Development of endoscopic dissection of perforating veins and fasciotomy for treatment of chronic venous insufficiency.
As the subfascial endoscopic perforator vein surgery (SEPS) has become increasingly popular, it becomes important to trace the development of this procedure first initiated in 1985. (Improvements in the technique and modifications of initial instrumentation have occurred. These changes are based on experience with greater than 1000 patients treated since 1980 at Krankenhaus der Barmherzigen Brüder in Munich, Klinikum Merheim in Cologne, and the Weilheim Hospital. Results obtained in 96 patients (140 legs) were examined retrospectively and are presented as well as the prospective evaluation of 39 patients with 56 operated legs. (Hauer G, Vasa 1985, 14:59-61; Hauer G, Barkun J, Wisser I, Deiler S, Surg Endosc 1988, 2:5-12; Schneidemann B, Inaug Diss, 1985). This report details the fact that in using our own instruments, including a specially designed videoscope, it has been possible to approach perforating veins of the medial anterior and posterior compartments. This can be done through a 2 cm incision in the proximal calf. Using these instruments, it has been possible to perform a fasciotomy under direct vision. This summary emphasizes that it is not necessary to locate perforating veins preoperatively, and that wound infection and recurrent ulcerations do not occur. This allows application of the method to patients with open ulcers. Further, this report emphasizes that patients with combined arterial and venous ulceration require arterial reconstruction rather than perforator vein interruption. The SEPS operation is relatively contraindicated if there is widespread necrosis and infection of the fascia, especially in combination with ankle ankylosis. In addition, this is the method of choice in patients with multiple incompetent perforating veins with or without open venous ulceration.