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Okay. All right. That's fine. Right. Uh Today's lecture, my name is uh for those who people who are, who are not there in the last lecture. Uh My name is Mr with uh we are called Misters in the UK because of, uh because we are surgeons and called Far CS. And uh we talked about arterial surgery. Uh I think we rush it through. Maybe we should repeat that. Uh I strongly believe that it should be repeated because we had to rush because of lack of time and the uh going to talk about varicose veins today. And the uh uh so then, uh definitely it's called, we call it venous disease is a very common disease and the impact on quality of life, especially people who have large varicose ulcers for years and years. The elderly people lying uh in pain, uh, and the absolutely no life at all. And it's so pathetic that with wrapped with green bandages and, and uh they could be wrapped with Betadine, which is a crime almost. I almost, I wrote a book about it because they are so painful. Uh not putting an appropriate dressing because Betadine stops feeling you know that and the expense on the National Health Service in any country is tremendous uh for venous diseases. So we need an MDT approach, multi uh disciplinary teams, surgeons, both vascular and plastic and the dermatologist, radiologists, especially for uh colored duplex scanning and also appliance sister that we need a sister for to do the lava therapy for the wounds, exit fly because varicose ulcers is a huge problem and the common denominator for all that is weariness hypertension. So that is the main cause of the, of the problem. So, think about that, right? So there are various theories where does it start? How does it start at in the Trendelenburg works? Uh said few things about it. We, we'll, we'll touch that in a minute. So retrograde flow away from the heart, it's term the venous incompetence or reflux underlying course of the venous disease. As we just said, is the hyper is the venous hypertension. And the main problems that we come across is the deep way in Trumbo. Sis, every medical student must know about Rudolph fluid, we call workouts because workouts red is asking every exam, you know, the three things, hypercoagulability, uh endothelial damage and stasis and the uh if you don't know that you will not become a doctor. Uh This is the man who uh developed the cell theory. Uh cell has to be born from another cell. That's what he said initially. Uh and the organism has to come from another organism. Uh So uh venous insufficiency, the other problem uh and causing venous hypertension. Now, as surgeons, we need to do, we need to divide this into various systems. Varicose veins are just a superficial system. But we there are other systems that the uh superficial system is about the investing fascia where you can almost see it. But uh is it really uh around the superficial fast here? But for, for our luck, it is not, the top part is not around the superficial faster but in it. So it splits it and, and that made us things much easier because uh we can put our probe into it. When we want to oblate the very close Wayne's, we can put our probe into it and put a thomason's around it because that split fascia, it has its own fascia that we did not learn for our anatomy. We thought it well long saphenous system is totally outside but not always. There is a special fascia and that, that was a gift for the surgeon. So we can inject our local anesthetic around the wane so that we crashed that wane onto the probe and the separate from the skin, at least you must separate for at least one centimeter so that the skin won't be born. So there are other surrounding uh structures won't be born, burned. So uh it is an important thing to create this heat sink. So that helped us. And so the other system is the deep system is one of the clinical questions you must ask because your superficial operations for the vast, for the varicose veins may not be successful. If the deep system is also incompetent and may not be even patent. If it is not patent, it will be criminal to touch the superficial system. You must think about that carefully. If you destroy that patient, we ended up with a post strong body, hugely soul and leg. And the, you know, the classical scenario of inverted champagne champagne bottle appearance. And therefore, if the deep system is not patent, you must not destroy the collaterals which are the varicose veins. Then for that particular patient and the patient will end up in a disastrous situation. And of course, the perforating systems, we know some of the perforators are incompetent and the superficial system may not be incompetent. So you deal with only with the perforating system. The most important uh important one is the void perforator just below the uh knee joint which almost surrounds with grapes of varicose veins. And you have seen that and never cut into that without uh full control above and below and from the perforators. So uh so perforator system and also that we as surgeons divide this into another high pressure system, we call it a cock it system which squeezes out the gastrocnemius, uh squeezes out the soleus muscle, it squeezes out everything into this per cock. It's perforators, five centimeters about the malleolus on the medial aspect, 10 centimeters about the medial aspect, which is the cock. It's two cock, it's three is about 15 centimeters from at