Varicose veins: SFJ ligation, GSV stripping / EVLA

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bruising, haematoma and pain along the stripped track
• groin wound infection
• numbness or burning along the saphenous nerve (medial leg and ankle)
• deep vein thrombosis
• bleeding from femoral vein injury
• recurrence of varicose veins
• leg swelling
• skin burn or pigmentation after laser ablation

Pre-operative details for this operation

1. SideRightLeftBilateral
2. Clinical class and symptomsCEAP C class; aching, oedema, skin changes, eczema, healed or active ulcer (site, size)
3. Venous duplex findingsSFJ reflux (seconds), GSV diameter at groin and knee, SPJ, perforators, deep veins patent and competent, date of scan
4. Veins marked standingYes, marked by operating surgeonDuplex-marked SFJ / GSV course
5. Deep vein thrombosis history / thrombophilia / oral contraceptives
6. Peripheral pulsespalpable or not; ABPI if compression planned and pulses weak
7. Planned procedureSFJ ligation + GSV stripping to knee + stab avulsionsSFJ ligation + stab avulsionsEVLA of GSV + stab avulsionsEVLA / RFA aloneSPJ ligation

Anaesthesia and position

1. AnaesthesiaSpinalGeneralTumescent local (EVLA)Tumescent local with sedationfor tumescent: volume and mix
2. PositionSupine, hip abducted and externally rotatedProne (SPJ surgery)head-down tilt during stripping / ablation
3. Ultrasound in theatreUsedNot used

Operative findings

1. SFJ anatomyposition, tributaries seen (superficial epigastric, superficial circumflex iliac, superficial external pudendal, anterolateral, posteromedial, deep external pudendal)
2. GSVSingleDouble / duplicateddiameter; saphena varix
3. Common femoral veinclearly identified above and below the junction
4. Perforators / varicosities avulsednumber of stab incisions and areas
5. EVLA: puncture site and tip positiondistance of fibre tip from SFJ on ultrasound; vein closed on completion scan; common femoral vein free of thrombus

Procedure (steps)

1. Skin preparation and drapingantiseptic; limb from groin to toes and perineum prepared
2. Groin incisiontransverse, in or just below the groin crease, medial to the femoral pulse; length in cm
3. SFJ exposed, common femoral vein identifiedabove and below the junction before anything is divided
4. Tributaries ligated and dividednamed and unnamed; ligature material
5. SFJ flush ligationtransfixed flush with the femoral vein, no narrowing, no long stump; suture material and size; second ligature
6. GSV strippingInvagination stripperStripper with olive / acorn headNot donefrom groin to just below the knee; direction; limb elevated during stripping
7. Stab avulsionsnumber of stabs, blade / hook used, areas
8. Track compressed and haemostasisrolled towel / pressure
9. EVLA: vein accesssite (above / below knee), cannula, guidewire, sheath size, tip 1 to 2 cm distal to SFJ on ultrasound
10. EVLA: tumescent anaesthesiavolume and mix, infiltrated under ultrasound around the whole length to be treated
11. EVLA: ablationlaser wavelength, fibre type, power in watts, total energy, length treated, pullback method
12. EVLA: completion scanvein occluded; common femoral vein compressible, no thrombus

Closure, drains and dressing

1. Groin: subcutaneous / Scarpa layerabsorbable suture, size
2. Groin skinSubcuticular absorbableInterrupted
3. Knee incision and stab incisionsAdhesive stripsSingle sutureLeft open under dressing
4. CompressionCotton roll and crepe bandage from toes to groinClass II stocking

Specimens and implants

1. Stripped vein / avulsed segmentsSent for HPENot sentlength of vein removed
2. Laser fibre / devicemake and batch sticker if single use

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Limb elevationfoot end raised or three pillows under the leg in bed
2. Compressioncrepe bandage or stocking; check for tightness; duration (usually 2 weeks after endovenous treatment)
3. Mobilisationwalk once the spinal wears off (within about 1 hour after EVLA under local)
4. Thromboprophylaxisearly walking; pharmacological prophylaxis in high-risk patients as per unit protocol
5. Analgesiadrug, dose, frequency
6. Groin wound checkhaematoma, infection
7. Activity adviceavoid running, straining and heavy lifting for the period advised
8. Follow-upwound review; duplex after EVLA if planned

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery