Removal of the vein is called 'phlebectomy'. In medicine, 'phleb' means vein and 'ectomy' means removal.
The word “Phlebectomy” is made up of 2 medical terms:
Phlebectomy is not the same as “stripping”.
Phlebectomy is only the removal of the bulging veins (called “varices”) that can be seen bulging on the surface of the legs when standing. These veins are only just under the skin.
Stripping is the old operation (that should not be done anymore) where the underlying truncal veins were surgically tied off and then the vein was stripped out. These underlying veins are called “Truncal veins”.
These truncal veins cannot be seen from the surface and are deep under the skin. Stripping these veins is very destructive, causing considerable pain and bruising. Research from The Whiteley Clinic has shown that stripping these veins out stimulates the body to start growing them back again, reducing the use of this operation.
Phlebectomy is effective at removing surface varicose veins – but not at treating the underlying cause. Hence phlebectomy is usually used in conjunction with other procedures, such as endovenous laser (EVLA or EVLT), radiofrequency, TRLOP or pelvic vein embolisation. All of these combinations are included in the Whiteley Protocol.
Stripping is not in The Whiteley Protocol and should not be used anymore. With appropriate skills and technique, stripping is now never needed.
When Mark Whiteley of The Whiteley Clinic brought endovenous surgery into the UK in March 1999, it was thought that the main advantage of this new system was the “keyhole” surgical technique. The scars were tiny and the pain of the procedure was much less than the old alternative of stripping.
Now that the operations can be done under local anaesthetic, this has meant that varicose vein surgery can be done as “walk-in, walk-out” procedures in clinics rather than needing to go into hospital or stay overnight. This “walk-in walk-out” surgery is also called “ambulatory” surgery.
Therefore ambulatory phlebectomies are phlebectomies that are done under local anaesthetic, as part of a walk-in, walk-out varicose vein operation.
1] Mark the veins
Unlike the truncal veins, pelvic veins and perforator veins that can only be seen using duplex ultrasound, the varicose veins that are removed by ambulatory phlebectomy are clearly visible on standing as bulges through the skin. However these bulges disappear again on lying down, making it impossible to see the veins when the patient is lying on the operating table.
Therefore the veins need to be marked before the surgery.
This is done by standing the patient up and then drawing around the bulging veins with a permanent marker.
When the patient lies down on the operating table, the marks show the surgeon where the deflated veins are.
2] Anaesthetising the area
The skin is cleaned and the patient prepared with surgical drapes. Any other vein procedure is done first, leaving the ambulatory phlebectomies to last.
Local anaesthetic is injected under the skin, making both the skin and the veins numb. The local anaesthetic injections do sting, and so The Whiteley Clinic is introducing new techniques to reduce the discomfort of local anaesthetic injections.
3] Performing the phlebectomy.
Using a very fine blade, tiny incisions (less than 2 mm) are made over the veins using the skin marks for a guide. This does not hurt as the area has been numbed with local anaesthetic. Most patients just feel a little pressure like a finger pushing on the skin.
A very fine hook is then used to pull the vein up through the skin. Using small and precise mosquito clips, the vein is held and is slowly “milked” out through the small incision. When sufficient has been pulled out, the vein is removed and discarded.
The patient can usually feel a little “pulling” sensation although there should be no pain at all. It is often described like “someone pulling on clothes that I am wearing”. It is important to have some feeling left. If a nerve was touched instead of the vein, the patient would feel a sharp pain and be able to tell the surgeon.
In this way we can avoid the nerve damage that is seen in some patients having varicose vein surgery under a general anaesthetic, epidural, spinal or sedation.
4] Closing the skin
After ambulatory phlebectomy, the incisions are so tiny that they can be closed with a sticky tape. There is absolutely no need for any stitches.
These tapes can be removed after 3 days.