Overview
Definition:
Varicose vein stripping is a surgical procedure to remove elongated, swollen, and twisted veins, most commonly occurring in the legs
It is performed to alleviate symptoms and prevent complications associated with chronic venous insufficiency
The procedure typically involves ligation of the saphenofemoral junction and removal of the great saphenous vein (GSV) or small saphenous vein (SSV) using an avulsion or inversion stripping technique
It is often combined with other minimally invasive techniques like phlebectomy for distal varicosities.
Epidemiology:
Varicose veins affect approximately 20-30% of the adult population, with a higher prevalence in women
Risk factors include genetics, age, obesity, prolonged standing or sitting, pregnancy, and history of deep vein thrombosis
In India, prevalence varies regionally but is significant, making it a common surgical pathology.
Clinical Significance:
Varicose veins can lead to significant morbidity, including pain, heaviness, swelling, skin changes (pigmentation, eczema, lipodermatosclerosis), and venous ulcers
Surgical intervention is crucial for patients with symptomatic disease or those at risk of developing complications, improving quality of life and preventing disability
Understanding the surgical management is essential for DNB and NEET SS candidates to manage these common vascular issues.
Indications
Absolute Indications:
Symptomatic varicose veins causing significant discomfort (pain, heaviness, aching, swelling)
Presence of complications such as superficial phlebitis, bleeding from a varix, or stasis dermatitis.
Relative Indications:
Cosmetic concerns with large or unsightly varicosities
Recurrent superficial phlebitis
Inability to perform daily activities due to symptoms
Preparation for other vascular procedures.
Contraindications:
Severe arterial insufficiency (Ankle-Brachial Index < 0.7)
Active deep vein thrombosis
Significant systemic illness making surgery unsafe
Patient refusal or inability to comply with postoperative care.
Preoperative Preparation
History And Physical:
Detailed history of symptoms, duration, risk factors, and previous treatments
Thorough physical examination to map all varicosities, assess competence of saphenofemoral and popliteal junctions, and evaluate for signs of arterial disease.
Investigations:
Color Doppler ultrasonography is the gold standard for mapping the extent of venous reflux, incompetent perforators, and identifying saphenofemoral/popliteal junction competence
Duplex scanning confirms the diagnosis and helps in planning the surgical approach
Arterial Doppler may be performed if peripheral arterial disease is suspected.
Patient Counseling:
Informed consent regarding the procedure, potential benefits, risks, complications, and alternative treatments
Discussion of expected outcomes, recovery period, and the need for compression therapy post-operatively.
Anesthesia Considerations:
Typically performed under general anesthesia, spinal anesthesia, or local anesthesia with sedation, depending on the extent of the procedure and patient factors
Anesthesia choice is discussed with the anesthesiologist.
Procedure Steps
Saphenofemoral Junction Ligation And Stripping:
A groin incision is made to expose and ligate the saphenofemoral junction (SFJ)
The saphenous vein is then dissected distally
A stripping wire is introduced into the vein and advanced to the ankle or foot
The vein is avulsed or inverted and removed with the stripping wire
Multiple small incisions are made along the course of the vein to remove visible varicosities (ambulatory phlebectomy).
Small Saphenous Vein Stripping:
Similar principles apply, with ligation at the saphenopopliteal junction (SPJ) and stripping of the SSV
Careful dissection is required to avoid injury to adjacent nerves, especially the sural nerve.
Adjunctive Procedures:
Endovenous thermal ablation (laser or radiofrequency) is increasingly used as an alternative or adjunct to stripping for the main truncal veins
Foam sclerotherapy can be used for smaller varicosities or as an adjunct.
Closure And Dressings:
Incisions are closed with fine sutures
Sterile dressings are applied, followed by compression stockings or bandages to minimize bruising and swelling and promote venous return.
Postoperative Care
Pain Management:
Analgesics are prescribed for pain relief
Early ambulation is encouraged to prevent deep vein thrombosis.
Compression Therapy:
Graduated compression stockings are essential and should be worn continuously for several weeks as advised
This aids in venous return, reduces swelling, and prevents recurrence.
Wound Care:
Instructions on wound care, monitoring for signs of infection, and dressing changes
Sutures are typically removed within 7-14 days.
Activity Restrictions:
Avoid strenuous activity and prolonged standing/sitting for the initial period
Gradual return to normal activities is recommended.
Follow Up:
Scheduled follow-up appointments to assess wound healing, symptom resolution, and monitor for recurrence
Doppler ultrasound may be used to evaluate treatment success.
Complications
Early Complications:
Bleeding and hematoma formation at the incision sites
Infection of the surgical wounds
Nerve injury (e.g., sural nerve neurapraxia leading to numbness or paresthesia)
Superficial thrombophlebitis
Deep vein thrombosis (DVT).
Late Complications:
Recurrence of varicose veins due to incomplete treatment, formation of new varicosities, or incompetent perforators
Chronic pain or discomfort
Skin discoloration
Lymphedema (rare).
Prevention Strategies:
Meticulous surgical technique with careful ligation and stripping
Adequate compression therapy post-operatively
Aggressive DVT prophylaxis where indicated
Thorough preoperative mapping with Doppler ultrasound to identify all incompetent segments
Patient selection and adherence to follow-up protocols.
Key Points
Exam Focus:
Understand the indications for stripping versus endovenous ablation
Know the anatomy of saphenofemoral and saphenopopliteal junctions and surrounding nerves
Be familiar with common complications and their management
Differentiate between primary and secondary varicose veins.
Clinical Pearls:
Always perform a detailed Doppler mapping before surgery to identify all refluxing segments and perforators
Ligate the SFJ/SPJ flush to prevent saphenous stump blow-out
Ambulate patients early postoperatively
Compression is key for long-term success.
Common Mistakes:
Inadequate ligation of the SFJ leading to stump blow-out and recurrence
Damage to the saphenous nerve during stripping
Incomplete removal of varicose tributaries
Failure to adequately map incompetent perforators
Insufficient or incorrect application of compression therapy.