Stefano Ricci
Although, according to Trendelemburgh1 in 1890: Scarsely anything needs to be said on the technic of operation. The vein is exposed through a skin incision about 3 cm long and isolated with the handle of the scalpel. Then a catgut suture is passed around above and below by means of an aneurysm needle, ... the vein doubly ligated and severed between the legatures, whereupon the skin incision is closed by suturing. The operation can be completed in a few minutes and is not painful enough that narcosis is indispensably necessary, in 1896 W. Moore published:2 The next four cases were treated in the outpatient room: they were operated on under chloroform, and were allowed to go home in an hour or two. More recently I have employed cocaine (... a very weak solution is injected into and underneath the skin...), and the patient goes home at once. W. Thelwell Thomas3 writes in 1896 about... ligature and division of the internal saphena vein at the saphenous opening: Anaesthetics firstly, and then antiseptic surgery, reopened the question, by relieving pain and allowing careful dissection by the surgeon, and doing away the desperate complications of septic phlebitis and pyemia, and in the literature of the subject one finds that only after 1870 did operative proceedings become general. And more: Cocaine may be used as local anesthetic if desired, - RECLUS, SCHWARTZ, WOLTT, and SCHLEICH do so. In 1895 G. Perthes4 (Trendelembugh’s pupil) reported data from 63 patients - 87 operations done since 1884, referring that: In our cases the operation was performed almost exclusively under narcosis. But experience showed that narcosis could be omitted. In one case, local anesthesia (Schleich) was used and it proved to be extremely suitable for this operation. In 1907 W. W. Babcok,5 announcing to the community the method that will become universally employed for the next 100 years reported: Spinal anesthesia by means of stovaine or tropocaine hydroclorate has been employed in nearly all of our cases. B. Schassi6 in 1909 (The Medical Press 1909) made saphenous ligature in local anesthesia and injected distally an iodine solution with very striking results. Interestingly, the beginning of GSV surgery, represented mostly by GSV ligature and division, experienced local anesthesia, and even spinal anesthesia, when cocaine could be dismissed. However during the first half of the XX century general anesthesia prevailed in GSV surgery as a consequence of its progressive safety, of more demanding operations, of more generalized patients request and of standardization of the treating method (stripping + varicectomies). In fact, in 1954 Tom Mayer7 published the paper on varicose veins surgery that will be nearly universally considered the gold standard for many years on (not forgotten still nowadays). This surgery ought to be accurate and complete: junction dissection and ligation of the GSV flush to the femoral vein; ligation and section of all the tributaries; ligation and section of the perforators; varicosities multiple ligation. The surgical time was long and tedious, often hemorrhagic, needing a transfusion at times.8 General anesthesia became obviously the preferred method by surgeons and patients, while postoperative bed rest was measured in weeks more than in days. This being the general trend, still some surgeons preferred to perform their veins surgery by local anesthesia,9 mostly considered as extravagance or originality. In a survey made by the French Society of Phlebology published in 196210 with the purpose of stating at that date the current treatment of varicose disease, over the 146 phlebologists answering (93 French, 53 from other countries for a total of 87,685 patients), the great majority was operating in general anesthesia. As an exception, 7 surgeons preferred local anesthesia, however with an experience of about 12,000 patients. Curiously, when asked, all declared that LA was possible in many cases but the impression is of a diplomatic sentence. Starting from the 60s of last century finally a technique of varices ablation suggested by R. Muller11 started to rise attention (not without scepticism), which was less aggressive, performed in an office setting and under LA (infiltration of 0.5 % lidocaine + adrenaline), treating each patient in a custom way, avoiding a standard procedure. Varices were eliminated by what was called Ambulatory phlebectomy, while the GSV, when needed, was stripped according to Mayo,12 always by LA. Ambulatory Phlebectomy spread slowly but constantly with a progressive number of followers and imitators13, 14 even with the creation of a specific Society (Societé Européenne de Phlebectomie Ambulatoire). The diffusion of Duplex facilities in the last 20 years of last century progressively induced to a better knowledge of the disease and, consequently, a less aggressive surgery;15 in the same time, sparing requests from the public health Systems became insistent, while patients expectation called for simpler/cosmetic methods. This complex of conditions gave rise to several (revolutionary) changes in the varicose veins treatment during the last 10 years of the century all in the direction of LA adoption. In 1988, Franceschi16 described an office-based procedure for the treatment of CVI with preservation of the superficial venous system. Franceschi called this procedure ambulatory conservative hemodynamic correction of venous insufficiency (CHIVA: cure Conservatrice Hémodynamique de l’Insuffisance Veineuse en Ambulatoire). The CHIVA method is a minimally invasive surgery procedure, performed under local anesthesia, based on a careful duplex analysis of the hemodynamic superficial venous network. Conservation of most of the dilated veins is obtained through precise venous ligation/sections (saphenofemoral ligation, disconnection from the great saphenous vein of the varicose tributaries and their avulsion through cosmetic incisions), achieving disconnection at the escape points, fractionation of the blood column, respect of the disconnected varicose veins physiological draining flow by preservation of the re-entry perforators. GSV endovascular thermal obliteration techniques appear at the very end of 2000, based on Radiofrequency in 199817 and Laser in 1999.18 These techniques do not need groin dissection, hospitalization, and are easily (even if not universally) performed in local anesthesia. Moreover, local infiltration anesthesia is a fundamental part of the procedure: used with a high dilution (tumescence) all along the GSV tract to be treated, it avoids skin burns by separating it from the vein.
Tumescent local anesthesia
In 1988 J. Klein19 introduces the principle of high dilution of the local anesthetic (1000 mL Nacl serum + 500 mg lidocaine + 1 mg adrenaline + 12.5 mEq lidocaine) for liposuction. This technique, historically referring to the hard infiltration suggested by A. Vishniewsky20 became the gold standard for liposuction after American Society of Dermatologic Surgery (ASDS) tumescent liposuction survey publication in 1995,21 reporting 15,336 patients treated by 66 dermatologists, without complications. In 1995 Cohn, Seiger and Goldman22 suggested it for phlebectomy procedures, and from that date several authors followed this way20 for the GSV stripping. It was adopted from the beginning by heat endovascular GSV operators with few exceptions. In reality the limit of tumescence is not precise, as local anesthesia may be submitted with different dilutions and volumes, according to the hydrodissection needed (high for endovascular heat procedure and lower for phlebectomy). The writer, for example, uses since 1980 a dilution of 0.4% for all the phlebologic procedures (phlebectomy, saphenectomy).23 At the beginning of the new century all the phlebologic surgery can potentially be performed in local infiltration anesthesia.
References
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