Plate 169

Stripping of the greater saphenous trunk and its varicose tributaries is indicated in symptomatic patients who have valvular incompetence, incompetent communicating veins, or resulting complications. The lesser saphenous system is unilaterally or bilaterally involved in 20 percent of these patients and, if affected, should also be stripped. Otherwise, this frequently causes recurrence. Before consideration of stripping, these patients must have a complete peripheral vascular examination to determine whether the varicosities are primary or secondary, to evaluate the status of the deep venous system, and to ascertain the adequacy of arterial circulation. Stigmata, history, suspicion, or other evidence of deep venous involvement suggesting that the varicosities may be secondary mandates the performance of impedance venous plethysmography or venography for objective evidence.

Incompetence or obstruction of the deep venous system to such an extent that the superficial venous system is necessary for return flow contraindicates complete saphenous system stripping. However, in selected cases in which the varicosities are a major contributor to disabling complications, stripping up to knee level may be safe after careful assessment and critical judgment by the surgeon.

Stasis dermatitis, cutaneous infections, or varicose ulcers result in a high incidence of postoperative wound infections. Pregnancy, advanced age, and systemic diseases constituting significant operative risks are relative contraindications, except in unusual circumstances.

Healing of varicose ulcers and elimination of stasis eczema can almost always be achieved by use of local treatment, compression dressings, and elevation when at rest. If such lesions are healed at least 4 weeks before operation, the incidence of postoperative infections will be minimized and wound healing will be normal.

The patient is instructed to take two cleansing hexachlorophene showers within 12 hours before operation. After the groin and extremity have been shaved, the involved saphenous trunks, major varicose tributaries, and location of suspected incompetent communicating veins—which can be detected by walking with a tourniquet applied at various levels or, better, yet with a Doppler—are then marked with indelible skin dye (Bonnie's blue or brilliant cresyl green). It is imperative that the surgeon understand that incompetent communicating veins often connect with major varicose tributaries, which must also be stripped to ensure a good result and to minimize necessary postoperative injections with sclerosing solutions.

General anesthesia is usually preferred, although epidural or spinal anesthesia is acceptable.

The patient is supine with the thigh and knee in slight external rotation and flexion. After the high ligation, division of the primary tributaries below the medial malleolus, and passage of the stripper through the entire length of the greater saphenous vein, moderate Trendelenburg position is used during segmental resection of the varicose tributaries and before the stripping. This lowers venous pressure and decreases bleeding during and after the procedure.

The skin of the foot, lower extremity, and groin is prepared in the usual manner. The forefoot is covered by a rubber glove, and usual draping is used (Figure 1). Specially designed holders may be used to suspend the leg at 30 to 40 degrees to facilitate skin preparation. The holder is adjustable and, as an alternative, may be used for positioning throughout the procedure.

A 6-cm oblique incision is made in the femoral skin crease with its lateral end over the femoral pulse (Figure 1). After the superficial fascia is incised, the proximal part of the saphenous trunk, one or more of its tributaries, and occasionally an accessory saphenous vein will be exposed at the center of the incision.

The adventitial sheath of the proximal saphenous trunk is incised longitudinally, and circumferentially separated from the vein. High early transection of the trunk greatly facilitates dissection proximally to the saphenofemoral junction as well as exposure of various tributaries. During this dissection the medial and lateral superficial circumflex iliac (Figure 2, A and B), the superficial epigastric (C), the superficial external pudendal (D), the medial superficial femoral cutaneous (E), and occasional deep muscular venous branches (F) must be meticulously divided and ligated to avoid later development of collaterals that would result in recurrences of the varices. The medial circumflex iliac artery lies at the lower margin of the fossa ovalis and consequently is a reliable anatomic reference to the saphenofemoral junction just above it (Figure 3). The proximal stump of the saphenous trunk is doubly ligated with a proximal free tie and then a transfixed nonabsorbable suture (Figure 3). The other end of the saphenous trunk is dissected distally until a large medial tributary, the medial superficial femoral cutaneous, is exposed, divided, and ligated (Figure 4). This avoids postoperative hematomas and excessive extravasation and ecchymosis of the medial thigh.

A 2-cm transverse incision, placed one fingerbreadth below and just anterior to the tip of the medial malleolus, and downward retraction will expose the trifurcated origin of the saphenous vein (Figure 5). Each of the three primary tributaries is divided and ligated. The saphenous vein is then dissected proximally above the malleolus for 4 cm. Sizable anterior and posterior tributaries are usually exposed, divided, and ligated (Figure 6). The edges of the transected lower end of the saphenous trunk are grasped between two mosquito hemostats and slit 1 cm to enhance the insertion of the probe end of the stripper (Figure 7). The instrument is then passed gently proximally with guidance by palpating, advancing fingers. The stripper can usually be passed through the entire length of the vein but may be arrested by large varices, tributaries, communicating veins, or by stenosis resulting from previous phlebitis. At these points an additional small transverse incision may be made to expose the vein and the tip of the stripper. The tip may then be manually guided proximally, or the vein may be transected to allow introduction of an additional stripper through the proximal end. Alternatively, a second stripper may be inserted into the proximal end of the divided saphenous trunk through the femoral incision and passed distally till it contacts the instrument inserted from the ankle. The end of the saphenous trunk is then securely tied to the stripper with two encircling ligatures of 00 silk, about 2 cm apart, to prevent inversion of the vein over the stripper (Figure 8).

At this point the surgeon may choose to strip the lesser saphenous vein if indicated. Approximately 20 percent of patients with varicose veins have involvement of one or both lesser saphenous systems, which should also be stripped. Adequate positioning can be achieved by flexing the knee 90 degrees, placing the sole of the foot flat on the operating table, and slightly internally rotating the hip (Figure 9). The primary tributaries converging on the lateral side of the ankle to form the lesser saphenous trunk can be exposed through a 2-cm transverse incision between the posterior tip of the lateral malleolus and the lateral edge of the Achilles tendon. Careful attention is given to identify and avoid damage to the sural nerve (Figure 9). The branches are divided and ligated, and a short stripper is inserted and passed proximally in the lesser saphenous trunk up to the popliteal skin crease (Figure 10). A small transverse incision is made over the palpable stripper probe, and the vein is isolated and divided, and the proximal end is ligated. Major varicose tributaries identified and marked before operation are segmentally stripped, as described below for the greater saphenous stripping. A large varicose tributary connecting the greater and lesser saphenous trunks is often present at the level of the upper medial bulge of the calf and requires similar resection.