Crosectomy

Crossectomy is a modern view of a technique known among surgeons, which is called the Troyanov-Trendelenburg operation. Today, specialists have significantly modernized it in order to reduce trauma for the victim, as well as significantly increase efficiency.

The meaning of the intervention of such a plan involves the classic ligation of the great saphenous vein of the thigh and the smaller branches closest to it. With the help of this, it is possible to achieve in a short time the elimination of the saphenofemoral anastomosis, or the point of confluence of a large subcutaneous vessel into the femoral part.

Indications and contraindications

The presented intervention for the most part belongs to the category of emergency operations, when it is required to eliminate the backflow of blood as soon as possible. Often the need arises when there is a threat of thrombosis of the lower extremities.

Doctors often choose just such a mechanism for neutralizing the blockage of the ileofemoral segment of the ascending vein collectors due to its minimal trauma. It will be possible to carry out the procedure even under cramped field circumstances, if the surgeon has the necessary skills, and the situation requires emergency decision-making.

Crossectomy itself is rarely used in practice. Most often, doctors include it as part of a combined phlebectomy, which is ideal for the treatment of extensive lesions or abnormalities at an advanced stage. As a planned tactic, the operation is prescribed exclusively for the so-called “cold period” of varicose veins. Sometimes the course of the operation becomes an effective tool for blocking chronic venous insufficiency with localization in the legs.

But if we are talking about an unscheduled therapeutic measure to save the patient’s life, then the operation is limited exclusively to crossectomy according to current medical indications. All other stages are carried out after the preparatory stage with a thorough examination of the victim, when the risks of death are reduced.

Separately, the reasons that affect the volume of future manipulation are taken into account. Here you have to rely on the existing pronounced inflammation of the tissues. Despite this, this format of dressing still remains a radical solution to the issue of the spread of venous thrombosis.

The price of the intervention depends on whether it was carried out independently or as part of a therapy. If an emergency crossectomy was first performed, then the treating phlebologist will decide when to remove the remaining affected vascular territory in a planned manner after the examination. Such treatment will be more expensive, but if a person wants to limit the risks of relapse, then it is better to go all the way to the end the first time.

In order for the lower body to again be able to withstand increased loads, surgery is indispensable. But it is allowed to carry it out only if there are appropriate medical indications.

They include:

• thrombophlebitis of an acute type, provided that thrombosis belongs to the category of a steadily ascending disease;
• thrombophlebitis of purulent course;
• panphlebitis, regardless of the specific localization, starting from the knee and femoral segment and above;
• thrombophlebitis, which is complemented by antibiotic resistance.

The last point is more suitable for people who, along with the underlying disease, also suffer from immunodeficiency of any origin. If we summarize all the indications, then they relate to a complicated form of classical varicose veins, which is extremely problematic to get rid of by alternative methods.

Despite the fact that the technique is in consistently high demand among narrow-profile surgeons and the victims themselves, it can not be used for all clinical pictures. A preliminary examination with the mandatory delivery of various tests will help identify contraindications.

The list of absolute prohibitions highlights:

• oncological neoplasms of any localization, benign or malignant;
• diabetic nephropathy, including suspected diabetic foot;
• pronounced obesity;
• insufficiency of the multiple organ format;
• diagnosed atherosclerosis;
• cachexia;
• exceeding the maximum age limit.

Pregnancy is considered separately, for which it is not the surgical excision itself that is much worse, but general anesthesia. It negatively affects the activity of the cardiovascular system, and can also harm the fetus with specific reactions of the body to the composition of medicines. General anesthesia is inherent in a complex procedure, where crossectomy is only part of an extensive program.

There is a group of relative contraindications, which means that it is possible to perform an operation in the presence of a specified diagnosis, if the benefits of the event outweigh the harm.

The category covers three states:

• trophic disorders that are localized on the diseased limb;
• limited mobility in the postoperative period;
• the impossibility after the performed surgical actions to clearly follow the mode of wearing the compression set.

In such scenarios, the final verdict remains with the attending physician, who is obliged to study the information from the victim’s medical record. Also, the current state of the ward, his hereditary predisposition and concomitant chronic ailments are taken into service.

Reviews of patients who underwent crossectomy confirm that exceptions are possible with relative contraindications.

How is the operation?

Having figured out what kind of operation it is, people begin to be interested in a step-by-step scheme of intervention.

The basis of the algorithm has remained since the time when surgeons practiced the traditional Troyanov-Trendelenburg program. Here, too, the intersection of the great saphenous vein is performed. But if in the standard version the intervention was carried out below the saphenofemoral anastomosis somewhere at a distance of about 10 cm or more distally, but in the new version the calculation is different. The reason for the radical changes was too frequent relapses, which provoked a new mark in the patient’s medical record – recurrent phlebitis. The basis for repeating the negative scenario was the ability of the vein to restore blood flow slightly above the place where the ligation was performed earlier.

To prevent this, the thrombosed vein during crossectomy is tied up much higher. Most often, the incision point is the place where the great saphenous vein flows into the main femoral vein. This approach made it possible to divide the blood flow into superficial and deep. This reduced the percentage chance of relapse to almost zero.

To implement the plan, surgeons almost always use local anesthesia, which is also called conduction. It is carried out at the preparatory stage, when an allergic test is additionally done to the patient. This will eliminate the possibility of developing anaphylactic shock as a natural reaction of the body to the medicinal composition of the anesthetic composition.

