Whenever I recommend or describe an ambulatory phlebectomy for any of my patients with varicose veins, I almost always get asked the following question: “Isn’t that a vein stripping?” This happens so routinely that I have often thought the procedure should be called an “Ambulatory-Phlebectomy-No-It-Is-Not-A-Vein-Stripping!”
In my experience, this is an excellent procedure, yet it has been largely ignored by most surgeons and even the majority of phlebologists. Many primary care physicians are completely unaware of this procedure as an option to effectively treat a variety of varicose veins.
Historical Development
A Swiss dermatologist named Robert Muller is credited with the invention and development of the ambulatory phlebectomy procedure. Muller first performed the procedure in 1956 and after gaining experience and follow-up on more than 500 patients, he published an article describing the technique in 19661.
Although the procedure has evolved in some of its technical details, the principles of the technique remain the same as originally espoused by Muller:
1. The absence of any venous ligatures
2. The exclusive use of local anesthesia
3. Immediate ambulation
4. Micro-incisions no more than three mm in length
5. The absence of any skin sutures
6. Post-procedure compression wrap for 24-48 hours
7. One week of a compression stocking.
Tumescent Anesthesia
Tumescent anesthesia is a technique of infiltrating large volumes of a 10-fold dilute concentration of lidocaine into the skin and subcutaneous tissues. The technique was developed by Dr. Jeffrey Klein, a plastic surgeon who has a PhD in pharmacology.
He developed the technique based on work he performed at the NIH during his post-doctoral research. Klein discovered that the widely held recommendation that the maximum safe dosage of lidocaine (7 mg per kg of the patient’s actual weight) was based on extrapolations from the toxicity studies done for procainamide levels; yet the 7 mg/kg dogma had been rigidly adhered to since 1948 because that was the manufacturer’s recommendation packaged with the product.
Klein’s studies proved that 35 mg/kg of a 10-fold dilution of lidocaine was safe, and tumescent anesthesia has now become the standard-of-care for office-based liposuction2. Subsequent clinical studies have shown that tumescent anesthesia is an excellent choice for the ambulatory phlebectomy.3
Wound Infections – None!
By the mid 1970s many physicians from the United States and Europe were traveling to Mueller’s offices in Basle to watch and learn from the inventor or this procedure. Many of the visiting physicians were somewhat taken back by Mueller’s casual attitude regarding sterile technique. Despite the fact that he never wore a mask, surgical gown or sterile gloves, Muller claims that wound infections were exceedingly rare after the procedure.
Although the medical community was appropriately skeptical of his claim, modern science would explain his surprisingly good results several years later with the discovery that the most commonly used local anesthetics (lidocaine and procaine) are both bacteriocidal and bacteriostatic to many of the commonly found skin pathogens4. This, coupled with the fact that the incisions are only 1-3 mm long, are done in the office and not the hospital, and are only made in healthy, well vascularized skin explains why wound infections should be extremely rare, even without using perfect sterile technique.
At the Midwest Vein Centers (where we always practice stringent sterile technique) we have made approximately 60,000 micro-incisions for ambulatory phlebectomies over the years (about 2,400 cases with an average of 25 micro-incisions each) and we have never seen a single wound infection.
Happy Patients, Great Results
With excellent cosmetic results like those shown below, this office-based procedure that requires no narcotic pain medicine and allows patients to return to work and exercise the next day has been very gratifying for our patients who are often very enthusiastic about their results and the ease of the procedure. VTN
About the Author
Steven P. Rivard, MD, FACEP, is medical director at the The Midwest Vein Center in Glenview, Ill. As a practicing phlebologist with a background in emergency medicine, Dr. Rivard has years of clinical experience in treatments of the circulatory system. His special area of expertise in phlebology is in the emergency management of DVT, pulmonary embolism and hemorrhage from varicose veins. He can be contacted by calling 708-590-7150.
References
1 Muller R: Traitment des varices par la phlebectomie ambulatore, Phlebologie. 1966; 19:277-79.
2 Klein JA: The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987; 4:263-67.
3 Cohn MS, Seiger E, Goldman S: Ambulatory phlebectomy using the tumescent technique for local anaesthesia. Dermatol Surg. 1995; 21:315-18.
4 Schmid RM, Rosenkranz HS: Antimicrobial activity of local anesthetics: Lidocaine and procaine. J Infect Dis. 1980; 121:597-99.
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