Lessons from the past guide the future: Is history truly circular?
1999; Elsevier BV; Volume: 30; Issue: 5 Linguagem: Inglês
10.1016/s0741-5214(99)70001-7
ISSN1097-6809
Autores Tópico(s)Venous Thromboembolism Diagnosis and Management
ResumoIn the last part of the 18th century, the German philosopher Georg W.F. Hegel proposed the concept of the cyclical nature of history and emphasized the corollary that man must learn from the past. Hegel stated that “experience and history teaches us this: that people and governments have learned nothing from history nor acted on principals deduced from it.”1Hegel GWF The philosophy of history.1837Google Scholar More than a century and a half later, the late President John F. Kennedy furthered the Hegelian concept of learning from the past. Kennedy stated that “we have an obligation to learn the lessons of history, if we don’t want to relive them.”2Kennedy JF. Address to the advertising council. Washington, DC: 13 Mar 1963.Google Scholar As we close this century and enter the millennium, it is apparent that the role and the treatment of superficial venous disease and particularly of incompetent perforating veins when combined with deep venous reflux emphasize the circular or cyclical nature of history forwarded by Hegel and Kennedy. Simply stated, history tends to repeat itself. This paper will review the role of surgery to the superficial venous system (saphenous and perforating veins) in advanced chronic venous insufficiency (clinical classes IV to VI; lipodermatosclerosis through healed or open ulcer) and the apparent cyclical increase and decrease in the use of superficial venous surgery. Particular attention will be paid to the relationship of both anatomy and pathophysiology to surgery. The relative interplay between investigators from the United Kingdom and Europe and their counterparts in the United States will also be emphasized. The treatment of venous ulcer, or as Arnoldi termed it “ulcus cruris venosum—crux medicorum? (translated as: chronic venous ulcer—a cross to bear?), has continued to thwart the best efforts of physicians in solving this problem.”3Arnoldi IC HaeGer K. Ulcus cruris venosum—crux medicorum?.Lakartidningen. 1967; 64: 2149-2157PubMed Google Scholar Although varicosities associated with the greater and lesser saphenous systems have been described since antiquity, the first extensive description of communicating or perforating veins in the lower leg was by Von Loder,4Von Loder JC Anatomische tafeln tex. 2nd vol. 1803Google Scholar a Russian anatomist. In 1803, he accurately drew and described calf perforating veins. In his Lettsomian Lectures a half century later, John Gay provided one of the first accurate descriptions of ankle perforating veins in a clinical situation.5Gay J. On varicose diseases of the lower extremities. Lettsomian Lecture. Churchill, London1866Google Scholar In his drawing that accompanied the clinical presentation of a 56-year-old man with venous ulcer, Gay described quite clearly the posterior arch vein and three communicating veins. In his line drawings, Gay also demonstrated post-thrombotic damage to the deep veins with thrombi present. In addition, Gay clearly recognized the difference between varicose and venous ulcers. Although Trendelenberg6Trendelenberg F. Uber die unterbindung der Vena Saphena Magna bie untershenkel varicen.Beitr Z Clin Chir. 1891; 7: 195-204Google Scholar developed an operation to ablate long saphenous vein reflux in 1891, it was Keller7Keller J. A new method of extrapating the internal saphenous and similar veins in varicose conditions.N Y Med J. 1905; 82: 385-391Google Scholar and Mayo8Mayo CH Treatment of varicose veins.Surg Gynecol Obstet. 1906; 2: 385-389Google Scholar who provided the instrumentation for stripping the greater saphenous vein 15 and 16 years later. In 1907, Babcock9Babcock WW A new operation for extirpation of varicose veins of the leg.N Y Med J. 1907; 86: 153-156Google Scholar introduced the intraluminal stripper, which survives today in a modified form as the principal technique for the treatment of varicose veins. John Homans contributed substantially to our fundamental understanding of chronic venous insufficiency. In his two seminal papers that were published sequentially in 191610Homans J. The operative treatment of varicose veins and ulcers, based upon a classification of these lesions.Surg Gynecol Obstet. 1916; 22: 143-159Google Scholar and 1917,11Homans J. The etiology and treatment of varicose ulcer of the leg.Surg Gynecol Obstet. 1917; 24: 300-311Google Scholar Homans clearly defined our modern concepts of venous physiology. He called attention to the structural liabilities of the superficial system and emphasized the critical role of valve competence in the prevention of reflux. Moreover, he accurately described the current pathophysiology of perforating veins. Homans devised the following classification of venous ulcers: (1) varicose ulcers that ride on veins, “secondary to impure and stagnant blood from the varicosities,” and (2) postphlebitic ulcers that are the result of destruction of deep and superficial vein valves coupled with incompetent perforating veins.11Homans J. The etiology and treatment of varicose ulcer of the leg.Surg Gynecol Obstet. 1917; 24: 300-311Google Scholar He also developed surgical procedures to cure the ulcer: “in surface varix complicated by varicosity of the perforating veins not only must the great saphenous be eradicated but many of its branches in the calf must be followed and excised in the search for incompetent perforating channels”.10Homans J. The operative treatment of varicose veins and ulcers, based upon a classification of these lesions.Surg Gynecol Obstet. 1916; 22: 143-159Google Scholar His operation for perforating veins was based on the development of deep thick flaps that were turned back and “the varicose perforating vessels…(never more than three)…are tied beneath this deep fascia.”10Homans J. The operative treatment of varicose veins and ulcers, based upon a classification of these lesions.Surg Gynecol Obstet. 1916; 22: 143-159Google Scholar The ulcer along with the fatty liposclerotic tissue was excised, and a split thickness skin graft then was applied. Homans’ influence was manifest in Robert Linton’s approach to incompetent perforating veins.11Homans J. The etiology and treatment of varicose ulcer of the leg.Surg Gynecol Obstet. 1917; 24: 300-311Google Scholar Homans was a visiting surgeon on the chief resident’s service at the Massachusetts General Hospital and obviously transmitted some of his concepts to Linton. Linton appreciated the anatomic work of Von Loder, and he included these drawings in his classic 1938 paper “The communicating veins of the lower leg and the operative technique for their ligation.”12Linton R. The communicating veins of the lower leg and the operative technic for their ligation.Ann Surg. 1938; 107: 582-593Crossref PubMed Google Scholar Linton delineated further the anatomy of perforating veins in dissections of 10 cadaver legs and in a series of 50 procedures for ligation of the communicating veins. Although Linton’s surgical approach was based on a “flap” operation that had been performed for years at the Massachusetts General Hospital, he believed that that curved incision of the flap procedure led to flap necrosis with an attendant high incidence of cutaneous complications. Therefore, Linton developed a direct approach to the perforating veins with vertical medial, anterior, and lateral incisions. He subsequently would limit his three incisions to one vertical incision that was carried posterior to the medial malleolus.13Linton RR The post-thrombotic ulceration of the lower extremity: its etiology and surgical treatment.Ann Surg. 1953; 138: 415-433PubMed Google Scholar Linton’s understanding of the anatomy and its relation to the pathophysiology allowed surgeons to take a direct surgical approach to incompetent perforating veins to prevent the abnormal transmission of pressure from the deep to the superficial veins. The decrease in the ambulatory hypertension would help to heal venous ulcers. This was a clear example of the knowledge of anatomy and pathophysiology driving the use of a surgical procedure. Sherman’s anatomic dissection of 73 cadaver legs and his 703 operations extended the knowledge of perforating vein anatomy.14Sherman RS Varicose veins—further findings based on anatomic and surgical dissections.Ann Surg. 1948; 130: 218-227Crossref Scopus (49) Google Scholar He described the sites of five perforating veins on the