the top of the medial malleolus. These three are very important and very difficult to treat. Uh There are various matters device for that because there's no point of tying off the saphenofemoral junction alone without dealing with the main problem because this could be the problem that the patient comes in with. So uh so there we divided into four systems. And also we asked the radiologist in our hospital here in Pembrokeshire, we have got the special uh square to for our to ask the radiologist. Uh the clinical question are the deepens patent and competent because you can warn the patient, the operation may not be that successful if the deep veins are not competent. But if the deep paints are not patent, you must not operate on that patient. So you have to be very, very careful because the lawyers are around, especially in Cardiff here, many lawyers who specialize with shorts self in a system and the neurological damage and etcetera. So you need to be very careful. So we divide that into four sections for us to treat this patient and not to do any mistakes. So the deep system should be investigated as well. So normal Wayne's are low pressure, high capacity and system hold most of the blood volume that what we replenish in the case of shock and etcetera. Okay. Right. Uh So as Trendelenburg thought that it all start from the top, but we know that descending theory does not hold true because the ascending theory is the one that we normally believe in because it starts from the lower part because sometimes the saphenofemoral junction will be, will be competent. So there's no need to uh operate on that part of the thing. So unfortunately, we have a new classification that all medical students must know. This is the CPAP classification. This is a clinical ideological, the path of physiological uh classification. So the C 0 to 6 are very important because it causes such amount of uh economic, huge economic problems to treat every bit of varicose veins. And so the National Health Service in UK cannot afford it. So the normal leg is known as C zero and this cosmetic problems like ridiculous Wayne's trade, Wayne's, they are known as C one and see two are the real varicose wanes which are wanes which are more than three millimeters in diameter, the smallest one, otherwise you cannot call that particular wane a varicose veins. And if you get a patient like this, you have to look at the territory, what territory is this wane? This is ob obviously uh the uh this is the long saphenous system. And uh so uh it could be short of in a system as well or, or it could be Cockers perforator system. We we we as surgeons like to talk about that separately although normally not, not related that in the book, obviously, see trees will be edema. And that one, we definitely need treatment whether whether it will cost money or not. Uh C three must be treated. So C three to C six must be treated. C four is a healed. Also with all these signs of uh of healing, there could be pigmentation due to him. Aside, Aerin deposit Asian, there could be a Dema Leiper dermatis sclerosis. You know all that inflammation and fibrosis. It's almost like a hard cardboard around the gator area. You know why gate area? Because that is the highest level of venous hypertension. If you take the leg, that's why everything to do with between us hypertension is in the gator area. So remember that, that that question will be asked from you why you get these problems in the gate area about the manual light around the ankle and that will be asked in the exam. So, so this is the uh atrophy blanche. Also a sign of heals also here. And uh atrophy bland is a white patch and it is definitely not Michael Jackson's with the lago, which is a totally different disease. This is due to varicose wins. So uh C four is that the fire is a healed ulcer, classical healed ulcer that also need to be treated. Why? And that is another question you will be asked, why do you need to treat, continue treating and healed? Also because of venous hypertension. We haven't dealt with it. We may have done it with various bandaging and etcetera or elevation by the patient, but we have not treated it. The, the ideological factor which is the venous hypertension. Therefore, that should be treated as well. There are various methods, we'll discuss that and the last one C six will be, will be the real ulcer. And uh so you need to know this Europe classification. Uh and the uh without that, we cannot go any further. Anyway, this ideological anatomical path, a physiological, we will not be asking you that much, you know whether they are congenital. There's a congenital condition called Klippel Trainer Units syndrome, which is a horrible thing obviously, for young young people with growing up legs, which becomes huge and they bleed and it is almost arterial weakness lymph anomaly. So, a primary Wayne's, you must differentiate primary vein. We are really, when we say about varicose veins, we are talking about primary veins, which is c too and also secondary range must be thought about because you must not destroy the collaterals and you must make sure the deep pains are patent before you deal with that. And that could be your take home message not to do a criminal act of dealing with secondary veins other than with stoppings. So, anatomical once in the superficial system, perforator system, we all already discussed that. And the path a physiological one, is it due