Recent Published Articles

Treating varicose veins with transilluminated powered phlebectomy

AORN Journal, Dec, 2002 by Lisa M. Zotto

The article "Treating varicose veins with transilluminated powered phlebectomy" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.
A minimum score of 70% on the multiple-choice examination is necessary to earn 3 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Dec 31, 2005.
Complete the multiple-choice examination and learner evaluation found on pages 991-994 and mail with appropriate fee to
AORN Customer Service
c/o Home Study Program
2170 S Parker Rd, Suite 300
Denver, CO 80231-5711
or fax the information with a credit card number to (303) 750-3212. You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.
BEHAVIORAL OBJECTIVES
After reading and studying the article on using transilluminated powered phlebectomy to treat varicose veins, the nurse will be able to
(1) identify the elements of clinical diagnosis pertinent to patients with varicose veins,
(2) discuss the components of preoperative patient preparation,
(3) describe the steps of the transilluminated powered phlebectomy procedure to surgically treat varicose veins, and
(4) explain the advantages of using transilluminated powered phlebectomy versus traditional surgical approaches.
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
Varicose veins are superficial veins that have expanded in response to increased pressure and turbulence. (1) This leads to venous valvular incompetence. The valves in the veins are unable to close properly. As the valves become defective, the venous walls become weak, which allows for distension and reflux. Varicose veins are most common in the lower extremities but also occur in other areas, such as the spermatic cord (ie, varicoceles), esophagus (ie, esophageal varices), and rectum (ie, hemorrhoids). (2) Many theories exist regarding risk factors that relate to the incidence of varicose veins, including
* genetic predisposition for weak venous smooth muscle tissue;
* gender;
* hormonal influences during pregnancy;
* prolonged standing;
* obesity; and
* age.
Gender is considered a risk factor because traditionally the female:male ratio for venous disease is four to one in the United States; however, new studies suggest this ratio may be changing. It is believed that 25% of the worldwide adult population has some form of venous disease in the legs. (3)
Patients usually present with various signs and symptoms. Signs may include unsightliness, hyperpigmentation, and lipodermatosclerosis. Symptoms may include episodes of aching, burning pain, nocturnal cramps, ankle edema, dermatitis with or without itching, superficial thrombophlebitis, external hemorrhage, and, ultimately, ulceration.
CLINICAL DIAGNOSIS
The physician takes an initial history and performs a physical examination when a patient presents with complaints of varicose veins. It is vitally important that a complete physical examination of the lower extremities be conducted with the patient in two separate positions, standing and either supine or prone. The varicose veins should be at their greatest dilation and easily observed when the patient is standing. The veins disappear when viewed in the supine or prone position because of the reduction of hydrostatic pressure (ie, the decrease in the equilibrium of fluids such as blood). This reduction in the hydrostatic pressure is caused by the decrease in gravitational pull when the patient is in the prone or supine position.
Duplex ultrasound has become the standard diagnostic test and is required by many insurance companies for precertification before surgical treatment can be authorized. It is performed to determine whether the greater and lesser saphenous veins are incompetent. This can be a primary source of the formation of the varicose cluster. Lower extremity venous duplex ultrasound can provide flow information while at the same time providing high resolution views of both deep and superficial venous systems, including delicate valves, small perforating veins, and even reticular veins as small as 1 mm in diameter. (4)
Another diagnostic test that can be performed preoperatively is a continuous-wave Doppler ultrasound. A probe is used to distinguish between flow and stasis in a major vein, such as the saphenous vein, and to determine whether the veins are patent or obstructed. (5)
TREATMENT OPTIONS
Historically, only two treatment options have been available for varicose veins, including conservative measures, such as compression stockings, or corrective measures, such as surgery, sclerotherapy, or laser treatment. Sclerotherapy and laser treatment generally are performed on the smaller surface veins, which often are referred to as spider veins. Surgical treatment is necessary to treat larger varicose vein clusters. In many situations, a combination of treatment methods is best.
Traditional surgical techniques include hook phlebectomy and stab avulsion. These procedures are performed by making multiple, small incisions directly over the varicose veins. A small hook or hemostat is introduced into the incisions. The varicosities are hooked and pulled through the incisions and then excised in small pieces. Although these techniques are successful in removing the varicosities, there are significant drawbacks.
