73

E 'STRIPPING' OPERATION FORVARICOSE VEINSBy HAROLD DODD, Ch.M., F.R.C.S.

Surgeon to St. Mary's Hospital Group, Paddington; King George Hospital, Ilford; Royal Hospital, Richmond;Royal London Homoeopathic Hospital

The procedure of stripping-out the varicosetrunk of the internal or external saphenous veinis being used increasingly. It was first devisedby Mayo (I906) and Babcock (1907), but it fellinto desuetude on account of the apparent effec-tiveness and simplicity of sclerosing injections forvaricose veins. During the last decade (i945-54),because the various remedies for varicosities haveproved to be often of temporary benefit, strippinghas been revived by surgeons in America (Barrow,I948), Britain (Foote, I954) and Canada (Fratkinand Jackes, 195 ).The purpose of this article is to describe the

stripping operation that has been carried out over400 times beginning January, I952. These caseswere undertaken to compare with 670 patientswith varicose veins treated by sapheno-femoral orsapheno-popliteal ligation followed by internalcurettage and sclerosant injection of the saphenoustrunk in the five years 1947-5i. This methodgave 92 per cent. of satisfactory results after twoand a half to five years. Although the periodduring which stripping has been performed isshort (two years), the results compare alreadyfavourably with those of the previous group,because they require fewer post-operative injec-tions (Linton (I949) also found this). Thusduring my out-patient sessions until I953 it wasusual to give 20 to 30 post-operative injections,but now after the stripping treatment only threetQ six injections will be needed during a similarclinic.The principle of the two operations is the same,

iLe. terminal sapheno-femoral or sapheno-poplitealligation for the incompetent internal and externalsaphenous veins respectively, division of anydefective communicating veins and elimination ofthe varicose saphenous trunk.

I would emphasize the importance of theaccuracy of the diagnosis, especially must ineffi-cient communicating veins be located and dividedas well as the varicose saphenous system terminallyligated. If these conditions are unsatisfied, the

best stripping of varicose veins will be followedby the reappearance of more varices in one to threeyears of the operation. Further, to avoid infec-tion, good technique and towelling are necessary.

The Technique of Stripping the InternalSaphenous VeinA ' hockey-stick' incision is made, its centre

approximately in the groin at a point Il in.below and external to the pubic spine. Theouter half of the incision lies in the crease of thegroin and the lower half curves downwards andparallel to the labia or scrotum for about 2 in.This approach will expose the end of the longsaphenous vein and its terminal tributaries, all ofwhich are divided. The saphenous vein is ligatedtwice at the sapheno-femoral junction; especialcare is taken that no tributary remains undivided,an easy condition apparently, yet after over 20years of varicose vein surgery I find that the deepexternal pubic or superficial epigastric veins areoverlooked readily. After general haemostasis, aswab is placed in the wound.

The AnkleThe internal saphenous vein is exposed at the

ankle as it lies in the groove in front of the anteriorborder of the internal malleolus; a transverseincision I in. long is made. The internal saphenousvein lies on the deep fascia, is straight, pale blue,thick walled and accompanied by the saphenanerve which is detached out of harm's way. Thevessel is ligated and half cut across just above this.

The Stripping InstrumentMyer's stripper (Fig. i) is an excellent pattern.

It consists of a flexible cable about a metre longwith a rounded tip at one end and a strippingshoulder at the other.

