half of the 20th century.

There were numerous opponents who were even carried away by exaggerated statements. Let us quote the royal fountain doctor Professor Winkler from 1917 (11):

„Babcock has indicated a method for cases where the dilated vein is rather straight, which surpasses everything that has been tried in this field in terms of crudeness. Before a patient gets involved in this graft, he should make his will“.

Dermatologists, in particular, have tried to achieve varicose veins or chronic venous insufficiency by intravascular occlusion of the saphenous septum and its lateral branches. Due to Linser’s success in Tübingen in the 1920s, when he first used sublimate and later high – percentage saline and sugar solutions, numerous surgeons left the surgical treatment.

Unfortunately, reports about recanalizations and critical opinions about the lack of long – term results of dermatologists became more frequent:

„Dermatologists always report on successes but rarely on long – term successes“. Moszkowicz complained in 1934. And Zeller suggested already in 1927,

„to combine „the well – founded bloody surgical therapy with the conservative method that is now so much in the process of being adopted“.

However, many years were to pass before the surgical therapy of the insufficient saphena was again accepted by the surgeons themselves.

In 1932, a survey showed that 11 out of 12 surgical university hospitals performed sclerotherapy! Just after the Second World War did an increasing differentiation begin between cases suitable for sclerotherapy and classical stem varicosis.

We  immediately experienced this period of departure and was able to dedicate ourself to questions about the Vena Saphena until Wolfgang Lahl´s  age – related retirement from clinical everyday life and also afterwards through cooperation with the organizer of the conference beginning today.

In the Sixties…

Unforgotten for me is the statement of the Nestor of German Vascular Surgery, Prof. Vollmar, at the Surgeons‘ Congress in 1969 that „the claim to sole representation of the sclerotherapy experts and leg wrappers as well as that of the exclusive strippers“.

Nonetheless, it was an expression of the still subliminal rivalry between surgeon and dermatologist for professional competence with regard to the clinical picture. Unfortunately, the longstanding disregard of many surgeons for the value of varicose vein disease has not helped us.

A great benefit was the introduction of duplex or color-coded Duplex sonography. Previously, we were always faced with the question of the indication for a phlebography, the decision for or against which could have legal consequences.

We do not like to say many words about the various procedures to tear poor Vena Saphena out of the tissue. Whether ante or retrograde stripping, whether CHIVA, cryo or trivex procedures, invaginating or PIN stripping according to Oesch, whether with or without bloodlessness etc., in the end all methods more or less injured the surrounding tissue and always contained the danger of damage to neighbouring structures. Therefore, we would like to touch on another area that is only given little attention in the publications of conventional varicose vein surgery.

Stripping: Nerve injuries/ lymph vessel destruction

Already in the seventies, Dr. Lahl was interested in lymphological questions, especially under the aspect of iatrogenic damage after arterial reconstructions or stripping procedures. The ventromedial lymph vessel bundle runs parallel to the Vena Saphena magna and is therefore directly endangered during stripping. The extent of a possible intraoperative injury was only poorly documented. At that time, lymphographies with the oily contrast medium lipoiodol were still allowed. Thus, we were able to perform postoperative examinations on selected patients, whose surprising results we also published. They showed how invasive the stripping procedure can be despite all caution and, on the other hand, they represent a not to be underestimated advantage of endovenous methods.

Lymphography after stripping – op:  lymph vessels destroyed

Dr. Lahl also point out the possible nerve damage. While an injury in the saphenous region can be observed relatively frequently and is usually tolerated by the patient, it can never be safely avoided in the course of the sural nerve and is extremely unpleasant for the patient in the long term.  We are not aware of any really reliable data on the frequency of suralis lesions.

A large repertoire of surgical instruments has been developed for the gentle handling of the saphenous tissue and the perivasal tissue. Almost every surgeon had his preferred instrument, often named after him.

Paul Linser

Venous Sclerotherapy

Despite the optimization of surgical therapy, the use of sclerosing drugs by our dermatological colleagues was unbroken. With the introduction of ultrasound-supported sclerotherapy and the use of microfoam, new possibilities arose to include not only side branch varices but also an inefficient saphena in the therapy concept.

Later, surgeons and phlebologists developed the various endovenous techniques at the beginning of the 1990s. Hence, they followed the demand of a nestor of phlebology, Urs Brunner, who already three decades ago formulated the desired treatment of Saphena as follows:

„Today’s concept is conservative, reflux-oriented, aesthetic“.

Endovenous gentler…

It is easy to answer the question of what led to the rapid development of endovenous forms of therapy that today replace the stripping method (19).

– they avoid larger wound areas, haematomas and infections – there is a general trend towards minimally invasive surgery – the patients demand a rapid

Rehabilitation, preferably without inability to work as well as optimal cosmetic results

– suitable technologies have been developed and modern catheter techniques
also developed for phlebology

– also a preferably radical approach in the conventional varicose vein surgery
could not prevent the recurrence,
with the actual recurrence rate after operative remediation of stem varicose veins has not yet been clearly proven. The information on this varies between 7 and 60 per cent.

And so, through the use of the new procedures adapted to the findings, the Vena  Saphena  long path of suffering also seems to have come to an end, in which it can remain closed but without damage to the surrounding structures and for the benefit of its bearers in its traditional place.

Literatur:

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