medial aspect of the leg and their frequency of incompetence. Although he preferred a short incision over the perforating veins rather than Linton’s long vertical incision, Sherman emphasized that perforating veins should be ligated subfascially to avoid missing one of the branches of the perforating veins that might escape detection if ligated extrafascially. As a senior lecturer at St Thomas’ Hospital, Cockett used both anatomic dissections and observations at surgery, as did the preceding investigators, but he added venographic studies to delineate the relationship between venous ulcers and incompetent perforating veins.15Cockett FB Elgan Jones DE The ankle blow-out syndrome. A new approach to the varicose ulcer problem.Lancet. 1953; 1: 17-23Abstract PubMed Scopus (124) Google Scholar Cockett emphasized the role of three large perforating veins in the medial calf and proposed the “blow out theory”: “the hypothesis is advanced that an ulcer is the end result of a local rise in venous pressure over this area”.15Cockett FB Elgan Jones DE The ankle blow-out syndrome. A new approach to the varicose ulcer problem.Lancet. 1953; 1: 17-23Abstract PubMed Scopus (124) Google Scholar Cockett used a vertical incision on the medial calf, as did Linton, but preferred to ligate the incompetent perforating vein extrafascially except when dense sclerotic subcutaneous tissue was present. Dodd, who later was to author with Cockett one of the most influential texts on the surgical treatment of venous disease, described his results with 174 cases of which 63% had ulcer.16Dodd H. The diagnosis and ligation of incompetent ankle perforating veins.Ann R Coll Surg Engl. 1964; 34: 186-196PubMed Google Scholar, 17Dodd H Cockett FB The pathology and surgery of the veins of the lower limb. ENS Livingston LTD, Edinburgh1956Google Scholar All the patients underwent subfascial ligation of the perforating veins of the leg. Dodd abandoned Cockett’s extrafascial approach for the subfascial approach because of a significant incidence of wound complications with the former approach encountered early in his surgical experience. Dodd’s experience with ulcer healing and prevention of ulcer recurrence was excellent. Richard Warren, a descendant of Joseph Warren, a surgeon and military leader who was fatally shot through the eye at the Battle of Breed’s Hill during the American Revolution, introduced physiologic measurements for the assessment of chronic venous insufficiency and their alterations by surgery.18Warren R White D. Venous pressures in the saphenous system in normal, varicose and post-phlebitic extremities.Surgery. 1948; 26: 43541Google Scholar Warren measured venous pressure in the calf branch of the saphenous vein in 102 legs both at rest and while walking. He showed that ambulatory pressure was high in patients with saphenous incompetence during walking and that this could be corrected with tourniquet compression. In contrast, in 12 limbs with postphlebitic changes, ambulatory hypertension did not decrease, but rather venous pressure increased in several patients. Parenthetically, it should be noted that Warren was the first to recommend vein valve transplantation for deep venous disease: “free transplantation of healthy valve veins from else where the body must be considered.”19Warren R Thayer R. Transplantation of saphenous vein for post-phlebitic stasis.Surgery. 1954; 35: 867-872PubMed Google Scholar Finally, Linton’s magnum opus on post-thrombotic ulceration that was presented to the American Surgical Association in 1953 was to further influence surgeons on their approach to venous ulceration during the next two decades.13Linton RR The post-thrombotic ulceration of the lower extremity: its etiology and surgical treatment.Ann Surg. 1953; 138: 415-433PubMed Google Scholar Linton called attention to the role of reflux through incompetent valves in the deep system, which, in concert with incompetent perforating veins, produced ambulatory hypertension. Frustrated with the results of ligation of incompetent perforating veins alone for ulcers in patients with deep venous reflux, Linton advocated ligation of the superficial femoral vein as a method for the prevention of deep venous reflux. Ligation was coupled with the radical removal of all abnormally dilated