SURGICAL ANATOMY FOR ENDOSCOPIC SUBFASCIAL DIVISION OF PERFORATING VEINS

Purpose: This study was undertaken to define the surgical anatomy of t he medial perforating veins (PVs) of the leg and to provide informatio n on how to gain access to all medial PVs from the superficial posteri or compartment during a subfascial endoscopic procedure. Methods: The venous anatomy of 40 limbs (from 23 cadavers) were studied. Medial. PV s located between the ankle and the tibial tuberosity were dissected. None of the subjects had pathologic evidence of venous disease. Each P V's type (direct or indirect), size (<1 mm, 1 to 2 mm, >2 mm), locatio n (distances from ankle [D1], and tibia [D2]), and accessibility from the superficial posterior compartment were recorded. Results: Five hun dred fifty-two PVs were identified (mean, 13.8; range, 7 to 22). Two h undred eighty-seven PVs (52%) directly connected the superficial with the deep systems, 228 (41%) were indirect muscle perforators, and 37 P Vs (7%) were undetermined. One hundred thirty-seven PVs (25%) were >2 mm. Sixty-three percent of PVs were accessible from the superficial po sterior compartment. In the distal half of the leg, two groups of dire ct PVs could be identified (Cockett II: D1, 7 to 9 cm; Cockett III: D1 , 10 to 12 cm). In the proximal half of the leg paratibial direct PVs (D2 < 1 cn) were found clustered in three groups (DI, 18 to 22 cm; D1, 23 to 27 cm; D1, 28 to 32 cm). Conclusions: Our study confirmed the p resence of the Cockett II and III PVs and three groups of proximal par atibial PVs, including the ''24-cm'' perforators. Two thirds of the me dial direct PVs are accessible for endoscopic division from the superf icial posterior compartment. To divide paratibial PVs, however, incisi on of the paratibial deep fascia is frequently required.