Varicose Veins: Beyond Cosmetic Concerns—What Are We Missing?

By Dr Menaka Sharma

At a glance, varicose veins raise cosmetic concerns, and signal an underlying medical problem.

 

We know they can cause pain, edema, skin changes, thrombophlebitis, and ulceration. 

The challenge is not convincing doctors that varicose veins matter. The challenge is understanding whether we have fully appreciated what they represent.

 

Traditionally, we have all studied and viewed varicose veins as the endpoint of a mechanical process: 

1.Valves fail, 2.Reflux develops, 3.Venous pressure rises, and 4.Veins dilate. 

 

Increasingly, evidence suggests that this explanation captures only part of the story.

 

The emerging literature points toward a more intriguing possibility. What appears to be a straightforward venous disorder may actually reflect a complex interaction of chronic inflammation, endothelial dysfunction, and vascular remodelling, and interestingly, genetic susceptibility!

 

We are also aware that in some patients, the visible varicosity may even be the first clue to a deeper pathology hiding upstream.

 

The question is no longer whether varicose veins are cosmetic, they are definitely not just cosmetic.

The question is whether they are more informative than we currently think.

 

The Genetics Question

One of the most curious observations in venous disease is that exposure does not equal outcome.

Millions of people spend decades standing for prolonged periods. Some develop severe chronic venous disease in their forties, while others reach old age with minimal venous changes. We are no strangers to the classical risk factors such as obesity, pregnancy, age, and prolonged standing, but these explain only part of this variation.

 

Recent genetic studies have begun to provide answers.

A landmark genome-wide association study involving nearly half a million individuals identified multiple genetic loci associated with varicose veins, many of which are involved in vascular development, extracellular matrix organization, smooth muscle biology, and inflammatory regulation. 

 

These findings suggest that some patients may possess an inherited susceptibility to venous disease long before the first visible varicosity appears. Rather than asking why the valve failed, researchers are increasingly asking why the vein was vulnerable in the first place.

 

Subsequent genomic studies have reinforced this concept, identifying additional genetic pathways that may influence venous wall integrity and disease progression. The implication is important: varicose veins may not be solely acquired disease. In many patients, they may represent the interaction between environmental stressors and a genetically predisposed venous system.

 

The Vein Wall Is Not a Passive Bystander

For decades, venous hypertension was viewed as the primary driver of disease.

Current evidence suggests a more complex picture.

 

Recent reviews have highlighted the role of endothelial dysfunction, oxidative stress, leukocyte recruitment, inflammatory signalling, and extracellular matrix remodelling throughout the course of chronic venous disease. Sustained hemodynamic stress appears to trigger biological changes within the venous wall that further impair vascular function, creating a self-perpetuating cycle of inflammation and remodelling (Does this sound similar to a very well-known pathogenesis? Let us know!)

 

In other words, the vein is not simply being stretched passively.

It is actively changing.

This distinction may seem subtle, but it changes how we view the disease. 

 

Varicose veins begin to resemble other chronic vascular disorders in which inflammation and tissue remodelling are central drivers of progression rather than mere consequences of structural failure.

 

Sometimes the Vein Is Not the Disease

Perhaps the most underappreciated aspect of varicose veins is that they can occasionally function as a clinical clue rather than a final diagnosis.

 

Most varicosities represent primary venous disease. Some do not.

Pelvic venous disorders, ovarian vein reflux, proximal venous obstruction, post-thrombotic disease, and syndromes such as May–Thurner syndrome can all manifest with lower-limb varicosities. 

In these situations, the visible vein may be analogous to jaundice in hepatobiliary disease: important in itself, but potentially pointing toward a deeper pathology. Advanced venous evaluation increasingly relies on identifying these underlying drivers rather than focusing exclusively on superficial reflux.

 

This perspective becomes particularly relevant in patients with recurrent varicose veins, atypical distributions, disproportionate symptoms, or disease progression despite apparently adequate treatment.

The question shifts from “How do we treat this?” to “How do we treat this, and why did this develop in one individual and not the other?”

 

Summary

The statement that varicose veins are more than a cosmetic issue is undoubtedly true.

A more interesting conclusion, however, is that they may be more than a diagnosis.

Emerging evidence suggests that varicose veins are not merely dilated superficial veins but the visible manifestation of a complex vascular process involving genetic susceptibility, endothelial dysfunction, chronic inflammation, and structural remodelling. In selected patients, they may even serve as the first clue to pathology elsewhere in the venous system.

As our understanding of venous disease evolves, perhaps the most important lesson is this:

The visible vein is often the end of the chapter we see, but only the beginning of the story we should be asking about.

 

References

1. Abrashev H, Abrasheva D, Nikolov N, et al. A Systematic Review of Endothelial Dysfunction in Chronic Venous Disease—Inflammation, Oxidative Stress, and Shear Stress. Int J Mol Sci. 2025;26:3660. PMID: 40332237. 