superficial veins, including the greater and lesser saphenae, with the interruption of the incompetent perforating veins, and with the resection of the area around the ulcer, including fascia. Interestingly enough, no data were presented to justify this approach. The work of Linton would influence American surgeons toward a surgical approach to incompetent perforating veins for the eradication of venous ulcer, and Dodd and Cockett would have a similar influence in the United Kingdom and the Continent. Series from several authors enthusiastically presented “excellent results” with sustained healing of venous ulcers.20Silver D Gleysten JJ Rhodes GR et al.Surgical treatment of the refractory post-phlebitic ulcer.Arch Surg. 1971; 1902: 554-560Crossref Scopus (22) Google Scholar, 21Field P Van Boxel P. The role of the Linton flap procedure in the managment of venous stasis dermatitis and ulceration in the lower limb.Surgery. 1971; 70: 920-929PubMed Google Scholar, 22Thurston OG Williams HTG Chronic venous insufficiency of the lower extremity: pathogenesis and surgical treatment.Arch Surg. 1973; 106: 537-539Crossref PubMed Scopus (10) Google Scholar The adoption of the subfascial ligation of incompetent perforating veins for the “cure” of venous ulcer is best summarized in a leading article in the British Medical Journal entitled “The hidden perforating vein,”23Br Med J. 1970; 1: 186Crossref PubMed Scopus (5) Google Scholar which recommended that surgeons “occlude the incompetent connecting vein between the superficial and deep system and so restore the pressure and flow to normal.” Ergo, the ulcer would be cured and remain so. There was an enthusiastic adoption of this surgical approach with the resultant increased use of perforator surgery. Although there was widespread use of subfascial ligation by many surgeons, other investigators noted an appreciable ulcer recurrence in certain limbs. Saint Thomas the apostle was perhaps the first proponent of evidence-based medicine. He would not believe that Christ had risen from the dead on the basis of hearsay and stated “unless I see in his hands the print of the nails and place my finger in the mark of the nails and place my hand in his side, I will not believe.”24The Holy Bible. The New Oxford Annotated Bible. John. 20. Oxford Press, New York1957: 24-30Google Scholar This skeptical approach was embodied in a philosophic movement during the Middle Ages called “Thomistic philosophy” with the credo “dubito ergo sum” (translated as: I doubt therefore I am).25Durant Wm The age of faith: a history of medieval civilization—Christian, Islamic, and Judaic—from Constantine to Dante: A.D. 325-1300. Simon & Schuster, New York1950Google Scholar The French philosopher Rene Descartes also adopted this questioning approach.26Descartes R. Discourse on method. Every Man, London1946Google Scholar As a young American post-surgical resident trainee, I was exposed to this questioning scientific method on a surgical unit appropriately situated at Saint Thomas’ Hospital in London. The probing and critical questions of the young professor of Vascular Surgery, Norman Browse, prompted a retrospective review of the experience at Saint Thomas’ with subfascial ligation of incompetent perforating veins for class V/VI chronic venous insufficiency.27Burnand K O’Donnell T Thomas ML Browse NL Relation between postphlebitic changes in the deep veins and results of surgical treatment of venous ulcers.Lancet. 1976; 1: 936-938Abstract PubMed Scopus (136) Google Scholar Forty-one patients who had undergone ligation of incompetent perforating veins through a medial vertical calf incision and who had undergone preoperative ascending phlebography were retrospectively divided into those with a healthy deep system (n = 17 limbs) and those with changes in the deep veins consistent with post-thrombotic damage (n = 23 limbs). During a 5-year period, one ulcer recurred in the limbs with a healthy deep system, and all 23 limbs with an abnormal deep system had an ulcer recurrence. This paper emphasized the need to define anatomically the status of the deep venous system and avoid declaring limbs post-thrombotic or not on the basis of clinical history alone. It also showed the relevance of deep venous anatomy and the implied physiologic abnormalities to outcomes after perforator surgery. In a subsequent prospective study, 109 limbs underwent: (1) clinical classification with physical examination, (2) anatomic description of the superficial and deep venous system by means of ascending phlebography, and (3) assessment of hemodynamic or physiologic status with preoperative ambulatory venous pressure measurements.28Burnand KG O’Donnell TF Thomas ML Browse NL The relative importance of incompetent communicating veins in the production of varicose veins and venous ulcers.Surgery. 