An oblique incision 3–4 cm long on the saphenofemoral crease is made, just above the saphenofemoral junction, as this has been defined with the preoperative ultrasound scan. If an ultrasound scan and a great saphenous vein marking have not been done before the procedure, the skin incision starts at the point of the femoral pulse and extends medially at a length of about 6–8 cm length. Using electrocautery, the subcutaneous tissue is divided. The superficial femoral fascia (saphenous fascia) is divided with the electrocautery as well. At this level a self-retainer retractor can be inserted across the skin incision under the fascial layers, and this usually reveals the great saphenous vein underneath, lying over the deep femoral fascia. Alternatively, a swab may be used to wipe away the adipose tissue from the great saphenous vein . Once the saphenous vein is identified, it is dissected free using forceps and scissors. A blunt grasp of the saphenous vein with the forceps facilitates its handling and dissection, minimizing the possibility of vein tear. Alternatively, two pairs of forceps can be used, one holding the vein and the other one grasping the surrounding tissues and pulling them away.

All the branches of the great saphenofemoral junction should be double ligated and divided, until the identification of the saphenous opening of the deep femoral fascia (fascia lata). Normally, there are six tributaries of the GSV close to its junction to the common femoral vein. However, this number may vary, and therefore it is necessary to dissect not only the GSV but the common femoral vein above and below the saphenous confluence. All the additional tributaries found directly from the common femoral vein should also be ligated. The common femoral vein can be clearly seen through the saphenous opening, and its course upward and downward underneath the fascia lata can be identified (Fig. 7.2). The recognition of the common femoral vein at the level of saphenofemoral junction “going up and going down” underneath the fascia lata should always precede the division of great saphenous vein. This is a critical step during the procedure. It is possible, especially in thin patients where the subcutaneous tissue is minimal and when the saphenous junction lies on a lower level than the inguinal crease, to dissect straight the common femoral vein instead of the great saphenous vein. In this rare case, if the surgeon does not recognize correctly the anatomy, it can result in the catastrophic complication of dividing and stripping the femoral vein instead of the great saphenous vein. On the contrary, this will never happen if the three main venous components are identified: the common femoral vein “going up,” the common femoral vein “going down,” and the great saphenous vein “going anteriorly” above the fascia lata.

After the proper recognition of the great saphenous vein emerging from the common femoral vein, the surgeon may double clamp and divide the GSV. This can be done by inserting two vascular clamps, the first one at about 0.5 cm from the SFJ and the second one about 4 to 5 cm distally. The vein is divided with scissors, and the proximal stump of the GSV is ligated with a 2.0 silk suture. We use to double-ligate the saphenous vein stump with a suture ligature 3.0 silk . This is achieved with a simple maneuver: when the surgeon ties the first knot of the GSV stump, the assistant releases temporarily the vascular clip, moves it 2–3 mm proximally, and reattaches this on the vein. Then, the surgeon may set the transfixion stitch under the vascular clip but at the same time above the first knot of the 2.0 silk suture.

Before going on to the next step, the surgeon must give a final look at the saphenous stump and around the CFV nearby. First, he/she must check whether the stitches are securely set on the GSV stump. Second, an inspection on both sides of the common femoral vein must be done laterally and medially. As explained previously, if any small branch directly from the common femoral vein is identified, it should be double-tied and divided. This is necessary when the branch is found on the medial side of the CFV as this can be a remaining branch of the SFJ, and this could be a reason for an early recurrence.

If only ligation of the SFJ and not stripping of the GSV is planned, the dissection should be extended caudally for about 10 cm to ensure division of any hidden tributaries, as lateral and medial accessory saphenous veins may enter the main saphenous trunk at a varying distance from the confluence .

The distal end of the divided GSV is grasped with two mosquito clips (Fig. 7.3) and the stripper is inserted. We prefer using a metallic Oesch^® pin stripper although a plastic stripper can be used as well. Occasionally there is some difficulty in advancing the stripper due to the existing venous valves of the GSV, but with slight massaging on the skin over the stripper, the surgeon can assist the stripper go through the valves all the way down the GSV to the upper third of the calf. We usually avoid to get the stripper lower close to the ankle level for various reasons. First, the part of the GSV on the calf is usually competent; thus, there is no need to remove it. In cases where the GSV is incompetent all way down to the ankle level, this part of the GSV can be stripped-out as well. Second, the saphenous nerve is in close relation to this part of the GSV, thus a stripping of this part of the vein could result in saphenous nerve injury, causing permanent sensory disturbances on the patient’s medial part of the foot. Last but not least, the various perforating veins in the calf do not emerge from the GSV but instead from the vein of Leonardo; thus, a removal of this part of GSV would not offer the benefit of perforating veins removal (Fig. 7.4).

