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With the greater and perhaps the lesser saphenous trunks traversed by strippers, attention is then turned to the varicose tributaries and suspected sites of incompetent communicating veins of the greater saphenous system (Figure 11). The latter most often occur adjacent to the saphenous trunk, at the junction of the middle third with the lower and upper thirds of the leg below the knee. Small and medium-sized major varicose tributaries that were marked preoperatively are removed with the stab avulsion technique. A No. 11 scalpel makes a 3- to 4-mm stab in the skin. Using blunt dissection with a hemostat, the venous tributary is isolated, clamped, and removed by avulsion. Larger tributaries are dissected free, ligated, and divided between ligatures. The veins are exposed, doubly clamped, and divided between hemostats. Subcutaneous dissection with tonsil hemostats in the plane between the vein and skin will mobilize and permit segmental stripping of these tributaries (Figure 12). During this dissection, communicating veins may be encountered, divided, and ligated. Other suspected sites of incompetent communicating veins located by a preoperative walking tourniquet test or venogram should be explored to allow appropriate ligation.

The distal end of the stripper is pulled upward about 6 cm to a subcutaneous position, and all the distal incisions are closed carefully and accurately with vertical mattress sutures of 0000 nonabsorbable suture (Figure 13). The greater saphenous trunk then is removed by pulling the stripper from distally out through the femoral incision. Very slow stripping of the saphenous trunks extending over 5 to 7 minutes while the surgical assistants apply advancing, firm pressure behind the instrument will minimize intraoperative bleeding and postoperative ecchymosis. The lesser saphenous vein may be similarly stripped. Stripping proximally is more effective in avulsing longer segments of undivided tributaries and is less likely to result in tearing the saphenous trunk and inverting it over the stripper. Free blood then is milked and extruded from the saphenous channel. The femoral incision is approximated in two layers with 000 interrupted absorbable sutures in the superficial fascia and a continuous subcuticular stitch. All other incisions are closed with a single layer of similar subcuticular suture. The operated extremities are snugly wrapped with a layer of elastic cotton gauze and compression elastic ...

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