* They tend to be tedious and require long surgical times.
* They require multiple incisions that cannot be hidden, resulting in undesirable cosmetic results and an increased chance of infection.
* The veins may be friable and break, leaving large vascular remnants.
* The varicosities are difficult to see during such procedures because of the reduced hydrostatic pressure while the patient is on the surgical bed. This leaves the surgeon virtually blind while striving for complete removal.
TRANSILLUMINATED POWERED PHLEBECTOMY
Several years ago Gregory Spitz, MD, Rush Copley Medical Center, Aurora, Ill, faced with an afternoon of tedious phlebectomies, asked his surgical staff members whether there was a piece of equipment that would "suck the vessel in, morsellate the vessel, and suck it out." (6) The circulating nurse handed him a small carpal tunnel resector blade. After several years of development, a procedure called transilluminated powered phlebectomy was perfected by a team of physicians with the assistance of industry partners.
Transilluminated powered phlebectomy is endoscopic resection and ablation of superficial varicosities using a powered vein resector, an irrigated illuminator, and tumescent anesthesia. The advantages of performing transilluminated powered phlebectomy versus stab avulsion or hook phlebectomy include decreased number of incisions and decreased surgical time. In addition, the surgeon is able to see the vein during the procedure with the aid of transillumination, allowing more complete removal of the varicosities.
A large cluster of varicose veins usually can be removed via two small incisions. The surgeon inserts an illuminator, which also has a channel through which tumescent solution can be introduced into a 2-mm to 3-mm incision. The light then transilluminates the vessels from underneath. The pressure of the fluid as the tumescent solution is introduced, hydrodissects the vessels from the surrounding tissues. While the illuminator still is in place, the surgeon makes a second incision and inserts a motorized resector. The resector, while connected to suction, draws the vessel into its opening, morsellates the vessel via the mechanical action of the resector, and suctions the fragments out of the body. The entire procedure is performed under direct visualization by using transillumination so the surgeon visually can confirm when the vessels are removed completely.
PREOPERATIVE PREPARATION
After the surgeon establishes a clinical diagnosis via history, physical examination, and diagnostic testing, an office staff member schedules the patient for surgery. Table 1 is a preoperative varicose vein questionnaire that can be used to obtain a history of the disease process before or after physical examination. During preoperative teaching, the surgeon advises the patient to stop taking any medications, herbs, or vitamins that increase bleeding or clotting time (eg, aspirin, ibuprofen, vitamin E). The surgeon also instructs the patient to remain NPO after midnight and not to use any creams or lotions on the legs after bathing the day of surgery. The patient should be provided with a list of postoperative instructions and expectations (Table 2), including
* leaving the surgical dressing in place for 48 hours postoperatively;
* understanding that ecchymosis, numbness, and paresthesia are temporary;
* managing postoperative pain by using analgesic medications;
* observing for signs and symptoms of infection; and
* using elastic support hose for two to six weeks postoperatively.
On the day of surgery, the patient arrives at the ambulatory surgery unit (ASU) one hour to one and one-half hours before surgery. A perioperative nurse instructs the patient to remove all clothing, including undergarments, and change into a hospital gown. The nurse checks the chart, verifying history, physical examination, surgical consent, and the surgeon's preoperative note. The perioperative nurse will confirm with the patient any allergies and NPO status. The perioperative nurse also checks the patient's vital signs, starts an IV, and reinforces education, including postoperative instructions.
The surgeon visits the patient approximately 15 minutes before the scheduled surgery to mark the patient's legs. The perioperative nurse ensures that the patient ambulates in the room or hallway for at least 20 minutes before the surgeon arrives. Ambulation dilates the varicosities and allows for more accurate marking of the legs preoperatively. The surgeon marks the legs using an indelible ink marker while the patient is standing. The varicose veins are not marked individually, as in stab avulsion and hook phlebectomy, but the entire varicose cluster is outlined (Figure 1). An ultrasound also may be performed at this time to verify preoperative patency and obstruction of the vessels. After the leg or legs, if procedure is bilateral, have been marked, the patient is placed on a stretcher and transferred to the surgical suite.