Stripping the Internal Saphenous VeinThe stripper is inserted into the already opened

saphenous vein at the ankle and is threaded up the

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74 POSTGRADUATE MEDICAL JOURNAL February 1955

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FIG. i.-Myer's stripper about to be introduced into the internal saphenous vein at the ankle.

saphenous trunk to the groin (Fig. i). It occa-sionally impacts in a varix but with twisting, toand fro movements of the stripper and manipula-tion of its tip through the skin at the hold-up itis usually possible to pass it through even asinuous saphenous vein. When the tip of theinstrument appears in the saphenous vein at thegroin, the vessel is divided distal to the sapheno-femoral ligatures and the stripper emerges and isdrawn out until the other end is flush with theankle wound. Here a ligature is tied round the veinand stripper and the saphenous vein is divideddistal to the insertion of the stripper. Tractionis made on the stripper at the groin; this drawsthe large stripping shoulder into the ankle woundwhich is done with the minimum of contact withthe skin edges, thereby avoiding the introductionof a skin infection into the vein bed. This isimportant when there has been an ulcer oreczema about the ankle. The act of strippingthe internal saphenous trunk from the ankle tothe groin is carried out by a steady to and frotraction on the stripper at the groin so the veinis detached from its bed and it ultimately appears

in the upper wound as a telescoped mass 2 to 3 in.long, impacted on the shoulder of the instrument.During the extraction, the stripper is often heldup where tributaries join the saphenous trunk,but insistent gentle pulling overcomes this andthe subsidiaries can be felt to snap off and theremoval proceeds. Great strength is avoided,time must be given for the separation of the veinfrom the tissues as it is being threadedthrough.

Subsidiary IncisionsOccasionally the stripper impacts in the vein

possibly caught in an eccentric varix or a sharp bend,or the vein may be narrowed by surrounding scartissue, previous thrombosis or injection. In thisevent an attempt to thread it downwards fromthe groin is occasionally successful. Failing this,the point where the stripper tip is impacted iscut down upon, the vein opened, the stripper isbrought to the surface and the vein from the ankleto this place is removed. The instrument is re-introduced as far as it will go and the procedureis repeated until the vessel is eradicated to the

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76 POSTGRADUATE MEDICAL JOURNAL February 1955

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FIG. 2. A stripper threaded through the external saphenous vein from the ankle to the popliteal space.

groin. Occasionally four additional incisions maybe required.

The Technique of Stripping the ExternalSaphenous VeinThe external saphenous is characterized by its

variability, in about 6o per cent. of cases it endsin the popliteal space, just over 30 per cent.terminate in the middle or upper third of thethigh, and nearly io per cent. end in the deepveins of the calf or in the internal saphenous veinbelow the knee. On account of these variations,external saphenous vein stripping begins at theankle. The vessel is exposed at the outer borderof the tendo-achillis 2 in. above the tip of theexternal malleolus, where it lies on the deepfascia, being straight, pale blue and thick-walledwith the large sural nerve on its outer side. It isdefined and ligated at the lower edge of the wound,just above this it is half cut across and the stripperis introduced; in many of the cases it impacts atthe sapheno-popliteal junction in the poplitealspace where it is cut down upon. In a thin

patient where the vein end is located surely, thiscan be done through a transverse incision, but itgives limited access and in stouter subjects,especially where the site of the sapheno-poplitealunion is uncertain, a midline longitudinal approachgives a surer approach although an unsightly scaris prone to follow. The deep fascia is incisedlongitudinally and the external saphenous vein withthe stripper inside it is felt for in the poplitealspace. The vessel is dissected out and followedupwards until the sapheno-popliteal union isexposed. This point is ligated twice and theshort saphenous vein is divided below this.Advancement of the stripper causes it to emergefrom the vein and it is drawn through the ankleuntil the stripping shoulder is almost in contactwith the lower wound (Fig. 2). A ligature is tiedround the stripper and the vein is divided distally.The saphenous trunk is stripped like the internalsaphena by pulling it from the ankle to the knee.The happy event of the stripper negotiating

the entire external saphenous trunk does notalways follow. It may impact as it enters the

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February 1955 DODD : The' Stripping' Operation for Varicose Veins 77

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FIG. 3.-The ' stripped ' vein, note the torn tributaries.