to obstruction when the wane becomes bigger during pregnancy, it becomes bigger. So the Wales go apart and become incompetent. So you wait until the pregnancy is over. At least 11 year after the pregnancy is over. You must not conclude that this patient needs treatment. So, uh that's an important factor. Okay. So uh see too, we said that we are really not going to uh like arterial disease to get mad about it unless there are skin changes. Uh we can give them uh pair of Stockings compression horse theory. And the uh that is, that is the important thing to do. So that is your c too. And we said that to be called a varicose when at least it could be should be called three millimeters. And the edema edema is due to back pressure with a venous edema. But really is it venous edema? It is because of the inability of the lymphatic system to adequately drain the excessive interstitial fluid. And if they are got fluid pouring out from the very close, also, obviously, uh lymph lymph uh partick system doesn't get involved. That's why the old uh all the material gets socked, you know, the bandages and everything and uh patient is in a pool of secretions uh when that happens, right? So, uh C four, we, I'm just going through it again because at least if you get this uh get this classification, right? I think that's enough for me. So, venous eczema uh it is uh due to venous stasis and pigmentation is due to hemosiderosis. It no sis and pigmentation happens because that's another question. Why do they get pigmentation and lie pododermatitis sclerosis. And this uh this is a clinical sciences called Corona Phlebectomy Tikka or called flare signs. It is just at the ankle. There's a flare sign right here and don't promise to cure that to the patient. But you can improve that because this bubbly veins uh subcutaneous here because of the high pressure league from the cork, it's perforator system. So that is why, that's why why it is happening. Um Right. And the uh there are a whole lot of other symptoms, patient complaints of heaviness, aching, itching, cramping, tingling. This correlation between this, the size of the vein never, never tallies. The the and especially by the patient exaggeration is possible because they want to get this treated somehow. But it is almost now. We have decided in the United Kingdom that we can't afford to go on treating everything. Uh And therefore we treat only C three to C six. So remember see up classification, you must try and get used to because and only see classification is the one you must think about right anatomy, anatomy. I ask you the question, where does the very cause when start? Everybody says it's from the groin. No, it does not start from the groin. It starts from the dose, Alvar venous arch, either laterally shorts a venous system going behind the Mallya list or anti or going anterior to the malleolus on the medial side. And that part is important that is where you do a cut down when you can't get a cannula in. So you may be working in the periphery in, in, in a conflict zone. And when you want to get a cannula in, you have to do a cut down. That's why you need to know that anatomy. So it goes upwards uh to the groin. And whenever we asked, where is the saphenofemoral junction? Everybody struggles again. It is 1.5 interest of 24 centimeters below and lateral to the pubic cubicle. And you cannot even when you, when, when, when we get the chose to explore this area, what they do is they go feeling the uh artery and then try and find it, find the vein that is not the way to do it because you will be looking for it for the next half an hour. So, uh so you what you find the pubic cubicle and then 1.5 inches below and lateral pubic cubicle bisecting and you make a small incision and you find yourself in a femoral junction, that's how you find it. And also uh there are the neurological damage is the problems during varicose rain, open surgery, even even laser or radio frequency ablation. Therefore, you must this a multiple choice question you'll be asked about this. What? No, will you damage when you strip the vein, uh, long saphenous vein below the need level? So, uh, the answer is, you know, everyone is the long stuffiness numb. And then the, as I said, the lawyers are really, really good at the other. No, uh, going close to the, uh, close to the shorts of, in a system, which is the sural now. And that is the only time I I uh somebody tried to sue me. Uh But the, but the patient got the distribution of the nerve uh wrong somehow. So, uh we knew that she was not genuine complain. So, uh so therefore, it is important to know the anatomy. So especially you must know the anatomy at the groin because if you do not tie off the tributaries, the recurrence rate is even higher. Normally, the recurrent rate under any whisk it still 22%. It, it was 22% during the trend. Ling Berg's times. It is still 22% doesn't matter who operates. But if you do not try off these tributaries and the uh you will have a recurrent rate of nearly 44%. So what are these tributaries? The same as the artery circumflex? A reac superficial epigastric, then, then the superficial, external parental and deep Odendaal. And also you got the, the LATV, lateral tie uh tywin and all the medial tywin also, you need to know occasionally you may have, have dual long saphenous system. So you may do one with your ablation with you and spending so much money and you may miss another way. And so, you know, you should know about the normal anatomy. Okay. Right. So, apologies for the interruption professor. Do you mind making the screen full? Uh Yes. Right. Can you still see? Right. Uh Right. Anyway, it is that it is easy for me as well. So the long saphenous short says it's uh venous system start from the docile venous art. And the, the the we talked about the fascial compartment compartment and the uh first to Wallace, I think that you must know where it is. So we always ask the uh, juniors as well as we ask the medical students, where is the uh saphenofemoral junction so that you must know good. So, uh, in the leg, of course, the, the cock, it's perforators are important. We already talked about it and it is in the posterior are Tshwane, which is also known as Davinci, Leonardo, Davinci, Zwane. I don't know why. And also these two systems are joined by JIA Kameni. I didn't know much about it until somebody sued me saying that I didn't do a proper operation and I missed the deer Kameni. But, but luckily for me, when we did the color duplex scan, dear Kameni was not there. It is that it is the vein with joints, the the the the short suffering a system to the long stuffiness system. It may connect up to any Profunda or or medial, medial uh Taiwan, etcetera. So it doesn't, it, it is variable but it is important that you know that. So this is the uh Leonardo Davinci, even these are pockets perforators and there are multiple perforators along the Thai which all need to be dealt with. So uh deep winds, we are not hardly any deep winds in the human body. It is just when our commitment is on either side of the arteries eventually forms in the popular vehicle fossa, the real vein with all those branches as this we discussed on Tuesday. So uh gastrocnemius vein is important and, and the LT A anterolaterally highway nous is also important because if you don't, because the laser techniques does not deal with the antral lateral thigh wane and your caffeine a varix, the bump, you must treat it, it has to be treated open because that goes mainly into the antral at lateral tywin. So that cannot be dealt by your. So femoral triangle are allowed to talk about that. We did talk about that on Tuesday and the, when you explore this area, there are lymphatics. So n we why? So the lymphatics are on the medial aspect. So you must not divide them because it will drain forever and the patient will become anaemic. It's uh it has happened to me as well. So try and lift that lymphatic structures up before you deal with the artery or that vein. So, remember that it's uh we always like to talk about it. So these wells are by caspit and the uh there is in the ways there are normal endothelial protection and the uh there is prostacyclin things and the normal natural plus means into it. So uh to make it a non Trumbo genic surface and prevent platelet aggregation. And the uh there are circumference sort of linked rings in the elastic tissue. And the uh uh and also smooth muscle says around it to give, give it some tone, right? So uh the the important perforators when you uh it's important to deal with them and find them, especially the boys perforator right here. Others are not that important, but if you find them, you must deal with them, right? So, uh we talked about how it starts and we already done that. So when a patient comes, look at the legs with the patient's standing. So uh the uh the uh scars of previous surgeries important because uh you may do more damaged because the exploration is difficult. And also think about neo angiogenesis. Why we don't get into the groin? Now is because of new angiogenesis because when you cut anywhere angiogenesis, because of the wound healing is rapid and it connects up the tributaries or whatever left and reform the whole structure because when you strip the wane, we you invert it, uh you know the inside out, you, you bring it out and what happens all the cells spilled along that far Shal tract. Remember? So it is not in the subcutaneous tissues. It is in that far Shal track where the wane came out and vein can be reformed. So, uh so remember that vein can be reformed. So, uh so you have to think about that and getting a colored duplex and done before. And also you look at the Safina varix with the patient standing and uh of course, the hernias and the notes due to some of the reason because as clinician you need to talk about that. So uh with the patient standing and the uh listen to the patient, what the patient came in with what the patient point at pointed at at the in the clinic that wane has to be done. Otherwise, you have a very unhappy patient. You may tie you off beautifully, the suffering of femoral junction. You do a beautiful ablation. You must treat the wane, the patient came in with and the main incompetent channel uh must be dealt with. And then of course, once you finish that, you get the patient to lie down and look at the abdomen because this could be secondary veins, there could be a tumor in the pelvis. So you and ask you questions, you know whether the patient has got blood pr you never know. So, so you must be very, very cold. Patient may have an ovarian problem. So think about that. So uh skin changes have a look at them, especially the ones that we just mentioned, the edema pigmentation, lipo dermatis, sclerosis alterations, etcetera, immobility and stiffness is important. Calf muscles and the state of the calf