Surgical interventions

The surgical interventions employed in the treatment of venous leg ulcers include:

• debridement
  • necrotic material or slough within a wound margin should be removed since they act as a medium for bacterial proliferation
  • debridement may be
    • sharp
    • e.g., using curette or scissors
    • should only be carried out by appropriately trained practitioners
    • local anaesthetic cream should be used to reduce the pain of sharp debridement in patients with venous leg ulcer
    • enzymatic
    • mechanical
    • biologic - using larvae
    • autolytic
• very few high quality studies exist which directly evaluate the effect of debridement versus no debridement or the superiority of one type of debridement on the rate of venous ulcer healing (1,2)
• skin grafting:
  • indicated for ulcers which fail to heal within 12 months
  • may be indicated earlier for large ulcers
  • performed using
    • autograft - skin or cells taken from another site on the same patient
    • allograft - skin or cells taken from another person
    • artificial skin - human skin equivalent (1,2)
  • pinch skin grafting, together with multilayer compression bandaging, has been utilized cost effectively (1)
• vein surgery:
  • patients with superficial venous incompetence benefits from superficial venous surgery
    • superficial vein surgery has been shown to be effective only if the deep venous system is competent
    • it can reduce the chance of recurrence and increase the ulcer-free period
    • indications for superficial venous surgery:
      • patient fit for surgery
      • there is sufficient mobility to activate a calf muscle pump
      • the patient is prepared to attend hospital for investigation and surgery
      • obesity is controlled (body mass index <30)
      • superficial venous incompetence: no deep venous incompetence on duplex imaging, or predominantly superficial venous incompetence on ambulatory venous pressures with tourniquet occlusion of the superficial veins (3)
• subfascial endoscopic perforator vein surgery (SEPS)
  • the role of SEPS is unclear, but may be useful when combine together with ambulatory compression treatment and surgery of the superficial venous system (1)

Reference:

• (1) van Gent WB, Wilschut ED, Wittens C. Management of venous ulcer disease. BMJ. 2010;341:c6045.
• (2) Collins L, Seraj S. Diagnosis and treatment of venous ulcers. Am Fam Physician. 2010;81(8):989-96.
• (3) Simon DA, Dix FP, McCollum CN. Management of venous leg ulcers. BMJ 2004;328:1358-1362