At the upper part of the calf, the stripper is taken out after a stab of the skin just above the end of the stripper. In case where a metallic stripper like the Oesch® pin stripper is used [12], the exit point of the stripper is clearly identified with a slight push of the stripper. In case where a plastic stripper is used, its end is palpated with the fingers and a stab is done just above it. Using a mosquito clip, the end of the stripper is grasped usually together with the vein and pulled out of the skin. After the tip of the stripper is outside the skin, it is grabbed with heavy hemostatic forceps. Its proximal part in the groin is secured on the GSV with a heavy tie which is left as long as the length from the groin to the exit site of the stripper on the upper calf. Then, the stripper is pulled out distally. We prefer performing an eversion stripping as this can minimize the damage of the surrounding tissues of the vein, thus reducing the postoperative bleeding inside the saphenous canal. In case where the GSV is torn during stripping and there is a doubt whether it has been totally removed or not, a second stripper is tied on the long remnant of the heavy suture and passed again through the saphenous canal to the same exit point. In this case, we prefer performing a classic stripping using the suitable stripper head , avoiding another eversion stripping. After the GSV has been removed, the assistant pressures the area of GSV canal using big surgical pads for about 5 min, to reduce any post-stripping intra-canal hemorrhage.

Stab phlebectomies follow stripping. Using an 11-blade or even a 14G needle, small incisions are done at the more emerging points of varicosities. For better cosmetic results, the directions of the skin incisions must follow the Langer’s lines (Fig. 7.4). Generally, the incisions should be longitudinal everywhere except the areas around joints, such as the knee or ankle, where they would better be transverse. Through the incision, a suitable vein hook is inserted and the vein is hooked (Fig. 7.5). To hook the vein, the surgeon performs a slight semicircular or circular motion; this varies depending on the specific instrument used. Special care should be taken to avoid hooking other elements than veins, such as muscle fibers, adipose tissues or more serious elements like nerves and arteries. After the vein is hooked, it is pulled out of the skin with slight small pendulum motions. When a part of the vein has been pulled out of the skin, it is grasped with a pair of forceps, and using subsequent forceps, the vein is pulled out of the skin as much as possible (Fig. 7.6). Finally, the vein either is totally removed or more often is torn with a part of it remaining in the leg. Obviously, it is the best to remove as many veins as possible and avoid leaving even small remnants. However, if the main tract has been removed, then usually, the remaining part is thrombosed and generally becomes invisible after the procedure. If there is continuous bleeding from the stab avulsion site after vein removal, then a slight local pressure for a couple of minutes will eliminate it. In case of persistent hemorrhage, a further exploration of the wound for remaining large venous branches using a hook is necessary. Perforating veins are removed using the same techniques. However, due to their connection with the deep vein system, persistent bleeding after vein removal may be noted. This is treated with local digital pressure for some minutes. Special attention must be paid on the areas of possible damage of underlying anatomic elements. Mainly these are the area around the head of the fibula, on the upper lateral calf, where there is danger of damaging the deep peroneal nerve, a complication that can be devastating as it can lead patient to a drop foot. Similarly, care should be given on avulsions around the ankle area, where there is danger of damaging the posterior tibial artery (medially), the dorsalis pedis artery (dorsal area of the foot), or the sural nerve (laterally).

After saphenectomy and phlebectomies, the skin is closed. There are two types of wounds: the small phlebectomy wounds and the larger groin crossectomy wound. Generally, the skin incisions for the phlebectomies do not require formal suture closure. Just using adhesive tapes like Steri-Strips of ¼″ or ½″ wide is sufficient (Fig. 7.7). The larger groin wound needs formal closure in two layers, first layer consisting of the superficial fascia with isolated 2.0 Vicryl sutures and the second layer consisting of the skin, either isolated skin stitches or usually with an absorbable continuous subcutaneous suture Vicryl 3.0. Before closing the superficial fascia, we prefer closing the opening of the saphenous canal, from within the wound using an absorbable 2.0 suture. This way we minimize the possibility of groin hematoma from any blood and clots coming to the groin from the saphenous canal, after the saphenectomy . After the skin is closed, the whole leg is cleaned and covered with either an elastic stocking up to the groin or wrapped by elastic bandaging to the same level starting from the foot. The elastic support of the leg is continuous for 2–3 weeks, the first week on a 24-h basis, and then only during the standing hours.