1977; 82: 9-14PubMed Google Scholar This categorization of patients follows closely our present CEAPS classification.29Porter JM Moneta GL International Consensus Committee on Chronic Venous DiseaseReporting standards in venous disease: an update.J Vasc Surg. 1995; 21: 635-645Abstract Full Text Full Text PDF PubMed Scopus (1032) Google Scholar Of the four groups, the first two groups underwent ligation and stripping for greater saphenous incompetence alone (n = 21 limbs). The second group with a phlebographically healthy deep system underwent subfascial ligation of incompetent perforating veins (n = 11 limbs), and a third group with a healthy deep system underwent ligation and stripping of the greater saphenous and subfascial ligation for combined greater saphenous and incompetent perforating veins (n = 37 limbs). And finally, 40 limbs with classic post-thrombotic changes in the deep venous system underwent subfascial ligation. These four patients groups were compared with 38 healthy limbs that underwent ambulatory venous pressure measurements. The two groups who had undergone ligation and stripping of the greater saphenous system either alone or in combination with the ligation of incompetent perforating veins had their postoperative ambulatory venous pressure normalized. Although there was an improvement in the 11 limbs with a healthy deep system that underwent subfascial ligation of incompetent perforating veins alone, the postoperative ambulatory pressure failed to return to normal levels. After subfascial ligation, the group of 40 post-thrombotic limbs showed the least improvement in ambulatory venous pressure, which was well below normal levels. Thus, our two papers cast doubt on the beneficial effects of subfascial vein ligation in limbs with post-thrombotic changes in the deep veins. The studies by Bjordal30Bjordal R. Pressure patterns in the saphenous system in patients with venous ulcers.Acta Chir Scand. 1971; 137: 495-502PubMed Google Scholar in Scandinavia appeared to corroborate this impression and called in to question whether the ligation of incompetent perforating veins alone even with a healthy deep system led to hemodynamic improvement. Bjordal carried out direct venous pressure studies and flow measurements with an electromagnetic flow probe placed on both the greater saphenous and the perforating veins. With the occlusion sequentially of the greater saphenous or the large incompetent perforating vein, Bjordal showed that ambulatory hypertension was only normalized when reflux via the greater saphenous was abolished. The abnormal pressure was not brought back to normal levels with the occlusion of the incompetent perforating vein alone. Most importantly, in those limbs with post-thrombotic deep venous systems, the occlusion of either the saphenous or the perforator normalized elevated ambulatory venous pressures. Bjordal concluded “the pressure observation reveals that in a patient with impaired deep venous pump of the calf, ambulatory hypertension persists after our current surgical procedures on the dilated perforator or on the saphenous system”.31Bjordal R. Circulation patterns in incompetent perforating veins on the calf and in the saphenous system in primary varicose veins.Acta Chir Scand. 1972; 138: 200-205Google Scholar These physiologic papers cast doubt that hemodynamics would improve in such limbs and questioned the clinical value of perforator interruption in limbs with deep venous involvement. These findings and the appreciable incidence of wound complications were associated with a decrease in the popularity of this surgical approach to the post-thrombotic limb. Into the mid 1980s, several authors showed low failure rates for subfascial ligation of incompetent perforating veins that ranged from 10% to 25%,32DePalma RG Surgical theory for venous stasis.Surgery. 1975; 76: 910-915Google Scholar, 33Hyde GL Litton TC Hull DA Long term results of subfascial vein ligation for venous stasis disease.Surg Gynecol Obstet. 1981; 153: 683-686PubMed Google Scholar, 34Negus D Friedgood A. The effective management of venous ulceration.Br J Surg. 1983; 7: 623-627Crossref Scopus (103) Google Scholar but other authors experienced higher failure rates. Bowen35Bowen FH Subfascial ligation (Linton operation) of the perforating leg veins to treat post-thrombophlebitic syndrome.Am Surg. 1975; 41: 148-151PubMed Google Scholar noted a 34% failure rate, we noted a 55% failure rate,27Burnand K O’Donnell T Thomas ML Browse NL Relation between postphlebitic changes in the deep veins and results of surgical treatment of venous ulcers.Lancet. 1976; 1: 936-938Abstract PubMed Scopus (136) Google Scholar and Johnson et al,36Johnson WC O’Hara ET Corey C et al.Venous stasis ulceration effectiveness of subfascial ligation.Arch Surg. 1985; 120: 797-800Crossref PubMed Scopus (24) Google Scholar working in a veterans population, noted a 51% failure rate, all of which questioned the efficacy of this procedure. Moreover, the long medial calf incision was associated with an appreciable incidence of wound complications, which prompted surgeons to develop alternative types of incisions. Felder et al37Felder DA Murphy TO Ring DM A posterior subfascial approach to the communicating veins in the leg.Surg Gynecol Obstet. 1955; 100: 730-739PubMed Google Scholar placed the incision along the posterior aspect of the calf as a posterior “stocking seam” incision that was later to be adopted by Rob38Rob C. Surgery of the vascular system. Proceedings of the Vascular Symposium.in: University of Minnesota, Minneapolis1972: 272Google Scholar in the East and by Lim et al39Lim RC Blaisdell FW Zubrin J. Subfascial ligation of perforating veins in recurrent stasis ulceration.Am J Surg. 1970; 119: 246-249Abstract Full Text PDF PubMed Scopus (13) Google Scholar on the West Coast. Dodd16Dodd H. The diagnosis and ligation of incompetent ankle perforating veins.Ann R Coll Surg Engl. 1964; 34: 186-196PubMed Google Scholar earlier had moved his incision site to the posteromedial aspect of the calf to avoid the poor quality skin anteromedially. In 1966, DePalma40DePalma RG Surgical therapy for venous stasis: results of a modified Linton operation.Am J Surg. 1979; 137: 810-813Abstract Full Text PDF PubMed Scopus (32) Google Scholar used a bipedicled flap with multiple incisions along Langer’s lines to avoid traversing damaged skin. All the authors appreciated the original observation of Cockett and Elgan Jones: “there is a natural reluctance to operate on an area of the leg which is infected, indurated, edematous and which has poor healing power”.15Cockett FB Elgan Jones DE The ankle blow-out syndrome. A new approach to the varicose ulcer problem.Lancet. 1953; 1: 17-23Abstract PubMed Scopus (124) Google Scholar The British surgeon Edwards41Edwards JM Shearing operation for incompetent perforating veins.Br J Surg. 1976; 63: 885-889Crossref PubMed Scopus (46) Google Scholar developed a phlebotome from a neurosurgical instrument. This device could be passed into the subfascial space at a more proximal site in the area of good tissue and passed distally to shear off incompetent perforating veins beneath the ulcer and surrounding compromised tissue. Pressure then was applied to reduce the bleeding. Obviously, the blind approach bothered some surgeons because of the proximity of both the posterior tibial artery and a nerve just beneath the lamina profunda to the subfascial space. In the United States, this approach was advocated by DePalma.42DePalma RG Surgical treatment of chronic venous ulceration.in: Venous disorders. WB Saunders, Philadelphia1991Google Scholar Other surgeons, including ourselves, tried laryngoscopes or lighted retractors, which were used in breast augmentation surgery to directly ligate the incompetent perforating veins with conventional instruments through an incision made more proximally in good tissue. Hauer was the first to apply endoscopic methods to the ligation of incompetent perforating veins.43Hauer G. The endoscopic subfascial division of