After anesthesia, the victim will have to go through several more stages, including:

• processing of the surgical field;
• incision of the skin with subcutaneous tissue in the groin area;
• carrying out a high selection of the saphenous vein near the confluence zone;
• ligation together with tributaries approximately at a distance of about 1 cm from the anastomosis.

At the end, the medical staff applies stitches. It follows from the instructions above that it is not necessary to remove the vessel. Because of this, the preparatory stage does not require significant efforts on the part of the victim. He will not have to endure general anesthesia, as happens with the involvement of a combined phlebectomy.

A complex approach

The algorithm described above is suitable for crossectomy as a monotherapy for emergency situations when it is necessary to block possible complications of thrombosis immediately. But usually the operation becomes only part of an extensive phlebectomy, acting as the first stage in restoring the health of the legs. Here, without excision of the affected vessel will not do.

The first step of the combined radical intervention involves an inguinal incision at the junction of the deep and superficial veins. The second vessel is cut off with an eye to the degree of damage, and then ligated.

The second step relies on making another incision at the top of the lower leg or near the ankle. Having selected the saphenous vein, a special probe made of metal material is launched there, which, as it moves, should reach the area of ​​the first cut.

After the probe reaches the designated place, the veins are fixed. To do this, use a special thread, after placing it on the probe tip. The third part of the intervention is called the Babcock operation. It provides long stripping on the left or right, which is made possible by the use of a flexible probe tip. It is pulled through the incision, and the sharp edge of the instrument cuts off the vessel from the nearest undamaged tissues.

Separately, the strategy of miniphlebectomy, which is also called the Narata method, is considered. This operational aspect includes the removal of previously marked venous nodules and tributaries, followed by ligation of the perforating veins.

It is especially difficult for the surgeon if the vessels have received a tortuous shape, which prompts the integrity of the cover to be violated in several places in order to remove the affected areas in parts. The knots are removed with a special surgical device called the Muller hook.

To make the result look aesthetically pleasing, the punctures are made very small, up to 2 mm. Such wounds heal on their own without the need for stitches, and after a couple of months there is not even a trace of them.

Postoperative rehabilitation

Some patients do not know how to live after venous ligation, considering that this is a serious contraindication to all usual activities. But in fact, everything is not so serious, if you stick to the right recovery.

In contrast to phlebectomy, single crossectomy at the postoperative stage pays special attention to the prevention of possible inflammation and thrombotic complications. This foresight is explained by the fact that emergency operations are always carried out in conditions far from ideal, which can aggravate the clinical picture in the future.

Against this background, powerful antibacterial therapy involving combined antibiotics is a completely reasonable decision if purulent thrombophlebitis is suspected in the victim.

Also for a speedy recovery you will need:

• get rid of dysbacteriosis;
• conduct anti-inflammatory therapy to reduce the resulting redness, swelling and simple swelling, soreness and fever;
• conducting phlebotonic therapy with the appointment of drugs designed to accelerate venous return and increase the tone of the walls.

The list of specific medications that have a lymphotropic effect should be selected by the attending physician according to the individual characteristics of the organism of his ward. Such foresight will protect against lymphostasis, when the lower limb is constantly swollen.

But painkillers are usually given only on the first day, since the area of ​​surgical intervention provides for minimal damage to the integrity of the skin. Therefore, doctors are focusing more on the prevention of possible thrombosis, using blood clotting drugs to control the condition.

Wound healing medicines are especially helpful if the victim had trophic ulcers on the operated leg. It would be useful to add vitamin supplements to the complex as prescribed by the phlebologist.

If, in the process of studying the results of tests, it suddenly turns out that a person’s immunity has been greatly shaken, then you will have to use drugs to increase nonspecific resistance.

In addition to the standard medical postoperative therapy, it is mandatory to wear compression underwear from the first day of the intervention. As an alternative, tightly wound elastic bandages are suitable for the first time. Next, you will have to buy special compression stockings at the pharmacy.

You should not assume that the procedure should chain the patient to the bed for many weeks. Even on the first day, experts advise walking a little along the corridor.

On the following days, walks should be arranged for an hour.

Probable complications

Since crossectomy is an emergency, it is often performed without proper preparation, which explains the increased chance of complications. Moreover, all the consequences can be divided into quite expected, which are within the normal range, and specific. The latter need urgent adjustment according to the circumstances.

Most often, patients experience damage to the great saphenous vein. This happens when the vascular wall is compacted or sclerosed. The main problem here is heavy bleeding. But usually surgeons successfully cope with such negative aspects of saving a life. It is much more difficult if the damage has affected the femoral artery or vein.

Among the relatively rare phenomena, post-thrombophlebitic syndrome, acute postoperative thrombosis of the iliac-femoral segment are distinguished. If during excision the lymphatic vessels in the groin are touched, then this threatens the development of lymphorrhea at the recovery stage.

Usually, lymphatic drainage goes away on its own in the first few days, but with a particularly large lesion, you will have to wait at least a couple of weeks. But postponing local assistance when signs of an inflammatory process are detected is akin to a time bomb.

If everything went well, then the positive dynamics will not take long, which allows the patient to quickly return to a normal physical state. The intervention itself lasts about an hour and a half, and with an integrated approach, the time interval increases.

The start of conservative postoperative therapy falls on the second day, when it is already necessary to wear compression underwear with an ideally selected degree of elasticity. You will have to wear it for about two months with the most successful outcome.

Additional levers for a speedy recovery are walking, performing special exercises to improve blood circulation. The program is compiled individually based on the recommendations of the treating specialist.