Common Conditions

Varicose Veins: Operative Information Sheet

You have varicose veins and have been advised to have them repaired. This is an information sheet which advises you of the pros and cons of having your veins treated and answers to common worries that patients have. It is not intended to replace a consultation nor is it intended to be a textbook of surgery.

The risks of not treating the veins include continuing discomfort, increase in size of the veins, bleeding, phlebitis, deep vein thrombosis, development of venous eczema and in some patients venous ulceration.

You will have had a non-invasive venous assessment (Duplex Ultrasound Scan) to look at the flow of blood in your legs and to check whether the valves are functioning properly. The treatment advised depends on the results of my clinical examination, the severity of the veins, presence of venous eczema and the results of the ultrasound examination. Varicose veins can be treated with injection sclerotherapy, elastic stockings or surgery. Injection sclerotherapy is only appropriate for early varicosities or to control small veins still there after the operation. Ointments and drug treatment are not helpful for your type of veins. The presence of non-functioning valves usually means that surgery or one of the newer endoluminal ablation techniques is the most appropriate treatment. Elastic stockings are helpful if you are not keen on an operation.

Depending upon your age, social circumstances and general health, the procedure can usually be done as a Day Case procedure i.e. You are admitted to hospital and discharged on the same day. Sometimes it may be necessary for you to spend a couple of nights in hospital. If this is the case you will have been advised of this.

Most varicose vein operations are undertaken without complications. Less than one in 20 of patients suffer any problems. The common complications are wound infection, blood or fluid collecting at the repair site (haematoma or seroma) and small patches of numbness of the skin of the leg. These are relatively minor complications which are usually dealt with by a course of antibiotics or drainage of the wound. The numb areas usually resolve after a period of a few months. On rare occasions more serious complications such as major nerve injury and deep vein thrombosis can occur. The surgical techniques used these days make these eventualities unlikely.

Closer to the date of your operation, you will receive an appointment for a pre-operative visit to the hospital. You will receive further details of the operation and pre-operative preparations then, and will have the opportunity to ask any questions. However, if you have any worries that cannot wait until then, please make an appointment for my Out-patient Clinic at the hospital.

Pre-operative

You may be required to visit the hospital a few days before admission, for any special tests (such as X-rays, blood tests etc) that I or a member of my team have requested. At your pre-operative consultation you will have been told what types of anaesthetic are appropriate for your procedure and you would have considered the options. In general, the newer endoluminal techniques can be undertaken with a local anaesthetic (i.e. you are awake during the procedure). Traditional surgical techniques require a general anaesthetic. If you are having a General Anaesthetic (i.e. you are asleep during the procedure) you will need to have starved (no fluids or solids) for at least 6 hours before the operation. If you are having a local anaesthetic, some fluid (e.g. coffee / tea / juice) first thing in the morning would be OK.

On admission to the ward you will have your details checked and have some basic tests done, such as pulse, temperature, blood pressure and urine examination. You will be asked to hand in any medicines or drugs you may be taking, so that your drug treatment in hospital will be correct. Please tell the nurses of any allergies to drugs or dressings. You will be required to shave the operative site before surgery. It is best if this is done a few hours before the operation.

I, or a member of my team, will check that all the necessary preparations have been made. You will have the operation site marked on you with a skin marker and asked to sign a consent form. The form signifies that you know and understand why the operation is required and what it involves. Make sure that all the veins that trouble you are marked with the skin pencil. If you are having a General Anaesthetic, the anaesthetist who will be giving your anaesthetic will also interview and examine you. He/she will be especially interested in chest troubles, dental treatment and any previous anaesthetics you have had, plus any anaesthetic problems in the family.

The timing of your operation is usually arranged the day before. The nurses will tell you when to expect to go to the operating theatre. Do not be surprised, however, if there are changes to the exact timing. The order of the list is usually on the basis of medical priority. Just because you are not 'first' on the list does not mean that you are unimportant.

You will be taken on a trolley to the operating suite by a ward nurse and a theatre porter. There will be several checks on your details on the way to the anaesthetic room.

Operative

The general anaesthetic is given through a needle in the back of your hand and you will fall asleep within seconds. A small dose of heparin is given to reduce the risk of deep vein thrombosis, the leg and groin area is cleaned with an antiseptic and the site draped with sterile towels. Local anaesthetic is normally given into the leg as the procedure is being undertaken.

Surgery for varicose veins usually involves a small cut (few centimetres) in either the groin or behind the knee (sometimes both). In addition there are tiny cuts ( a few millimetres) over each of the varicosities. The number will depend on the extent, distribution and severity of the varicose veins. The cuts in the skin are then closed up. My preference is to use 'dissolvable' sutures which are absorbed by the body over a period of a few weeks and therefore do not have to be removed. The entire area is treated with a long acting local anaesthetic which provides excellent pain relief for the first few hours. The leg is then covered with a bandage from the foot to the upper thigh.