2. Costa D, Andreucci M, Ielapi N, et al. Molecular Determinants of Chronic Venous Disease: A Comprehensive Review. Int J Mol Sci. 2023;24(3):1928. PMID: 36768250. 

3. Fukaya E, Flores AM, Lindholm D, et al. Clinical and Genetic Determinants of Varicose Veins: Prospective, Community-Based Study of ≈500,000 Individuals. Circulation. 2018;138(25):2869–2880. PMID: 30566020. 

4. Helkkula P, et al. Genome-wide association study of varicose veins identifies novel susceptibility loci and therapeutic targets. Commun Biol. 2023. 

5. Shadrina AS, et al. Varicose veins of lower extremities: Insights from the first large-scale genetic study. PLoS Genet. 2019. 

6. Patel SK, Surowiec SM. Venous Insufficiency. StatPearls. Updated 2024. 

By Author 

Dr Menaka Sharma

MBBS, IGGMC Nagpur

Co-Author

Dr Danish Sheikh (Kaif)

MBBS, MS General Surgery, FIAGES, FMAS, MACS

Consultant General & Laparoscopic Surgeon

Central Hospital & Critical Care Centre

Awake Craniotomies: A Dance Between Consciousness and Surgery

By Dr Menaka Sharma

In neurosurgery, few procedures feel as rebellious against intuition as an awake craniotomy. A patient is not only alive and alert while a part of their skull is removed, they are talking, counting, sometimes even singing or playing an instrument. It is a moment where the brain, the master organ, becomes an active conversational partner in its own salvation.

My fascination began back in 2020, the day I first saw a video of a patient playing the violin while a tumour was meticulously dissected away from eloquent cortex by Professor Keyoumars Ashkan and his team, a procedure called intraoperative tumour monitoring. Until then, the brain had always seemed like a black box, untouchable during consciousness. Yet here was proof that the surgical world could bend that rule in service of preservation.

Historically, the roots trace back to pioneers like Wilder Penfield, who used cortical stimulation in awake patients to map epileptic foci and functions. It was a radical idea at the time: instead of rendering a patient silent under deep anaesthesia, let them speak to guide the surgeon’s hand. That simple reversal changed the trajectory of neurosurgery. Suddenly, removing a tumour didn’t have to mean sacrificing speech. Resections didn’t have to steal movement. Surgeons could listen to the brain while they operated on it.

Modern awake craniotomies are even more elegant. A calm patient lies under conscious sedation during scalp incision and craniotomy. Then, when the brain is ready to speak, anaesthesia lightens and the world re-enters the room. The surgeon resects, the patient responds, and the anaesthetistorchestrates the balance like a quiet conductor. Every word, nod, hesitation, or joke becomes clinical data.

There is something profoundly human in those exchanges. A patient counting to ten while a surgeon navigates Broca’s area. A musician playing to preserve hand function. A teacher naming animals to protect language fluency. Long before MRI tractography and neuronavigation, this was precision surgery guided by cortical truth.

From a medical student’s perspective, awake craniotomy feels like a perfect contradiction: the most invasive procedure performed in the most conscious state. Yet it works because the brain itself feels no pain. What surgeons unleash during those hours is not just technique, but trust, between patient, anaesthesiologist, and neurosurgeon. The operating room becomes part theatre, part science, part intense collaboration.

And it changes people. Surgeons describe the strange intimacy of watching a patient speak memories, sing songs, or joke while you hold the organ that generates every part of their identity. Patients describe a surreal pride: fear dissolving into participation, knowing they protected their own speech by using it.

We tend to think of surgery as a cold, silent battlefield. Awake craniotomy proves the opposite. It is dynamic, emotional, unpredictable, and profoundly shared.

The evolution continues. Better sedation protocols. Real-time stimulation mapping. Functional MRI guidance. Smaller craniotomies. Greater patient comfort. Each advancement pushes the boundary of how much of the person we can preserve while removing disease. Someday, I hope to witness that impossible combination of scalpel, dialogue, laughter, and neuroscience first-hand.  Until then, the thought of it is a reminder that neurosurgery is not just about operating on a brain, but preserving an identity.

By Author

Dr. Menaka Sharma

MBBS, IGGMC Nagpur

Co-Author

Dr. Danish Kaif

MBBS, MS General Surgery

FIAGES, FMAS

The Quiet Revolution: From Open Surgery to Invisible Incisions

By Dr Menaka Sharma...

There was a time when surgery meant long incisions, heavy bleeding, and weeks of painful recovery. Surgeons depended on wide exposure to understand anatomy and control complications. Today, many of those same procedures are done through tiny ports, or sometimes without a single visible incision. In just a few decades, surgery has quietly transformed from an art of large, heroic cuts to a discipline of precision, optics, robotics, and intelligent assistance. This is the quiet revolution of modern surgery.

The Era of Open Surgery: The Original Standard

For more than a century, open surgery was the foundation of operative care. Techniques such as laparotomy, thoracotomy, and craniotomy allowed direct visualization and tactile feedback, fundamental for safe dissection and control of bleeding. Millions of lives were saved through open approaches, advancing trauma care, cancer surgery, and emergency interventions.