[FIGURE 1 OMITTED]
OPERATING ROOM SETUP
The circulating nurse and scrub person set up the OR for the transilluminated powered phlebectomy. The scrub person sets up standard sterile equipment and instruments (eg, mixter right angles, Richardson retractors, Debakey tissue forceps, Weitlaners, electrosurgical pencil, ligating clips, vein stripper, suction) used for phlebectomy and greater saphenous vein ligation and inversion stripping. The surgeon addresses the sources of venous hypertension (ie, increased pressure and turbulence) while correcting the varicose clusters. If the duplex ultrasound determined that saphenous incompetence is present, the surgeon removes a portion of the saphenous vein as part of the surgical procedure. Sterile components, available as a system, are needed also for transilluminated powered phlebectomy. These components include the
* motor drive unit hand piece,
* disposable illuminator tubing,
* disposable resector,
* irrigated illuminator,
* light cables, and
* threaded metal adapters to connect the light cable to the irrigated illuminator.
The circulating nurse sets up the room with the standard surgical equipment used for phlebectomy and greater saphenous vein ligation and stripping. He or she adds the nonsterile components specific for this procedure, including
* a control unit,
* a light source, and
* an irrigation pump for tumescent solution.
The scrub person connects the resector, suction tubing, and irrigation tubing to the hand piece. He or she then connects the illuminator to the light cable and disposable illuminator tubing through which tumescent solution will flow. The scrub person passes the ends of the light cable, hand piece, suction, irrigation, and tumescent solution off the sterile field so the circulating nurse can connect each to its specific source.
The circulating nurse prepares the tumescent solution by adding 80 mL of 1% or 40 mL of 2% lidocaine to 1,000 mL of 0.9% normal saline. He or she then adds 1 mL to 2 mL of 1:1,000 epinephrine. The circulating nurse connects the tumescent solution to the illuminated irrigation tubing passed off by the scrub person. The circulating nurse places the solution in an irrigation pump and sets it at 500 mm Hg to 900 mm Hg. He or she attaches the illuminator to the light source, sets it at 1,000 lumens, and places the light source on standby to reduce the chance of burns.
Another 1,000 mL bag of 0.9% normal saline is used for resector irrigation. This bag of solution does not need to be pressurized, so it can be hung from a standard IV pole and used to irrigate the resector via gravity. The circulating nurse connects the end of the hand piece to the control unit, sets the revolutions per minute (RPM) at 1,000 (range 700 RPM to 1,200 RPM), and the suction on high. Table 3 is a sample surgical preference card for use in setting up the OR.
INTRAOPERATIVE CARE
The circulating nurse arrives in the ASU to greet the patient, introduce surgical team members, and explain the procedures that will take place in the OR. The circulating nurse has the patient confirm the surgical procedure to be performed, laterality if applicable, NPO status, and presence of allergies. The circulating nurse reviews the chart and diagnostic test results. Based on his or her assessment, the circulating nurse then develops a care plan (Table 4). After the anesthesia care provider interviews the patient, he or she and the circulating nurse help the patient onto the OR bed in the supine position. The circulating nurse secures the safety strap, places the padded arm boards on the OR bed, and secures the patient's arms on the arm boards.
Depending on surgeon, patient, and anesthesia care provider preference, transilluminated powered phlebectomy can be performed under general, spinal, or local anesthesia. A light general anesthetic is preferred with the use of a laryngeal mask airway. The anesthesia care provider induces the preferred anesthetic and secures the patient's airway.
The anesthesia care provider places the OR bed in Trendelenburg's position. If possible, the circulating nurse elevates the patient's legs 30 degrees using a picket-fence leg holder. The circulating nurse preps the patient's leg circumferentially from toes to the groin. The surgeon and scrub person drape the patient in sterile fashion, allowing for repositioning during surgery. The circulating nurse and scrub person place the instrumentation and equipment around the sterile field and connect each piece to its own power sources.
PROCEDURE
Patients having greater saphenous incompetence may undergo ligation and division of the greater saphenous vein. Patients with lesser saphenous vein incompetence may undergo ligation and division of the lesser saphenous vein, as indicated by preoperative testing. (7) Many techniques can be used to manage saphenous vein incompetence. All techniques are compatible with transilluminated powered phlebectomy. The surgeon determines which technique is appropriate for each patient.
