Six of the Best, Vascular 20

In this prospective study, we attempted to explain the reasons for the high failure rates of venous surgery at the popliteal fossa, and the ideal place for the skin incision for short saphenous ligation. Eighty-nine consecutive patients (100 limbs) presenting with suspected primary short saphenous varicose veins had their popliteal fossa assessed by duplex ultrasound and the sapheno-popliteal junction located and marked relative to the skin crease. In 34 per cent of patients, either the giacomini or the gastrocnemius vein was incompetent rather than the short saphenous vein, furthermore in 9 per cent of patients the short saphenous vein terminated either with the giacomini or the gastrocnemius vein rather than the popliteal vein. In 87 per cent of the cases, the sapheno-popliteal junction was found to be within 6 cm of the skin crease, but in 8 per cent of cases the sapheno-popliteal junction could not be identified. A significant proportion of patients with primary short saphenous varicose veins had variable venous anatomy and sites of reflux at the popliteal fossa, accounting for the potential for inadequate surgery at this site and hence high rates of recurrence, requiring mandatory preoperative duplex assessment. In the majority of cases, a transverse incision placed at the site of the sapheno-popliteal junction is adequate, however, in a few cases the transverse incision can lead to difficulty in accurately ligating the sapheno-popliteal junction, an S-shaped incision may become necessary.