But the trade-offs were clear: long scars, significant post-operative pain, pulmonary complications, wound infections, prolonged bed rest, and extended hospital stays. Even with the introduction of antiseptics, anaesthesia, and antibiotics, large incisions meant significant physical trauma. Open surgery worked, but it worked at a cost.

Early Attempts at Minimally Invasive Surgery

The first attempts at minimally invasive procedures were limited- simple drainages, stone extractions, or diagnostic scopes. Surgeons wanted smaller wounds, but technology simply wasn’t ready. Early scopes lacked illumination, stability, and precision. Depth perception was poor, instruments were rigid, and safety was uncertain. Many procedures began with small incisions but converted to open surgery mid-way. Engineers and surgeons responded with better lenses, fibre-optic lighting, insulated instruments, and eventually video systems. Those incremental improvements set the stage for the breakthrough that followed.

The Laparoscopic Leap

The late 1980s changed surgery forever. When laparoscopic cholecystectomy proved feasible, the surgical world pivoted almost overnight. Using carbon dioxide to create space, fibre-optic cameras for visualization, and slender instruments for dissection and suturing, surgeons learned to operate inside the abdomen without opening it. The advantages were undeniable:

• Smaller incisions

• Less blood loss

• Reduced pain

• Shorter hospital stays

• Faster return to normal activity

Procedures that once required a week in a hospital now sent patients home in a day or two. Laparoscopy expanded rapidly—hernias, appendectomies, colectomies, bariatric surgery, gynaecological surgery , urology, and oncology.

But the transition was not effortless. Operating on a two-dimensional screen removed depth perception. The fulcrum effect reversed instrument movements. Tactile feedback disappeared. Training moved from textbooks to simulators, porcine labs, and supervised operative experience. The surgeon’s hands were no longer in the abdomen; the instruments were.

The message was clear: smaller cuts did not mean inferior surgery, just a different kind of skill.

The Robotic Renaissance

In the early 2000s, robotic systems entered the operating room, most famously the da Vinci platform. Surgeons sat at a console with magnified 3D vision, controlling robotic arms capable of wristed motion, tremor filtration, and sub-millimetre precision. What laparoscopy made possible, robotics made elegant.

Robotic surgery proved particularly valuable in confined spaces like the pelvis and chest. Complex suturing became easier. Visualization improved. Nerve-sparing accuracy increased in procedures such as prostatectomies and hysterectomies. Patient outcomes reflected fewer complications, shorter recovery, and improved function.

Of course, robotics came with challenges: high cost, specialized training, and longer initial operative times. But as experience grew, robotics moved from novelty to expectation. Young surgeons today are expected to be dual-trained in laparoscopy and robotics, because many procedures now use robotic platforms as the default approach.

Beyond Ports: NOTES and Advanced Endoscopy

Natural Orifice Transluminal Endoscopic Surgery (NOTES) pushed the boundary further by eliminating external scars altogether, avoiding injury to the abdominal wall. Early clinical work showed feasibility, though concerns remain about closure reliability and contamination. Still, the concept opened a new frontier. Flexible robotic endoscopes now allow biopsy, resection, cautery, and suturing from inside hollow organs. Procedures once considered purely diagnostic have become therapeutic.

The line between surgery and endoscopy continues to blur.

Smarter Eyes: Augmented and Image-Guided Surgery

Augmented reality and image-guidance are no longer science fiction. Surgeons can now superimpose CT or MRI maps onto the operative field, highlighting tumours, vessels, and nerves in real time. This technology has already improved accuracy in neurosurgery, spine surgery, hepatobiliary procedures, and oncology.

Instead of guessing where margins lie, surgeons can see them.

Artificial Intelligence in the Operating Room

AI is becoming the next major shift. Currently, AI systems assist through image recognition and workflow analysis in controlled research environments. Full autonomy remains distant—ethical responsibility, unpredictability of anatomy, and real-time decision-making are enormous challenges. For now, AI is a safety net, not a replacement.

The Surgeon Remains Central

Despite the advancements; from open to laparoscopic to robotic and AI-supported, one constant remains. Surgery depends on judgment. Technology amplifies skill; it does not substitute for it. The best outcomes still require anatomical knowledge, adaptability, situational awareness, ethical reasoning, and human intuition.

The surgeon of the future must be part clinician, part technologist, and part strategist.

The Revolution Continues

Surgery has evolved from large incisions to procedures that sometimes leave no external trace. Recovery times have shortened. Complications have decreased. Surgeons who once relied on their hands now rely on optics, consoles, and data.

This revolution didn’t arrive with fanfare. It arrived quietly, one smaller incision, one clearer camera, one smarter algorithm at a time.

And the transformation is still unfolding.

By Author

Dr Menaka Sharma

MBBS

IGGMC, Nagpur

Co- Author

Dr Danish Sheikh (Kaif)

MBBS, MS General Surgery

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