In contrast, the endoluminal techniques do not require an incision in the groin and are therefore 'sutureless'. The dressings and bandaging are otherwise similiar.

Post-operative

Although after a General Anaesthetic patients are conscious a minute or two after the operation ends, you are unlikely to remember anything until you are back in your bed on the ward. Some patients feel a bit sick for up to 24 hours after operation, but this passes off. You will be given some treatment for sickness if necessary. You may be given oxygen from a face mask for a few hours if you have had chest problems in the past.

The local anaesthetic in your wound may make your leg give way for 12 hours or so. Be especially careful when getting in or out of a car, when climbing stairs, or when getting in or out of bed. The drugs we give for a general anaesthetic will make you clumsy, slow and forgetful for about 24 hours. This happens even if you feel quite alright.

For 24 hours after your general anaesthetic:

• Do not make any important decisions.
• Do not drive.
• Do not use machinery at work or at home. (e.g. do not mow the lawn).

There is some discomfort on moving rather than severe pain. You will be given injections or tablets to control this as required. Ask for more if the pain is still unpleasant. You will be expected to get out of bed the day of the operation despite the discomfort. You will not do the wound any harm, and the exercise is very helpful for you. The day after the operation you should be able to walk slowly. By the end of the second week the wound should be virtually pain-free.

You will be able to drink and have some light food within an hour or two of the operation provided you are not feeling sick. The next day you should be able to manage a normal diet. It is quite normal for the bowels not to open for a day or so after operation. If you have not opened your bowels after 2 days and you feel uncomfortable, you can take a laxative.

It is important that you pass urine and empty your bladder within 6-12 hours of the operation. If you find using a bed pan or a bottle difficult, the nurses will assist you to a commode or the toilet. If you still cannot pass urine let the nurses know and steps will be taken to correct the problem.

The groin wound (if you have one) has a dressing which may show some staining with old blood in the first 24 hours. The leg will be covered from foot to upper thigh with a bandage. Occasionally when you first stand up, there may be a considerable ooze of blood from one of the leg wounds. Don't panic, lie back on the bed and let the nurses know. They will then re-bandage that area. The following morning the bandages will be removed (by the District Nurses if you are at home or by the hospital Nursing Staff if still an in-patient) and replaced with a tight elastic stocking. The thigh and lower leg is considerably bruised at this stage - this is normal. The stocking needs to be kept on day and night for the first seven days and during the day only for the subsequent week. Whilst this may sound like torture, wearing the stocking will reduce the amount of post-operative bruising and hasten resolution of the swelling.

You can take the groin dressing off after 48 hours. Most patients prefer to keep a dressing on the wound to protect it from rubbing from clothing. There may be some purple bruising around the wound which spreads downward by gravity and fades to a yellow colour after 2 to 3 days. It is not important. There may be some swelling of the surrounding skin which also improves over 2 to 3 weeks After 7 to 10 days, slight crusts on the wound will fall off. Occasionally minor match head sized blebs form on the wound line. These settle down after discharging a blob of yellow fluid for a day or so. You can wash the wound area 48 hours after the operation. Soap and warm tap water are entirely adequate. Salted water is not necessary. You can shower or take a bath as often as you want although this may be difficult with the stockings. Patients sometimes prefer to leave the stockings on and only wash around the necessary areas rather than struggle with the stockings.

You will be given an appointment to visit the Outpatient Department about two weeks after you leave hospital. If your sutures have not still dissolved they will be removed at this time. Please ask the nurses for sick notes, certificates etc, the day before discharge.

Back at home

You are likely to feel very tired and need rests 2 to 3 times a day for a week or more. You will gradually improve so that by the time 2 weeks has passed you will be able to return completely to your usual level of activity. There is no value in attempting to speed the recovery of the wound by special exercises before the month is out. You can drive as soon as you can make an emergency stop without discomfort in the wound, i.e. after about 3 to 5 days. You can restart sexual relations within a week or two, when the wound is comfortable enough and you should be able to return to a light job after about 14 days, and any heavy job within 4 weeks.

Complications are rare and seldom serious. Bruising and swelling may be troublesome, particularly if the veins were extensive. The swelling may take 4 to 6 weeks to settle down. Infection is a rare problem and settles down with antibiotics in a week or two. Aches and twinges may be felt in the wound for up to 6 months. You may also feel 'lumps' under the skin along the inner part of the thigh. These are occasionally quite hard and tender. These are nothing to be particularly concerned about and will resolve over a period of time. Smaller 'thread' veins may become more noticeable at this stage. These and any residual veins are usually injected at this stage

Practically all patients are back to their normal duties within one month. If you have any problems or queries after discharge, please ring the ward who will advise and contact me if necessary.