The transilluminated powered phlebectomy procedure begins with the identification of the venous clusters. The surgeon makes small, 3-mm incisions in strategic locations to best facilitate complete removal of the clusters and provide positive cosmetic outcomes. After the surgeon makes the first incision, he or she introduces the irrigated illuminator directly under the veins. The circulating nurse dims the room lights so the veins can be illuminated (Figure 2). Using the trumpet valve on the irrigated illuminator, the surgeon instills tumescent solution under the subcutaneous layer using pressure, which causes hydrodissection of the vessels and expands the area of visualization.
The surgeon makes a second incision, and the scrub person connects the resector to the hand piece so the surgeon can place the resector underneath the patient's skin. The opening at the tip of the resector should be underneath the vessel to be resected. The circulating nurse turns on the suction to draw the vessel into the resector. The surgeon presses a button on the top of the hand piece to activate the rotation of the inner resector blade, which then morsellates the vessel. After the vessel is morsellated, the suction removes the debris. The surgeon or scrub person provide cross tension on the patient's skin during resection to prevent it from being drawn into the resector, which could result in puncture wounds (Figure 3).
[FIGURE 3 OMITTED]
After the surgeon has removed the first varicose cluster, he or she instills a second stage of tumescence. Unlike the first stage of tumescence, which is used to hydrodissect the vessels and expand the area of visualization, the second stage is employed to minimize postoperative ecchymosis and hematoma formation and to aid in postoperative pain management. The surgeon uses a larger volume of tumescence than used during the first stage of tumescence. The surgeon instills the second stage of tumescence until the patient's skin has a peau d'orange (ie, orange peel) effect.
The surgeon repeats the procedure for each area of varicose clusters. The scrub person places a stack of drapes under the patient's leg to ensure that the leg remains elevated as additional varicose clusters are removed and until a compression dressing can be applied.
The surgeon closes the incisions with a single subcutaneous stitch or self-adhesive wound approximating strips. The surgeon may place sterile gauze over the incision sites and wrap the leg in a sterile compression dressing.
POSTOPERATIVE CARE
The anesthesia care provider reverses the anesthetic and ensures that the patient has a patent airway. Surgical team members help the patient move back onto the stretcher. Usually the patient can be brought immediately to the phase II recovery area. The postanesthesia care unit (PACU) nurse assesses the patient's vital signs, pain control, and neurological status and checks the patient's dressing for bleeding and compression. Before discharge, the PACU nurse reviews the postoperative instruction sheet and medication prescriptions. The patient usually is discharged one to two hours postoperatively if his or her vital signs, pain control, and neurological status are all within normal limits.
Postoperatively, the patient comes to the surgeon's office three times a week for two weeks for ultrasound and electronic stimulation treatments. Combining the benefits of ultrasound and electrical stimulation helps decrease pain, swelling, and ecchymosis by increasing cell wall permeability. This accelerates the movement of interstitial fluid into the lymphatic system. (Figure 4)
[FIGURE 4 OMITTED]
CASE STUDY
Ms S, a forty-year-old Caucasian female who is a cashier at a grocery store, presented with symptoms of heaviness and tiredness, mostly in her left leg, with some ankle edema, swelling, itching, night cramps, and pain in the calf of the left leg.
The patient had used compression stockings faithfully during pregnancy 10 years earlier. Ms S stated that the large varicose veins in her legs caused her disability at work because swelling, pain, and discomfort occurred two to three hours after starting to work her shift as a cashier. Ms S previously had superficial thrombophlebitis associated with pain and discomfort. She self-treated the condition with anti-inflammatory medications, and it resolved approximately two years ago.
Ms S takes 20 mg of citalopram hydrobromide once per day for depression. She has no known allergies. Ms S underwent an inguinal herniorrhaphy in 1993. She has a significant family history of peripheral vascular disease. Her father had varicose veins, and her mother has hypertension. Both parents still are living.
On physical examination, Ms S demonstrated large varicosities in distribution of the greater and lesser saphenous vein, as well as Hunter's perforator on the left leg. Perforating veins drain reticular veins and varicose tributaries to the deep system and via the long or short saphenous systems. They play an important part in the venous drainage of subcutaneous veins. (8) Hunter's, Boyd's, Cockett's, and Dodd's are names given to large perforators of the saphenous system. Ms S is a good candidate for lower extremity venous duplex to delineate the exact pattern of incompetence. Her lower extremity venous duplex revealed the right side to be essentially normal. The left side showed an incompetent saphenofemoral junction as well as Boyd's, Cockett's, Dodd's, and Hunter's perforators. The deep system was completely competent.