muscle. Are they a trophy arterial ST status is very important because you may be operating on the patient and the patient wounds may not heal and the patient and you may destroy some veins that can be used for a rainy day. So don't destroy them unnecessarily if the patient is an arterial, but don't try to use do the very close veins is an important message again and the general patient status and also there may be various signs without vary close wayne's obvious. You you have a look at the leg, there is pigmentation, etc hma, etcetera, but you cannot really feel any varicose veins. So that is no and not an excuse not to investigate the patient because he may have superficial incompetence. Yes, maybe the saphenofemoral in cos you tie that off and the patient is cured. So don't totally ignore because you can, you could not see a single varicose veins. So remember that. So uh we are not going to talk about the upper uh upper leg and the the patient even he stands up, the pressure builds up because of the gravity and and therefore, it may even go up to 300 millimeters of mercury. That's why they bleed heavily. And if we, if somebody's bleeding in the park, the medical students is there right in the park, they will be called in. What will you do? You lift the leg up in the park with the patient lying down and the bellicose bleeding will stop, put a bandage around it, send the patient to that uh patient patient to the hospital. So the when you walked 20 yards, the pressure comes down to 20 millimeters of mercury, but it could be as high as 303 100 millimeters of mercury. So remember that anyway, uh this was done in uh so that the what are very close veins, they are permanently excessively dilated, twisted, ugly, unsightly tortuous veins and the uh when patient's upright obviously. And uh Latin word is varix is pluralist. Various is and the uh various is bent and 5 to 10% of the population has it. 80% is the great saphenous vein and look at these rains. This is definitely come from the uh the uh the boys perforator here. So remember the boys perforator and you have grapes around it, you know, under huge tension. Remember carpenter is working around suddenly punt uh goes into one of these with this uh with a nail or something and I think you had it. So you lift the leg up uh to to 90 degrees bandage it and send the patient to, to, to the hospital. Uh, anyway, we talked about that already who get very close friends. Uh This is never a conclusive evidence. The Edinburgh study men could equal to women, but it is very much less in the Asian countries. The reason we actually don't know, it may be high fiber diet and less constipation, less training. That's just a guess. So, uh, so age as you age obviously, and sometimes if the parents had it, the Children get it very early, even at the age of 15, 20 it could be due to a genetic mutation. Uh fox uh see to gene abnormality, but I'm not an expert on that height and weight, very unlikely during the pregnancy. We did talk about that weight for a year minimum before you start operating. And uh maybe we should believe in the Asian ladies and give them a good fiber diet. So uh that is just uh why do you get varicose wins? Why do you get venous hypertension? And the I will talk about that now because uh it will be in the late slides, but we may not have time. Therefore, uh mainly if you ask that question in the exam. So you have to say two things. One is loss of unit directionally flow towards the heart against the gravity due to uh insufficiency of the valves, especially saphenofemoral junction could be or the way in itself. And the other thing is loss of half muscle pump. So it is a real pump because there are venous sinuses. There have been a sinus within these muscles. That's why when you cut into muscles, there are no arteries to clam. You do a figure of eight to stop the bleeding. Remember that it's an important point. So because it is a venous sinus like a little heart and it's come, come from one side, comes out from the other side, it is also valid. So, uh so these squeezes out through the cock, it's perforators and uh and then pumped outwards upwards with the calf muscle pump. And the uh the pump is, is a great structure. Uh So uh it is not only calf muscle, all the muscles with the venous sinuses are involved, including the plantar surface, there is a huge plexus of veins in the plantar surface. So, uh you know, so when you put a put down uh squeezes the plantar surface, so I can call this a calf muscle plant a pump. So there are two things which causes venous hypertension. One is the the unit loss of unit direction and flow and also also the uh failure of the calf muscle pump. This could fail because of the lack of good muscle musculature. That's what we were talking about. We need to examine the uh muscles because it could be a trophy or may the, the there may be a fixed are through day basis because of the ankle. So all this has to be has to be thought about. So the main two reasons remember that the loss of unit direction and flow and the loss of calf muscle pump. So secondary varicose veins, you already said that is it the message that you must not operate on the secondary verticals when you deal with the second primary problem. So that whether it's a tumor in the uh or the pregnancy or, or, or the other problems. And one of the questions you must ask in the clinic is that is relating to the deep wind. You must ask this