Varicose Veins

1.Obtain a pre-operative US of incompetent perforators and have them marked on the skin. Mark individual varicosities with a permanent marker with the patient standing.
2.Position the patient supine, exsanguinate the limb with an Esmarch bandage and prepare the entire lower limb from groin downwards.
3.Make an oblique groin incision in line with a skin crease over the site of the SFJ (3.5cm below and lateral to the pubic tubercle) measuring 4-5cm.
4.Dissect down to the SFJ and delineate tributaries to be divided once SFJ has been identified. The tributaries are superficial circumflex iliac, superficial epigastric, superficial and deep external pudendal, a deep vein that pierces the fascia over adductor longus, anterolateral and posteromedial (accessory saphenous) thigh veins.
5.Dissect the SFJ and divide between artery forceps having clearly identified the femoral vein and ensured there is not a deep external pudendal vein entering the femoral vein as this can lead to recurrent vulval varicosities. Transfix the SFJ using 3/0 vicryl. Then individually ligate tributaries.
6.Insert a vein stripper without the bulky head attachment into the cut end of the saphenous vein and run it down as far as the upper third of the tibia if possible. Below this level the saphenous nerve is closely associated with the vein and a subsequent greater incidence of neuralgia. Make a 1cm incision over the site of the stripper pointing and extract it. Suture the end of the stripper at the cut superior end and strip the length of the vein with an assistant putting pressure on the thigh.
7.Perform haemostasis of the groin wound and close in layers.
8.Perform stab avulsions over the marked individual varicosities via 5mm incisions and small Kocher forceps.
9.Close the stab wounds with steristrips and dress with gauze, velban and crepe from ankle to groin (leave intact for 1-2 days then discharge home or arrange RDNS home visit at 1-2 days for removal of dressing and application of full length graduated compression stockings).