Ms S returned to see the surgeon and receive her test results. The surgeon advised Ms S to have a ligation/division of her left greater saphenous vein and removal of the large varicosities just below the knee via transilluminated powered phlebectomy. The surgeon discussed the risks and benefits in detail with the patient. The patient was scheduled for surgery two weeks later.
The surgery was accomplished without complications via one groin incision and two counter incisions, each 2 mm in size. Ms S's dressings were removed on the second postoperative day during which superficial bruising in the distribution of resection was noted. Ms S was scheduled for and underwent ultrasound and electronic stimulation treatments three times per week for two weeks, which reduced pain, swelling, and time for the bruising to heal. Ms S wore antiembolism stockings eight to 12 hours per day for four weeks, depending on her work schedule.
Ms S returned to work one week after surgery and was seen in the office at six weeks postoperatively. Ms S had no complaints and was very happy with her surgical results at six weeks and also at her three month postoperative appointment.
CONCLUSION
Transilluminated powered phlebectomy provides a new and safe alternative to traditional phlebectomy procedures because it
* reduces operating time,
* requires fewer incisions, and
* allows direct visualization of the vessels as they are being resected.
Fewer incisions provide improved cosmetic results and increased patient satisfaction. Direct visualization gives surgical team members immediate positive feedback during the procedure.
Table 1
PREOPERATIVE VARICOSE VEIN QUESTIONNAIRE
Please circle all that apply Including body part and side, If applicable.
1. Do you take any of the following medications on a regular basis?
Aspirin
Digoxin
Oral contraceptive medications
Premarin
Steroids
2. Are you allergic to any of the following?
Iodine
Local anesthetic (ie, xylocaine, tetracaine)
Tape
3. Do you have a family history of varicose veins or spider veins?
No
Yes
If yes, please list relatives who have them.
4. How many years have you had varicose veins or spider veins?--
5. When did you first notice these veins? Before, during, or after pregnancy
After taking premarin or oral contraceptives
After an accident or injury
6. Are you required to be on your feet or sit for long periods of time?
No
Yes
7. Are you developing new veins?
No
Yes
8. Do you bruise easily?
No
Yes
9. Have you had bypass surgery?
No
Yes
10. Do you have any of the fallowing problems?
Bleeding disorders or bleeding too much
Dizzy spells
Transient (ie, temporary) vision loss
Transient weakness of limbs
11. Have you ever had any of the following problems?
Aches and pains In your legs Right Left
Ankle edema or swelling Right Left
Bleeding from the veins Right Left
Dermatitis (eg, eczema) Right Left
Itching Right Left
Heaviness or fired legs Right Left
Night leg cramps Right Left
Pigmentation (ie, discoloration) Right Left
Ulceration Right Left
Unsightly veins Right Left
12. Do you have a previous history of any of the following?
Deep vein thrombophlebitis Right Left
Pulmonary emboli Right Left
Superficial phlebitis Right Left
13. Have you had any of the following treatments?
Compression stockings Right Left
Electrosurgery Right Left
Local excision Right Left
Sclerotherapy (ie, injections) Right Left
Vein ligation Right Left
Vein stripping Right Left
14. Do you have leg pains while walking? If so, where?
Foot Right Left
Calf Right Left
Thigh Right Left
Buttock Right Left
15. Do you have leg pain while resting? If so, where?
Foot Right Left
Calf Right Left
Thigh Right Left
Buttock Right Left
Table 2
POSTOPERATIVE INSTRUCTIONS FOR PATIENTS UNDERGOING TRANSILLUMINATED POWERED PHLEBECTOMY FOR VARICOSE VEINS
Dressing
For the first two postoperative days, your leg will be wrapped from toe to groin in a sticky elastic bandage. Keep this on until you return to your surgeon's office to have It removed.
If the bandage is too tight causing numbness or pain,
* walk to loosen it or
* cut it just enough to relieve the pressure.
