Nerve Injuries and Varicose Vein Surgery

Abstract

Varicose vein (VV) surgery remains one of the commonest surgical operations performed across Europe. In the UK, it is also the commonest single cause of medico-legal action against general and vascular surgeons. Most of these actions appear to arise because patients have a poor understanding of the risks and benefits of intervention and are, therefore, surprised and aggrieved when the end-result (cosmetic improvement and/or symptom relief) is less satisfactory than they expected, or they suffer from unexpected complications. In the majority of cases, this situation arises because the surgeon has failed, either consciously or sub-consciously, to properly inform their patient of the risks and benefits. There are a number of reasons why this might happen including a lack of time and/or a wish not to cause unnecessary patient anxiety. The latter may be due to a genuine desire on the part of the surgeon not to alarm the patient or for fear that admitting to complications and occasional poor results may damage practice and livelihood. Another reason why surgeons may not be in a position to discuss their complication rates with their patients is ignorance. As most surgeons do not follow-up their VV patients, they usually lack valid personal audit data with regard to medium and longterm outcomes. This, together with a natural reluctance to publish anything other than excellent results, means that the true risks associated with VV surgery are surprisingly poorly documented in the literature. Probably, the most honest account of the morbidity associated with VV surgery remains Corbett’s personal series of almost a 1000 limbs in ,600 patients. Although, in this large prospectively documented consecutive series, major morbidity and complications were extremely low, there was a significant incidence of minor morbidity (17% patients) and, in particular, neurological complications (11% patients). In the UK, the commonest single cause of litigation following VV surgery is alleged injury to cutaneous sensory, specifically the saphenous and sural, nerves. However, as discussed above the true incidence and, most importantly, natural history of such injuries are poorly described. This means that surgeons have limited information to pass on to their patients and that the questions most frequently posed to ‘expert witnesses’ in medico-legal cases are difficult to answer with authority. For example, does objective evidence of nerve injury constitute a ‘breach of duty’ or should nerve injury be regarded as unavoidable consequence of VV surgery that can occur even in the best of hands? What is the true incidence of nerve injury after VV surgery? Why should the majority of people with nerve injury remain relatively asymptomatic while a small minority develop a chronic dysaesthetic pain syndrome such as saphenous nerve neuritis? If nerve injury is apparent following VV surgery, what should the patient be told about its likely resolution or chronicity? Is specific treatment ever indicated; for example, nerve repair? What reasonable steps can the competent surgeon be expected to take in order to Eur J Vasc Endovasc Surg 27, 113–120 (2004) doi: 10.1016/j.ejvs.2003.11.007, available online at http://www.sciencedirect.com on