the perforating veins—preliminary report [in German].VASA. 1985; 14: 59-61PubMed Google Scholar In his important paper published in 1985, Hauer introduced the minimally invasive approach “to gain optimal access to the subfascial region from a healthy area in order to be able to ligate, coagulate or clip the perforating veins.”43Hauer G. The endoscopic subfascial division of the perforating veins—preliminary report [in German].VASA. 1985; 14: 59-61PubMed Google Scholar Subsequently, this technique was adopted by Fisher44Fischer R. Surgical treatment of perforating veins: endoscopic treatment of incompetent Cockett veins [in German].Phlebologie. 1989; 42: 1040-1041Google Scholar and other European surgeons.45Couto JS Baptista AL Endoscopic ligation of perforator leg veins [letter].Lancet. 1991; 337: 1480Abstract PubMed Scopus (6) Google Scholar, 46Jugenheimer M Junginger Th Endoscopic subfascial sectioning of incompetent perforating veins in treatment of primary varicosis.World J Surg. 1992; 16: 971-975Crossref PubMed Scopus (94) Google Scholar Both techniques used endoscopic visualization or light source, such as a bronchoscope or mediastinoscope. Later, a single light source with a working port would be developed for this procedure. Conventional instrumentation was used through the working port. Some investigators have found the limited visualization and narrow surgical field a challenge. In 1990, provoked by a prescient and rhetorical question by Charles Rob,47Rob CR. The bizarre and useless in vascular surgery. Proceedings of the 17th annual Montefiore Vascular Surgery Symposium Lunch Time Address; 1990 Nov 18; New York.Google Scholar “is there a role for laparoscopic surgery in vascular disease,” during his lunch time address at the 17th Annual Montefiore Vascular Symposium, I believed that an ideal application for the laparascopic technique in vascular surgery was its application to the ligation of incompetent perforating veins. We then developed a procedure, which was presented at the next Montefiore Symposium in 1991,48O’Donnell TF. Minimally invasive venous surgery. Proceedings of the 18th Annual Montefiore Vascular Surgery Symposium; 1991 Nov; New York.Google Scholar that used standard laparoscopic technique: a laparoscopic source for visualization of the perforating veins and a working port through which laparoscopic surgical equipment for dissection and for clipping/division of the incompetent perforating veins could be passed. In our initial descriptions of the technique, Ringer’s lactate was used to distend the subfascial space because of the fear of air (CO2) embolus from the subfascial space, used in the conventional laparascopic technique.49O’Donnell TF Surgical treatment of incompetent perforating veins.in: Atlas of venous surgery. WB Saunders, Philadelphia1992Google Scholar, 50O’Donnell TF Laparoendoscopic Venous Surgery.in: Current critical problems in vascular surgery.Vol 4. Quality Medical Publishing, St Louis, Mo1992Google Scholar The Australian surgeon Conrad51Conrad P. Endoscopic exploration of the subfascial space of the lower leg with perforator vein interruption using laparoscopic equipment: a preliminary report.Phlebology. 1994; 9: 154-157Google Scholar and the Mayo Clinic’s Glovickzi et al52Gloviczki P Cambria RA Rhee RY Canton LG McKusick MA Surgical technique and preliminary results of endoscopic subfascial division of perforating veins.J Vasc Surg. 1996; 23: 517-523Abstract Full Text PDF PubMed Scopus (116) Google Scholar both suggested CO2 insufflation, but it was Glovickzi and colleagues who popularized the tourniquet and CO2 approach used by many surgeons in the United States today. Laproscopic subfascial ligation allowed skin incisions to be made distant and above the “underprivileged tissue” and provided direct visualization of the perforating veins. Perforator surgery could now become an ambulatory procedure with minimal morbidity, and it accomplished the goals of perforator surgery: (1) interruption of abnormal perforating veins, and (2) avoidance of tissue damage. The use of subfascial endoscopic perforator surgery (SEPS) has exploded and is an excellent example of new technology that drives the use of a surgical procedure. Unfortunately, the widespread adoption of SEPS has not al
Referência(s)