If bleeding occurs through the bandage, place gauze and tape or an elastic bandage over the outer dressing to reinforce it.
First postoperative appointment
Return to your surgeon's office on the third day after surgery to have the sticky elastic bandage removed.
Begin wearing your prescription compression stockings after your surgeon removes the bandage. Wear these stockings for 12 hours per day while awake.
Write down questions you would like to ask your surgeon so that you do not forget them.
Activity
You may begin your normal activities after the appointment with your surgeon on the third day after surgery.
Avoid sitting or standing in one place for long periods of time.
Walking and exercise will help you recover more quickly from your surgery. Talk with your caregivers about an exercise program that is right for you.
When sitting, use a recliner, if possible, or use a foot stool so you can keep your legs up.
Keep your legs up on a pillow when lying down.
Try to lie down with your legs above the level of your heart for 15 minutes at least twice per day.
Do not drive while taking prescription pain medication.
Showering
You may begin showering after the appointment with your surgeon on the third day after surgery.
The self-adhesive wound approximating strips that cover the incisions
* need to remain in place until they fall off by themselves in approximately seven to 10 days or when your surgeon removes them and
* can be washed gently with soap and water and patted dry.
Wound care
The following problems are normal and should go away two to four weeks after surgery. You may have
* areas under your incisions that are bruised, lumpy, or bumpy or
* numbness, tingling, burning, or intermittent sharp shooting pains in your legs.
Deeply massage the area on your legs where the veins were removed. Do this for 20 to 30 minutes every day with the ointment your surgeon told you to use.
When to call your surgeon
Your temperature is greater than -- F (--C).
Your stitches/staples come apart.
Your bandage becomes soaked with blood.
The skin around your stitches is red, swollen, or has pus coming from the incision. This may mean that you have an infection.
You have chills, a cough, or become congested. These are signs that you may have an infection.
Your skin is itchy, swollen, or has a rash. Your medication may be causing these symptoms, which maymean you are allergic to your medication.
You have questions or concerns about your surgery or medications.
Table 3
PREFERENCE CARD FOR TRANSILLUMINATED POWERED PHLEBECTOMY
Equipment
Electrosurgical unit
Light cable
Phlebectomy hand pieces
Phlebectomy light source
Phlebectomy power unit
Picket-fence leg holder
Pressure irrigator
Suction canister
Supplies
Drape towels
Electrosurgical unit dispersive pad
Electrosurgical pencil
Illuminator tubing
Knife blades #15 X 2
Medium vessel clip appliers and clips
Medium drape sheet
Major laparotomy pack
Needle, 22 g, 1 1/2 inch
Prep set
Radiopaque sponges, 4 inch X 4 inch
Resector kit
Self-adhesive skin approximating strips, 1/2 inch
Stockinette, 6 inch X 2
Suction tubing
Surgical drapes X 2
Surgical gloves
Syringe, 10 mL
U-shaped drape
Medications
Epinephrine 1:1,000 (1 mL ampules X 2)
0.25% bupivicaine with epinephrine 1:200,000
0.9% sodium chloride 1,000 mL X 2
1% or 2% lidoocaine plain
Suture
4-0 monofilament poliglecaprone (small cutting needle)
3-0 braided polyglactin 18 inch ties
3-0 braided polyglactin (medium taper needle)
2-0 braided polyglactin (medium taper needle)
Nylon ties to secure cords together
Instruments
Debakey tissue forceps, medium X 2
Knife blade handles X 2
Mixter right angles, shod X 4
Richardson retractors X 2
Weitlaner self-retaining retractor
Notes
* Surgeon marks the patient's legs with an indelible marker while the patient remains standing in the holding area before receiving any sedative-type medications.
* Prep the patient in the usual sterile fashion with the patient's legs on the padded picket fence.
* Surgeon injects the patient's groin with bupivicaine.
* To prepare the tumescent anesthesia, mix 80 mL 1% lidocaine or 40 mL 2% lidocaine, 1 mL to 2 mL epinephrine 1:1,000, and 1,000 mL sodium chloride.
* Place mixture in pressure irrigator set at 500 mm Hg to 900 mm Hg.
* Set the power unit between 700 revolutions per minute(RPM) and 1,000 RPM, per surgeon preference.
