VARICOSE VEINS

CONVOLUTECTOMY ACCORDING TO MULLER

Introduction

Last updated: apr 5, 2023

Robert Muller (1919–2012) trained as a dermatologist in the Department of Dermatology at the University Hospital (Insel spital) in Bern, after which he started up his own practice in the historic town centre of Neuchâtel in 1951 (2–3). In the beginning, he treated varicose veins with sclerotherapy and removed blood clots through incisions, in accordance with the standard technique of the time. He later began to re-
move the blood clots together with the vein and so iscovered the technique of phlebectomy under local anaesthesia.

As long as the indication is correct and the procedure is performed well, the long-term results of ambulatory phlebectomy are ex- tremely good

Muller
 

Anatomy

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Indications

  • All types of varicose vein (CEAP classification C1-C6), including
    • the saphenous veins and their tributaries (special care needed with incompetent junctions)
    • varicose veins on the lateral aspect of the leg (lateral subcutaneous vein system of Albanese)
    • spider veins
    • veins on the dorsum of the foot
    • varicosities of the pudendal vein
  • Varicose nodules
  • Perforating veins (including bone perforators) (27) • Curettage for telangiectasia
  • Facial veins (temporal, periorbital), hands, arms

 

Contra indications

Absolute

• Severe arterial ischaemia
• Infections
• Allergy to local anaesthetics
• Bedridden patient
• Coagulopathies
• Weakened immune system

(Anticoagulation is not a formal contraindication to phlebectomy.)

Relative

 

Workup

  • CEAP classification
  • Duplex/doppler

 

Pre procedural

  • Mark the varicose veins with an indelible surgical marker with the patient standing upright

 

Materials

Essentials

  • Sterile drapes
  • Local anaesthetic (diluted with normal saline or Ringer’s solution),
  • Sterile gloves and a mask, disinfectant (which should not remove the markings on the skin)
  • No. 11 scalpel blade
  • Mosquito forceps,
  • Phlebectomy hooks (Ramelet, Muller, Oesch, Varady)

Non-Essentials

 

Positioning the patient

  • Mostly supine, depending on the location of the convolutes

Muller
 

The procedure in steps

  • Time out
  • Marking the tortuous veins in upright position
  • Positioning the patient
  • Sterile preparation
  • The distance between incisions depends on the size and nature of the varicose veins to be treated
  • The hook is inserted gently through the incision into the subcutaneous tissues (to a depth of 5–7 mm)
  • The aim is to position the vein crosswise and grasp it, preferably with the tip of the hook
  • The soft white part of the vein is easy to recognise, as it is clearly different from the surrounding fibroadipose tissue
  • I can be extracted with the mosquito forceps held ready in the left hand
  • Gentle traction or a rotational movement can be used, pulling on the same or opposite side (pulley effect). The forceps should be placed as close as possible to the vein to prevent unwanted tearing and retraction
  • Neither venous ligation nor skin sutures are necessary
  • Haemostasis is achieved by compression
  • Sign out

 

Tips and tricks

 

Complications

Skin

  • Blisters
  • Hyper- or hypopigmentation
  • Local infection
  • Visible scars
  • Very rare complications: tattooing, skin necrosis,
  • silicotic granuloma from the application of talc,
  • Koebner phenomenon (psoriasis, vitiligo, lichen planus or necrobiosis lipoidica, etc.)

Vascular
  • Postoperative bleeding
  • Haematoma
  • Neo-telangiectasia (matting), most often spontaneous resolving
  • Lymphatic pseudocysts, lymphorrhoea
  • Postoperative oedema (dorsum of the foot)
  • Superficial thrombophlebitis
  • Deep vein thrombosis

Neurological
  • Transient or permanent injury to sensory nerve tracts
  • Tarsal tunnel syndrome as a result of inappropriate compression
  • Neuroma

General
  • Weakness
  • Allergy to the anaesthetic

 

Post-op

  • The small incision are closed with Steristrips
  • Compression is applied with a strong elastic bandage, extending proximally from the toe joints up over the operated area, which is left there for 24 h.

 

Follow-up

  • 14 days

 

Report

 

Patient folder

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Literature

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  29. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010 Dec;33(6):1088-100. doi: 10.1007/s00270-010-9829-7. Epub 2010 Mar 16.

  31. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006 Jun;17(6):959-64.

  32. Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007 Oct;62(10):938-49.

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  39. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  40. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008;143:457-461.

  42. Gordon RL, Ahl KL, Kerlan RK, Wilson MW, LaBerge JM, Sandhu JS, Ring EJ, Welton ML. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997;174(1):24-8.

  43. Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001;177:829-836 7.

  44. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001;12:1399-1405.

  45. Maleux G, Roeflaer F, Heye S, Vandersmissen J, Vliegen AS, Demedts I, et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009;104:2042-2046

  46. Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg 1989;209:175-180

  47. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB 2nd, Healy JF. Postembolic colonic infarction. Radiology 1982;142:47-51.

  48. Koh DC, Luchtefeld MA, Kim DG, Knox MF, Fedeson BC, Vanerp JS, et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009;11:53-59

  49. Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008;51:301-305

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The information contained herein has been obtained from sources believed to be reliable. However, no warranty as to the accuracy, completeness or adequacy of such information is implied. No liability is accepted for errors, omissions or inadequacies in the information contained herein or for interpretations thereof. The reader assumes sole responsibility for the selection of these materials to achieve its intended results. The opinions expressed herein are subject to change without notice.

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