Aim: The main aim is to prospectively study the safety, feasibility and clinical outcome of SEPS performed by the
technique of CO2 insufflation and use of regular laparoscopic instruments in patients with chronic venous insufficiency (CVI) suffering from advanced disease (Class IV to VI). Equally the study is meant to trace the evolution of steps and improvements introduced to the technique and whether the present proposed version of the procedure can achieve both completeness of perforator control with low cost and safety.
Material: Prospective collection of data from patients operated upon with SEPS starting form July 1997. 59 limbs in 52
patients fulfilled the inclusion criteria (A venous origin for the ulcer-presence of incompetent perforator veins (IPVs) with an average of 12 months follow up). Obesity, infected ulcers, extensive skin changes, large ulcers, lateral perforators or even previous SEPS were not considered as contraindications).
Methods: Demographic, physical examination and vascular laboratory data were prospectively collected for all
patients. Preoperative duplex mapping of (IPVs) was done. A modified clinical severity score and clinical outcome score was given to each limb pre and post SEPS. Modification of the regular SEPS technique included the use of 5mm instruments and clip applier, use of endoretractors, use of mini-laparoscopy instruments, use of short hand instruments (24cm) especially bipolar scissors, use of Veress needle, percutanenous introduction of short small diametered metal instruments of ENT and arthroscopy and perforator control with ligation. Concomitant surgical procedures were dictated by duplex findings. Total ablation of perforators was done except a selective ligation of the Cockett group was practiced in post-thrombotic patients.
Results: 60 procedures were performed in 59 limbs of 52 patients (mean age 37.5 years and male to female ratio of 7:1)
Seven patients underwent bilateral SEPS (never simultaneously) and one patient underwent a second procedure on the same leg. Healed ulcers were found in 12 limbs (20%) class V, while active ulcers were found in 21 limbs (35%) class VI. Superficial system reflux was noted in 26 limbs (42%) combined superficial and deep reflux in 20 limbs (34%), isolated deep system reflux in 10 limbs (17%) while isolated (IPVs) was only seen in 4 limbs (7%) Number of perforators ligated per leg ranged from 1 to 12 perforators (mean of 3.6 perforators per leg). The average period of follow up was 12 months (ranging from 6 to 30 months).
The duration of the procedure had a mean of 32 minutes with a learning curve. The clinical severity score dropped from 2.775 preoperatively to 1.183 post SEPS (statistically significant P < 0.0001). Clinical outcome scale showed that only 6% were unchanged but all the rest improved. No single patient had worsening of his condition. At the turn of a year follow up the cumulative ulcer healing rate was 95%. Ulcer recurred only in 2 limbs (6%) one of which was small and transient. Ulcers which did not heal or tended to recur had residual perforators (lateral perforators in one case and ankle perforators in the other case which had failure of tourniquet during its initial SEPS). The 3th ulcer which did not heal had no residual perforators it was a long-standing ulcer (28 years). No serious peri or post operative complications were noted like wound infection, hematoma, DVT, tibial nerve injury, only 2 cases with edema and cellulitis post SEPS. No ulcer recurrence in postphlebitic limbs was recorded.
Conclusion: The collected data suggest that when used as a part of a treatment plan to correct deep and superficial venous insufficiency; SEPS results in a high rate of wound healing with practically no recurrent ulceration. The modifications
and improvement that were evaluated in this study ended up into a simple, cost-effective, fast, safe, feasible and easy-tolearn way of comprehensively attack the (IPVs). Key points in the technique evolve around the prevention of air leak,
prevention of cross-swording of the instrument and scope, the paratibial fasciotomy, the exploration of the intermuscular
septum and the high manoeuverability offered by directly introducing short, small diametered ENT(Ear forceps), or
arthroscopy curved shaft 3mm scissors or Veress needle