* Place the light source and power unit on the surgical side at the foot of the bed.
* Use nylon suture or self-adhesive wound approximating strips to tie the following cords together:
* light cord to tumescent tubing and
* power cord to irrigation and suction tubing.
Table 4
NURSING CARE PLAN FOR PATIENTS UNDERGOING TRANSILLUMINATED POWERED
PHLEBECTOMY
Nursing
diagnosis Interventions
Deficient * Determines knowledge level, assesses readiness to
knowledge learn, and identifies barriers to communication.
related to
unfamiliarity * Explains sequence of events and reinforces teaching
with information about the procedure and expected postoperative
about the course.
surgical
procedure * Provides instruction (ie, verbal, written) for
surgical procedure and discharge based on age and
identified needs of patient and family to include:
* bandage care,
* activity,
* showering, and
* when to call the surgeon.
* Evaluates response to instruction.
Risk for peri- * Identifies baseline tissue perfusion including
operative injury preoperative neurovascular status of lower
due to position- extremities.
ing and intraop-
erative manipu- * Assesses factors related to risk for ineffective
lation of the tissue perfusion (eg, chronic diseases,
surgical leg immunosuppression).
* Positions the patient neutrally and anatomically
correct and pads pressure points.
* Evaluates for signs and symptoms of positioning
injury by comparing the patient's bilateral lower
extremities' neurovascular status with preoperative
status.
Acute pain * Assesses pain control.
related to
surgical * implements pain guidelines.
intervention
* Identifies cultural and value components related to
pain.
* Provides pain management instruction.
* Implements alternative methods of pain control
(eg, perioperative sedation, epidural analgesia).
* Evaluates response to pain management interventions.
Nursing Interrim Outcome
diagnosis outcome criteria statement
Deficient The patient The patient
knowledge communicates demonstrates
related to concerns related knowledge of
unfamiliarity to the surgical medication
with information procedure, management,
about the sequence of postop- rehabilitation
surgical erative events, and process, and
procedure wound management wound care
techniques. at time of
discharge.
Risk for peri- The patient's The patient is
operative injury function and free from signs
due to position- sensation is and symptoms
ing and intraop- maintained or of injury
erative manipu- improved from related to
lation of the baseline levels positioning.
surgical leg throughout the
perioperative
period.
The patient's bilateral pedal pulses are present and equal throughout the perioperative period.
Acute pain The patient The patient
related to communicates out- demonstrates
surgical come expectations and/or reports
intervention and understanding adequate pain
of the pain control
management plan. throughout the
perioperative
period.
NOTES
(1.) R A Weiss, C R Fried, M A Weiss, "Venous physiology and pathophysiology," in Vein Diagnosis and Treatment: A Comprehensive Approach (New York: McGraw-Hill Medical Division, 2001) 23-42.
(2.) L W Way, "Current surgical diagnosis and treatment," in Veins and Lymphatics, 10th ed, J Goldstone, ed (Norwalk, Conn: Appleton & Lange, 1994) 783-797.
(3.) G Fowkes, "Prevalence and risk factors of chronic venous insufficiency," seminar presented at World Congress of the Union at Internationale de Phelebologie, Rome, 11 Sept 2001.
(4.) R A Weiss, C R Feied, M A Weiss, "Venous imaging/duplex ultrasound," in Vein Diagnosis and Treatment: A Comprehensive Approach (New York: McGraw-Hill Medical Division, 2001) 85-92.
(5.) Way, "Current surgical diagnosis and treatment," 783-797.
(6.) G Spitz, Transilluminated Powered Phlebectomy: A Smith & Nephew Technique Plus Illustrated Guide (London: Smith & Nephew, 2000) 1-5.
(7.) Ibid.
(8.) M P Goldman, J J Bergan, "Duplex anatomy of telangiectasis as a guide to treatment," in Ambulatory Treatment of Venous Disease (St Louis: Mosby, 1996) 29-35.
RESOURCES
Chandler, J G, et al. "Defining the role of extended saphenofemoral junction ligation: A prospective comparative study," Journal of Vascular Surgery 32 (Nov 2000) 941-953.
McCollum, C; Wright, D; Coleridge-Smith, P. "Initial results of polidocanol microfoam treatment of saphenous incompetence," seminar presented at 20th World Congress of International Union of Angiology, New York, 8 April 2002.
