[Development of perforator vein surgery from the Linton and Cockett procedure to endoscopic dissection]

Interruption of incompetent perforator veins (PV) is regarded as one of the principles of therapy in cases of severe stages of chronic venous insufficiency. This paper is to demonstrate the development of PV surgery from the original procedure (termed the radical Linton's operation after its originator) to minimal invasive approaches as the subfascial endoscopic perforator vein surgery (SEPS). Subfascial or epifascial interruption is frequently complicated by poor postoperative wound healing (sometimes more than 50%) even in cases with smaller incisions as the former Linton's procedure. PV interruption by hooks and special knives has been in wide use, however, the procedure is not as precise as a direct subfascial approach. The blind subfascial perforator interruption and fasciotomy by Hach has been advocated in severe forms of chronic venous insufficiency. It was Hauer at the beginning of the eighties who introduced a video-controlled surgical approach using a scope with fiberoptic lighting and video camera. At this time, a variety of instruments and modified techniques exists, but the effect of SEPS on venous hemodynamics and clinical outcome is not totally proven due to an additional reflux or obstruction in the deep or saphenous veins and concurrent epifascial surgery. A lower rate of complications of the endoscopic procedures is described, however, there is still a rate of about 5% hematoma and about 7% delayed wound healing. SEPS is an important adjunct in severe cases of PV insufficiency with chronic venous ulcers and lipodermatosclerosis. SEPS will fail in circular crural ulceration where the lesion should be totally excised and covered with skin transplantation. Up to now there is no study to demonstrate the efficacy of SEPS in patients with primary saphenous vein incompetence without deep reflux.