Page 42 - Journal of WALS

WJOLS

10.5005/jp-journals-10007-1127
REVIEW ARTICLE Subfascial Endoscopic Perforator Surgery in Perforator Vein Insufficiency
Subfascial Endoscopic Perforator Surgery in

Perforator Vein Insufficiency

Ravikumar S
Consultant Laparoscopic Surgeon, Assistant Professor, Department of General and Laparoscopic Surgery, SS Institute of Medical
Sciences and Research Center, Davangere, Karnataka, India

ABSTRACT
Surgical treatment of incompetent perforating veins of the lower leg performed by open method carries considerable morbidity and also
associated with poor wound healing. Subfascial endoscopic perforator surgery (SEPS) is a new, minimally invasive endoscopic
technique performed in patients with advanced chronic venous insufficiency. This technique offers an effective treatment alternative
which avoids the lengthy incisions of the classical open Linton subfascial ligation techniques. The favorable ulcer healing rate and
improvement in clinical symptoms suggest that SEPS is a feasible, safe and effective treatment of the incompetent perforator veins in
patients with advanced chronic venous insufficiency.
Keywords: Subfascial endoscopic perforator surgery (SEPS), Minimal access surgery, Incompetent perforator, Chronic venous
insufficiency.

INTRODUCTION MATERIALS AND METHODS
Patients with chronic venous insufficiency and venous ulcers A literature review was performed using SpringerLink, HighWire
were surgically corrected using long incisions through diseased press, BMJ, Journal of MAS and major search engines, like
skin and subcutaneous tissues already compromised by venous Google, MSN, Yahoo, etc. The search term was the role of SEPS
hypertension. This procedure involved ligation of incompetent in perforator vein insufficiency. Citations found in selected
3
1,2
perforator veins described by Linton, Cockett and Dodd, 4 papers were screened for further references. Criteria for selection
this technique was often complicated by wound infections and of literature were the number of cases (excluded if less than 20),
poor healing. method of analysis (statistical or nonstatistical), operative
5
But in 1985, G Hauer demonstrated a new surgical procedure (only university accepted procedures were selected)
technique where incompetent perforator veins were directly and the institution where the study was done (specialized
visualized using an endoscope in the subfascial space. This institutions for endoscopic procedure was given more
seminal contribution marked the advent of subfascial preference).
endoscopic perforator vein surgery (SEPS). The idea to use
this approach was based on the possibility to create, using EQUIPMENT FOR SEPS
the laparoscopic instruments, a virtual space and seemed to Most of the instruments used in this procedure are usually
be very interesting since it offered the possibility to avoid used for laparoscopic cholecystectomy.
further damaging to the scarred tissues surrounding the ulcer
and thus to eliminate the wound complications that affected Instrumentation Includes
Linton’s technique. • Insufflator for introducing carbon dioxide to maintain the
In comparative studies, SEPS was associated with fewer working space
wound complications compared with Linton’s procedure. 6,7
• A rigid 5 or 10 mm endoscope
• A three-chip video camera preferably with xenon light source
AIMS
• A TV monitor (Fig. 1)
The aim of the study was to study the role of subfascial • A 10 mm cannula, rigid endoscope is introduced into the
endoscopic perforator surgery (SEPS) in perforator vein subfascial working space
insufficiency. The following parameters were evaluated: • 5 mm cannula is used for all other equipments.
• Operative technique Other additional instruments important for the successful
• Operative time performance of the operation are: A balloon dissector (General
• Intraoperative and postoperative complications Surgical Innovations, Cupertino, CA, USA). Although
• Postoperative pain dissection of the subfascial plane can be created via endoscopic
• Postoperative recovery instruments manually, the balloon dissector significantly
• Patient acceptance. expedites the dissection process and helps to create a large,

World Journal of Laparoscopic Surgery, May-August 2011;4(2):117-122 117