question. Have you ever had a DVT? Have you ever had pulmonary embolus them? This come from DVT, obviously, have you ever had long born fracture? That if that is not written down in the notes, I get very annoyed with my household, sir. So it is very important to get that long gone fracture. You must investigate the deep wanes. So, uh that's very, very, very important and try and stop the DVT. Uh DVT prophylaxis, try and stop the A charity four weeks before and restart two weeks later. And the uh my vote sister complained to me that she got pregnant when she stopped it. So it was not my fault. Uh just to uh that has happened 20 years ago, right? Okay. So do not ablate or destroy the patient collateral system. The only system the patient has for that leg. Otherwise you ended up with inverted champagne bottle appearance, right? So we said the common denominator is venous hypertension, congenital veins we did talk about and the intradermal venues we did talk about uh spider veins. Trade Wayne's hyphen web Starburst. There are various names but they are intradermal and they are less than 0.1 millimeter in diameter, uh one millimeter in diameter and there are subdermal wanes which are much larger reticular wanes, but they are not as large as three millimeters on standing. So history, we are not going to talk about history because we got time. I think they were talked about even 460 BC and all that. And Hippocrates also talked about it and he said something very interesting. The what cannot be killed by medicaments is cured by knife. What cannot be cured by knife is killed by searing iron? Hmm. Did he think about the modern laser and radio frequency ablation? So that is my question. Okay. Galen 25 BC. Yes. Did the same incision and, and phlebectomies just little cut, lift up the vein and tie it off or pull it off. So, uh even Galen had done in uh in 25 BC. So, uh anyway, I thought I should tell that. Uh oops. And we wonder why the giraffe don't get varicose wanes. So it must be a nice because they definitely don't have a calf muscle pump here and, and the bars must be great. Uh Okay. So we did talk about symptoms and signs. Um And this is the gate area. We always ask the question, why gate area? So remember the two nerves that could be damaged. Uh And that is a multiple choice question, bleeding, you know what to do when bleeding and of course, superficial from the probiotics, you may come across as a venous disease. Very easy to treat. That is not an infection. Everybody use antibiotics is no use giving antibiotics because it's not an infection. It's a segment of inflammation of the vein, superficial vein. So you give NSAID S with uh PPI cower and uh put a compress, felt bad as to any inflamed area. You, you immobilize it and leave it for about 10 days um and carry on with you and stids and PPIs and it will get better. Okay. So, uh uh but we did talk about that ulceration. I think we need that is the champ inverted champagne bottle appearance and the gate area, gate area. Remember that? Okay. So venous uh ulceration is due to two theories. We give five green cuff theory. That's one which is you do two huge pressure, it leaks out proteins. That's what we use. You see everything on the bandages, everything, you know, green bandages around the ulcers all wet because the pseudomonas loves moist moisture. Therefore, every patient with varicose also leaking out has got pseudomonas. So you need to dry it up if you want to get rid of the pseudomonas. So, fibrin calf theory, fibrin leaks out and, and stop the nutrition exchange of gas is everything. That's why you get tissue damage. Uh and and ulceration. The other one is the white cell trapping theory. Uh that is the uh the leukocytes become trapped in those capillaries under pressure and they produce cytokines. Every disease now is given cytokine theory, whether it's crone's disease because it causes inflammation, maybe it's true. So white cell trap in theory is the other one. The third one will be uh it is in my book on, on wound care. They, the third one will be the the uh the perfu the re perfusion theory causing oxygen radicals and all that. I'm not going to talk about that today. But because of the tremendous pressure, the uh the article supply get stopped. But when the patient starts walking or keep the leg elevated, then of course, the uh the elevated, then of course, the uh very good reef perfusion walkers and that also caused damage to the tissues. Uh So those are so inflammation due to repetitively ski mia during dependency and sustained venous hypertension and re perfusion. So that is the cause of the venus ulceration. So that those are the two theories. Okay. So these are the huge under pressure. Obviously, this patient need treatment. Uh they always have the skin changes, there are more than C three to C six. So uh and uh some people bleed from these, they burst, especially the, the inky blue Wayne's stick to the skin itself almost to the, almost to the dermis. And it is, that's why they are blue and they get, they cause more bleeding than anything else. And these are reticular veins under the skin. It just lifted the skin up when the patient got up. So, uh skin changes, we all. So anyway, we have spoken about the Cr classification Trendelenburg test. I think even if I stop here, that's enough Trendelenburg test. Uh I'll talk about the treatment quickly. Uh Every medical student must know you may not be asked to do