Venous Insufficiency/Varicose Veins – Operation

High Ligation of the Great Saphenous Vein

The GSV is most easily approached through an oblique incision 1 cm above and parallel to the groin crease. This location provides the best cosmetic results and the most reliable access to the saphenofemoral junction. Some surgeons, however, recommend an incision right in the groin crease. The incision should start over the palpable femoral artery and extend medially, to balance the better cosmesis of limited incisions with the necessity to ensure appropriate visualization of the saphenofemoral junction and its tributaries. Preoperative DUS-guided marking of the saphenofemoral junction further improves the precision of incision placement and allows minimal incision size and subcutaneous dissection. As the subcutaneous tissue is split, the main trunk of the GSV is identified. A self-retaining retractor is helpful, and the plane over the saphenous vein is extended toward the saphenofemoral junction. This anterior plane is generally free of encumbrances and allows exposure to the junction. Each of the tributaries is divided and ligated because the saphenofemoral junction needs to be clearly identified. Failure to clearly define the saphenofemoral junction has resulted in disastrous injuries to the femoral vein or artery.

There are six main tributaries joining the GSV near its termination ( Figure 79-1-1 ). However, the number and position of these tributaries vary greatly, and therefore it is necessary to dissect the femoral vein 2 cm above and below the confluence to be sure that no additional tributaries join the femoral vein directly. Lateral and medial accessory saphenous veins may enter the main trunk between 2 and 20 cm below the confluence. When stripping is planned, these distal tributaries are avulsed, but if ligation alone is planned, the dissection should be extended caudad for approximately 10 cm to ensure division of these hidden tributaries. High ligation of the GSV is performed close to the femoral vein. Double ligation is generally performed on a proximal stump with the second ligation being a suture ligature. Care should be taken to avoid narrowing the femoral vein in the process. Equally important is to avoid leaving a long stump with a risk for thrombus formation and potential embolism. Alternatively, the GSV may be divided close to its termination and the femoral side closed with a two-layered monofilament suture. If high ligation alone is to be performed, one should resect the segment of GSV exposed in the surgical field, generally 5 to 10 cm in length. The incision is closed in layers by approximating the subcutaneous tissue with absorbable suture and the skin with absorbable subcuticular or interrupted nylon suture. The requirement for sufficient exposure of the saphenous vein and its tributaries should be tempered by new data suggesting that extensive dissection results in local humoral changes and upregulation of vascular growth factors that lead to neovascularization, which in turn is believed to be an important cause of recurrent varicose veins.

Great Saphenous Vein Stripping

GSV stripping is the central component of the classic operation for varicose veins. Recurrence rates are markedly reduced when the GSV is stripped as opposed to performing high ligation alone, and therefore high ligation is usually performed in conjunction with treatment of the GSV. During preoperative marking for L&S of the GSV, the surgeon should review the extent and distribution of reflux disease in the saphenous system. The GSV in the thigh is incompetent in only about two thirds of patients undergoing surgery for symptomatic varicose veins or CVI. In addition, unless the caudal below-knee saphenous vein is obviously incompetent and varicose, there is no need to remove it. Similarly, when H- or S-type anatomy is defined ( Figure 79-1-2 ), there is no need to treat normal or atretic segments of the GSV, and in fact such treatment may worsen the clinical situation by removing competent drainage paths ( Figure 79-1-3 ). This targeted approach to stripping leaves normal distal veins for potential future grafting, avoids injury to the saphenous nerve, and results in less postoperative pain and bruising without compromising the goals of surgery. If present, incompetent accessory saphenous veins should be addressed during the initial surgery. It is likely that the high recurrence rates noted for vein stripping in the past have resulted in part from unrecognized accessory veins. The availability of high-resolution DUS and awareness of the issue may result in improved efficacy in the future.

After flush ligation is performed, a transverse venotomy is created and a stripper is passed distally. Wire strippers or disposable plastic strippers are commonly used. In most cases the presence of reflux allows easy passage of the stripper to the level of the knee. A second small incision is made over the palpable stripper near the knee. The caudal incision is made transversely and the subcutaneous tissues dissected to allow recovery of the saphenous vein. This top-down passage of the stripper not only facilitates identification of the saphenous vein at the knee and allows a small lower incision to be made but also avoids the potential for the stripper passed from below to enter the femoral vein through a thigh perforator and cause the femoral vein to be mistaken for the saphenous vein. The GSV should be stripped in a downward direction, which results in improved avulsion of tributaries and diminished injuries to the saphenous nerve. To avulse the vein with the endoluminal stripper one needs to affix the catheter to the most cephalic portion of the vein. This may be accomplished by attaching the classic stripper head ( Figure 79-1-4 ) to the top of the disposable stripper after first placing a silk ligature around the vein and the stripper just below the head. Using the smallest head size minimizes tissue injury and bruising, whereas a larger head size will improve one's chance of recovering the entire vein and the tributary segments. A long trailing silk suture is initially attached at the stripper head and drawn through the tunnel with the vein. After all the tributaries are avulsed and the caudal GSV divided and ligated, the vein is drawn back up to the groin incision, thereby minimizing the distal incision.

Although many variations of this technique have been described, the most common alternative approach involves invagination of the GSV into itself. This technique may be performed with a disposable plastic Codman Vein Stripper without attaching a stripper head but instead intussuscepting the vein as shown in Figure 79-1-5 . Alternatively, a reusable metal cannula may be used in a similar fashion. This technique minimizes the diameter of the tunnel created by vein removal in an effort to diminish local trauma to soft tissues and nerves. However, the saphenous vein is susceptible to tearing at the sites of tributary confluence and thus could result in incomplete stripping of the target vein. Consequently, when the vein is removed, it should be unfurled and compared with the planned treatment length. When the vein is torn during stripping, the caudal end typically remains in place at the lower incision. In this case, if a trailing heavy silk suture has been affixed to the stripper (see Figure 79-1-4 ), a second inversion technique could be performed in the opposite direction ( Figure 79-1-6 ).