The term indicates ligation and division of the GSV at its confluence with the common femoral vein (CFV) along with ligation and division of all upper GSV tributaries [1]. The patient is positioned on the table with a Trendelenburg tilt. The limb to be operated is slightly abducted and externally rotated and the knee joint slightly flexed and supported on a roll.

Siting the incision at the appropriate level is a crucial step. One of the common errors is to site the incision too low. According to textbooks of anatomy, the SFJ is located 4 cm below and lateral to the pubic tubercle [9]. During surgery, it is found to be much higher. We make a transverse incision of sufficient length, with its center located 2 cm below and lateral to the pubic tubercle. This incision is cosmetically pleasing and gives a good exposure of the SFJ and all the terminal tributaries. The hockey stick incision described by Dodd and Cockett gives an excellent exposure, but such extensive exposure is not really needed.

There are three basic steps involved in the surgery:

The location of the SFJ is confirmed by displaying the anterior surface of the common femoral vein. Another useful landmark is the superficial external pudendal artery. It runs along the curved lower border of the fossa ovalis, usually posterior to the trunk of the GSV. In a small subset of patients, this vessel runs anterior to the GSV. Its pulsation can be made out and this is a useful pointer to the position of SFJ (Fig. 7.2).

The tributaries to be controlled include the named terminal tributaries – superficial circumflex iliac, superficial epigastric, and external pudendal veins (Fig. 7.3).

The anterior accessory saphenous vein and posterior accessory saphenous vein in the thigh are also controlled. Hidden tributaries entering on the posterior aspect of the GSV may be evident by transecting the GSV at a point 7–10 cm from the SFJ and turning the proximal stump upward. The deep external pudendal vein may join the GSV on its posterior aspect close to the femoral vein. Sometimes this vessel can enter the femoral vein also [2]. The tributaries are ideally controlled beyond their secondary branch [10].

Confirming Reflux at SFJ: We always confirm reflux at the SFJ by the intraoperative test for SF incompetence. For this, the GSV is divided about 7–10 cm from the SFJ between two bulldog clamps. The bulldog clamp controlling the proximal end is released under control. If the SFJ is incompetent, there is a brisk bleed back from the divided proximal stump even as an arterial flow [11] (Fig. 7.4).

The SFJ is ligated with double ties with nonabsorbable sutures. The second tie may be a transfixing ligature. The stump should be about 1–2 cm long. Too short a stump has a risk of slipping of ligature. Too long a stump can produce a cul-de-sac. Covering the stump with a patch of PTFE graft is recommended by some to prevent neovascularization. This is not recommended in the guidelines of the American Venous Forum [4]. The distal end is removed along with stripping. The wound is closed with a suction drain after completing the stripping procedure.

Two problems can add on to the technical difficulties:

In a series of 80 dissections in the groin for high ligation of the groin, we made the following observations:

The term stripping indicates removal of a large segment of the vein, the GSV or SSV, by means of a device. This is an essential step in the surgery of GSV varicose veins. It is recognized that the recurrence rate can be minimized by including this procedure [4]. One of the important causes of REVAS is presence of refluxing channels [12].

Total stripping from groin to ankle is not practiced currently because of the risk of damage to the saphenous nerve in the leg and the high incidence of postoperative saphenous neuralgia [4, 10]. Moreover, even total stripping does not disconnect incompetent ankle perforators [2].

Short-segment stripping from the groin to below-knee level is the recommended option now. This procedure removes the incompetent thigh segment of the GSV (the below-knee segment of the GSV is usually competent in the majority of patients); at the same time, it avoids injury to the saphenous nerve.

Perforate-invaginate stripping (PIN stripping) minimizes these events and is the preferred option. In conventional intraluminal stripping, the stripped vein gets rolled over and wrapped around the acorn-shaped stripper head to form a thick hard “plug.” The tissue trauma along the stripped tract can be considerable. Again, a large exit wound is needed. The PIN stripping uses an instrument with a miniscule head and flat neck. It is a minimally invasive procedure and can be carried out even in an office setting under local anesthesia. The technique was introduced by Oesch in 1993, initially for short saphenous varicosity [13]. A flexible Codman disposable stripper without the removable acorn can also be used for invagination stripping [4].

To reduce bleeding during stripping, the limb is elevated and as the stripping progresses, compression bandages are applied. Infiltration of the perivenous space by tumescent anesthesia is recommended by Gloviczki et al. to reduce bleeding [4].

Cryostripping of the GSV: This is recommended to decrease hemorrhage from the stripped tract. The procedure needs the use of a cryosurgical system. After high ligation, the cryoprobe is passed down to the desired level around knee and freezing initiated. The saphenous vein is invaginated by pulling the vein with force. The incidence of post stripping bruising and complications were less compared to standard stripping [14].

This procedure is aimed at excising local blowouts and bulging veins. It improves the cosmetic appearance of the limb, an important goal of treatment of varicose veins. Meticulous preoperative mapping of the veins is essential to achieve optimum outcome.

Cosmetic phlebectomy: The procedure was described by Dodd and Cockett. Through 1–2 cm long vertical incisions, large segments of the veins are excised. It is compared to birds picking out worms from burrows and hence is also called “worming.” The wounds are sutured. Vertical incisions in the extremities are preferred between joints since they fall in the natural Langer’s line. The resultant scars are cosmetically acceptable [2].

Ambulatory phlebectomy: The procedure is also known as stab or hook or mini phlebectomy. It involves the avulsion or removal of varicose veins through small 1–2 mm stab wounds made by a number 11 blade. Avulsion of varicose veins is performed with hooks (Muller or Oesch) or forceps. The procedure can be performed under tumescent local anesthesia. The skin wounds are approximated with steristrips. Thigh-length compression stockings/bandages are applied on completion of the procedure [4].

Light assisted stab phlebectomy: Lawrence and Vardanian have reported a newer technique stab phlebectomy. It combines transillumination, tumescent anesthesia, and stab phlebectomy using special surgical instruments. It provides better visualization and more rapid and complete removal of veins [15].

Transilluminated powered phlebectomy (TIPP): This is a useful technique for the removal of larger clusters of varicosities. The procedure is done under spinal, epidural, or general anesthesia. Tumescent anesthesia is added with infusion of dilute lidocaine with epinephrine. Transillumination is achieved by a specially designed cannula. Vein extraction is done using a resector [16]. The procedure is combined with HL/S. The advantages claimed include a decrease in the number of incisions and much faster removal of a large amount of varicose vein tissue [4].