that. So you empty the vein, put a tourniquet and a clamp. Don't try to do it with your finger as every book says, because you, your finger goes in somewhere with a sweaty groin and when the patient comes down, the finger get displaced. So you cannot really do that. So you put a tourniquet and the clamp. I have asked everyone to keep a tonic and a clamp in the clinic to show the medical student because we don't have to do pendulum birth test. Trendelenburg test can be done in three ways. One is the tonic a test and you get the patient to stand up, take your clamp out and then you see it feeling from about make sure you look at it like you look at the thyroid. So when the patient swallows, you get the patient, hold the water in the mouth and then get the patient to swallow and, and then you look at it. So look at the leg and then take the tone K off. You can see it feeling from about. So that is incompetent. Well, what is the other way to do to do that is the, the handle Doppler showed you about the Doppler. So you put that onto the groin, squeeze the calf and locate your vein by you can hear arush. So you can locate the vein and then you get rid of your calf. And then the uh so not only case put in here, you get it of the calf hand from the calf and who's followed by who sh incompetent. Well, you hope you understood that you squeeze it, blood goes up through, uh just beside your probe and then blood comes back. That means, well, these damaged. So that is an incompetent. Well, so was followed by uh Bush is an incompetent. Well, and who's followed by nothing is a competent. Well, so, so remember that. So I think I will talk about uh there are other clinical signs and Chavarria signs, you tap the vein and you feel it and you do Perthes test for the deep wayne's. You tiptoe. I think I showed one during the arterial surgery. Uh the you tiptoe with uh with the, with the tonic A on then the patient get to win a sporadic Asian in pain. So therefore you stop that. And then of course, you can get the color duplex scan done. You must get a colored Rupel expand done regardless because of these lawyers. So especially Saphenofemoral, Safina Popliteal junction because it varies. So because it varies, you may open up the open up just one centimeter about the uh about the knee crease from the back and your junction could be seven centimeters up. So that's why it's a variable one. It's not like the top one where you can uh where it is constant for South Wales. Uh 1.5 inches below and lateral to the pubic cubicle. So, right, uh we're running out of time and how do you do, how do you do the colored duplex? Of course, this is the mickey mouse sign anyway, look it up in the internet. So that is the artery and that is the femoral vein, common femoral vein and that is your great saphenous vein. So and and that is your superficial epigastric because you must not put your proud beyond that level because you may from both the main vein and you had it, you will be in prison. So, so uh think about that's how you, that some people do it in different methods, color do play scan. We don't do any venogram that is a waste of time and a dangerous one to do. Uh patient come to the clinic with wearing genes and it's terrible. So you cannot really expose this patient properly. And that code become when they lie down. Of course, that becomes a problem for the venous hypertension. Okay. I'll try and go through this. So the first thing to do is compression stockings. Before you do compression stockings, you must make sure the A BP I is more, more than 0.9. Otherwise you may cause problem because they roll backwards and have a tonic a effect and you have a skin necrosis. Actually, I had a patient over the 31 years who lost the leg after becoming gangrenous uh skin on the forefoot. So, sclerotherapy is my boss uh uh in Dublin uh Saint Winston's Hospital who invented it, Professor WGI Fagan. And uh we used to inject about 100 veins from all over the island and the uh and it causes inflammation and you put a band aid. So, sclerotherapy, you use uh you use STD and I think in the exam they may ask you about STD and the uh that is uh sodium tetra diesel sulfate uh and the feagans technique. Now, of course, we added uh added uh the uh uh forms sclerotherapy to that. That's because we can see that in the color duplex scan. Uh I have no time to go through the details of it sclerotherapy. And of course, the laser techniques. So these are the compression stockings. Uh So you must never use more than medium compression. Uh this is the medium compression and the, this is the kind of thing how you have to know how to put these things in because you have a plastic bag here and pull it up. And so that's how you have, you have you put on these ones, patient find it very hard to put in. For form sclerotherapy, you mix that. So it is one step about and the uh so you inject the form into the, into the vein here, form sclerotherapy. And you can see. So when the form get absorbed carbon dioxide, we put. So the for, for what happens is the sclerotherapy start acting on the endothelium. So that's what the, what what the plan is. But you are to make sure that does not go beyond the superficial epigastric wane. Because if it goes to the deep waned, that's a problem. And also ask the patient about migraine because for some reason in our practice, migraine is a problem because I I have stopped injecting these uh these patient's