Min, R J, et al. "Endovenous laser treatment of the incompetent greater saphenous vein," Journal of Vascular Interventional Radiology 12 (Oct 2001) 1167-1171.
O'Donnell, T F. "Lessons from the past guide the future: Is history truly circular?" Journal of Vascular Surgery 30 (Novemer 1999) 775-786.
Spitz, G A, et al. "Powered phlebectomy (TriVex[TM]) in treatment of varicose veins," Annals of Vascular Surgery 16 (July 2002) 488-494.
Spitz, G A; Braxton, J M; Bergan, J J. "Outpatient varicose vein surgery with transilluminated powered phlebectomy," Vascular Surgery 34 (November/December 2000) 547-555.
Weiss, R A; Weiss, M A. "Controlled endovenous occlusion unique RF catheter under ultrasound guidance to eliminate saphenous reflux: Two-year follow-up," Dermatological Surgery 28 (January 2002) 38-42.
Examination

TREATING VARICOSE VEINS WITH TRANSILLUMINATED POWERED PHLEBECTOMY

1. Many theories exist regarding risk factors that relate to the incidence of varicose veins, including all of the following except
a. genetic predisposition.
b. hormonal influences during pregnancy.
c. obesity.
d. hyperpigmentation.

2. -- is a test used to distinguish between flow and stasis in a major
vein and to determine whether the veins are patent or obstructed.
a. Continuous-wave Doppler ultrasound
b. Lower extremity venous duplex ultrasound
c. Ankle-brachial index
d. Digital subtraction angiography

3. During preoperative teaching, the surgeon advises the patient to stop taking all of the following medications, herbs, or vitamins that increase bleeding or clotting time except
a. aspirin.
b. ibuprofen.
c. vitamin [B.sub.6].
d. vitamin E.

4. The preoperative varicose vein questionnaire asks the patient whether he or she has a previous history of any of the following conditions except
a. deep vein thrombophlebitis.
b. coronary artery disease.
c. pulmonary emboli.
d. superficial phlebitis.

5. On the postoperative instructions form, the patient is instructed to remove the self-adhesive wound approximating strips that cover the incisions five days after surgery.
a. true
b. false

6. The perioperative nurse ensures that the patient ambulates in the room or hallway for at least 20 minutes before the surgeon arrives because it
a. increases the patient's fatigue and, therefore, his or her susceptibility to anesthesia.
b. stimulates onset of asthma, allowing the anesthesia care provider to administer preventive medications.
c. dilates the varicosities and allows for more accurate marking of the legs preoperatively.
d. stretches the lower extremity muscles, allowing easier access to the vascular system.

7. Which of the following interventions is applicable for the nursing diagnosis "Risk for perioperative injury due to positioning and intraoperative manipulation of the surgical leg?"
a. Determines knowledge level based on physiological status.
b. Evaluates response to pain management interventions.
c. Implements alternative methods of pain control.
d. Identifies baseline tissue perfusion including preoperative neurovascular status of lower extremities.

8. The surgeon instills tumescent solution under the subcutaneous layer using pressure
a. causing hydrodissection of the vessels and expanding the area of visualization.
b. expanding the vascular sheath to widen the area of visualization.
c. minimizing hydrodissection of the epidermal layer and preventing postoperative infection.
d. expanding the vascular sheath and preventing postoperative infection.

9. The purpose of the second stage of tumescent anesthesia is to
a. hydrodissect the vessels.
b. expand the area of visualization.
c. minimize ecchymosis and hematoma formation.
d. decrease the incidence of infection.

10. Transilluminated powered phlebectomy provides a new and safe alternative because it does all of the following except
a. allow direct visualization of the vessels as they are being resected.
b. reduce operating time.
c. require fewer incisions.
d. make vessels less friable.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not Imply that
AORN or the American Nurses Credential Center approves or endorses products mentioned in the activity. AORN is provider approved by the California Board of Registered Nursing, Provider Number CEP 13019.
Lisa M. Zotto, RN, BS, CNOR, is the clinical education specialist for the surgeon education department of Smith and Nephew, Inc, Endoscopy Division, Andover, Mass.
COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2003 Gale Group