uh if they have migraine, I don't know the connection, but we stopped injecting. So this is the probe put in here and this is the split farce here and that is the wane. So we injected Thomason's anesthetic liquid uh with carbon dioxide as well because less irritating and then we've compressed the vein onto the probe uh and uh and uh burn it from upward downward. So that's how you do that. So uh professor, whatever you do, you still need to uh do a phlebectomy. Did somebody say something? Yes, sorry. We've got five more minutes left and there are some students who are required if you can make a quick recap. Is that possible? Okay. So, so the main thing is the old method is the, is the, is the uh is the open method trendelenburg procedure with ligation of tributaries and stripping the Tywin only. And the, the new methods are ablation of the vein tywin only again with the radio frequency ablation and laser techniques. So forms sclerotherapy, uh and sclerotherapy also can be used. So not a single operation fits every patient. So that's what I have to say. So I hope you enjoyed that. So this is how do you a blade, the vein never put it back in again. So, because this is a disaster and also don't forget about modeling ulcer in varicose veins because that's a malignancy. So you need to do a biopsy before you start treating about varicose Swain's. So, and I'll be finishing now. So, perforator ligation can be done separately. Biceps, superficial Trump providers. We did so and flag Maziar Ceruleus Dolan's and Alba Dolan's. I don't think anybody's going to ask you is the worst form of DVT. Uh We have no time to go through that and the uh I'll be finishing now. So this uh valuable Wayne's is very difficult to treat. It. Has to be done by the radiologist from about uh by embolization. We cannot you uh do valuable wanes. So, varicose veins are important and are the cause of considerable mobility, mobility and the extent and pattern of treatment is tailored to the individual. Very cause wane treatment have advanced now. And remember the see classification and that's very, very important. Hope you enjoyed it. I think we must repeat the arterial surgery one because we couldn't do it. We started late as well and uh we will meet again soon. Thank you very much. Any comments, any questions uh ready to answer. Um If anyone has any comments, please, do you raise your hand or pop in the chat for the time being? It looks like no one has any. Okay? Okay. Never, never afraid to uh afraid. Yeah, you can talk to me in any of the lectures that I'm giving 12 lectures. I think. Unfortunately, I can't give the uh the uh the wound care lecture because I'm flying off to somewhere else. Uh We can do that some other time or you can read my book on wound care and management. Thank you. Lovely. There's a, there's a participant called Akram has raised this land? Hmm Yes, you may speak. Uh Yes, we can hear you. I just want to ask about the c to buy cause pain. What is the appropriate uh surgical? Uh What is sorry, can you repeat the question? Can the uh can the uh, convener, repeat the question for the varicose went in c too. What does he do appropriate? We, we are in the National Health Service. We try not to, you do any in any investigations or, or treatment. Uh We, we, uh, maybe we will do a colored duplex scan, uh, just as a primary investigation, but uh we won't do for cosmetic reasons because we sent them to the private sector. So see two, we don't uh do that unless the patient is the breadwinner again. You know, because uh we haven't got the money to the time to do that. So uh see two wins, we are unable to treat. But if there's any sign of skin changes, edema, we do treat them appropriately in one of the matters we described. Thank you. There's one more question, doctor. What is the prognosis of a very close vein? Prognosis is uh the prognosis, you must get rid of the main insufficiency. So once you uh prognosis is good, the current rates are high, the prognosis is good. I mean, I had a patient with 47 years old patient's uh ulcer and, and was dying in an old people's home, but we just brought the patient in and dealt with it. Uh It took three months but uh everything healed up and the uh uh the uh prognosis is good. Uh recurrence rate problems are there, but we need to deal with them as they arised. OK, lovely. Doctor. There are some students asking for the PDF or PPT. Um, if you have any other lectures in the upcoming term in terms for, would it be possible? I thought you are, you are recording it? The, the, the problem here is that I am working for a private medical, two medical universities. They do not like passing the, uh, they don't approve. That's the main problem, but you can record it, you can take pictures of the slides, have no objections. I put it, uh uh I'll maximize it every time I give the lecture. Yes. Sorry, I didn't mean to send it. I meant if you have any other next lessons in the future, if you could just give a quick recap because some students said it was a bit fast. But thank you very much for the presentation. Uh It is in the list if you can have a look at it. Uh, that is one on the uh intestinal obstruction and one on I think the next week I can't really uh just what let's have. So I'm doing uh benign intrarectal condition. I think the next one, diverticular disease, uh colorectal cancer, breast surgery. And that will be an interesting one. And uh there is another code.