aponeurotic canal at the mid-calf, at the entry ofa large tributary where there may be a blow-out,especially at the upper two-thirds of the calf andagain where it dips into the popliteal space.When this occurs, if manipulation fails, the veinis cut down upon by a transverse incision, dividedand stripped up from the ankle. The stripper isre-inserted until it lodges at the sapheno-poplitealjunction.The stripper may run up the saphenous vein to

the middle or upper third of the thigh; this ischecked by appropriate exposures until thesapheno-popliteal union is found. The hightermination of the external saphenous vein intothe internal saphenous is likewise followed up byfurther incisions and the vein stripped to here.The high termination suggests the possibility ofthe internal saphenous vein being inefficient sothis is tested and dealt with if necessary.The stripper may impact at an ending of the

external saphenous vein in the muscular part ofthe calf or in the internal saphenous vein below

the knee. In either case, it is cut down upon andthe vessel stripped.

BleedingAfter stripping the saphenous trunk the bleeding

is sometimes copious, but it is quickly relieved bytilting the patient into the Trendelenberg position.A further haemastatic step is that of after about3 in. of vein have been stripped above the ankle,the wound here is sutured and the assistant startsto bandage the limb firmly with a sterile crepebandage beginning at the ankle and following thestripper as the surgeon eradicates it. Thusimmediate pressure is applied to the vein bedand haemorrhage is minimized; it is referred toas the ' clean stripping' method.

Closure of the Wound and DressingThe wounds are closed accurately and dressed

securely. The leg and thigh are bound with acrepe elastic bandage starting round the foot andextending to the groin; this is kept on for 36 to 48

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78 POSTGRADUATE MEDICAL JOURNAL February 1955

hours. The foot of the bed is elevated I2 in.for two days. Patients get up as soon as theyare round from the anaesthetic for bed making,toilet purposes, and to walk round the bed. Theymay not stand, or sit with the legs down for aweek, and during resting or sitting the feet arewell elevated.

After-CareThe discomfort after this admittedly crude

procedure is surprisingly small; extensive bruisingof the thigh and leg often follow, but it is of noconsequence; the subcuticular varices after thestripping generally thrombose spontaneously, butthose remaining patent are injected subsequentlywith i to 2 ml. of a sclerosant. All patients areseen at least annually for three to five years.

The SpecimenWhen the telescoped 'trophy' of the internal

saphenous trunk is extended it is 24 to z8 in. long;the external saphenous vein is correspondinglyshorter. Several tributaries hang from it snappedoff about I in. in length (Fig. 3). On openingthe vessel, the valves are apparent, they arevariable in number although normally there areI2 to 20 valves from the groin to the ankle, but inthe average varicose internal saphenous trunkthere are only two to four; they seem to be fewerin older patients.

Stripping by Mayo's Ring StripperIn I906 Mayo started stripping varicose veins

by threading the saphenous trunk through a ringon a steel shaft and moving this subcutaneouslyalong the outside of the vein, thereby freeing itfrom the fat and tearing off its tributaries.When the instrument is passed to its full lengthits ring is cut down upon, the vein brought outand the instrument re-inserted along the saphenoustrunk until all that it is considered necessary toremove is freed. This method has fallen intoobeyance, but occasionally tortuous veins arcencountered through which it is impossible tothread Myer's stripper and in such circumstancesMayo's stripper is useful. In gross varicositiesall the surgeon's ingenuity is needed to removethe saphenous trunk completely.

Haematoma of the WoundTwo cases of haematoma of the wound have

occurred in over 400 stripping operations; thefirst was cleared by aspirating several times

through a large bore needle; the second requiredthe lower end of the wound at the groin to beopened.

Deep ThrombosisThe possibility of thrombosis of the deeper

veins after any treatment of varicose veins is areal one. One case of complete thrombosis of thelower limb has occurred after stripping andanother of the leg. Deep thrombosis is a seriouscomplication because it launches the patient onan inevitable career of aching, swelling, itching,eczema or ulceration of the leg, although it maytake 30 years to develop. Consequently residentmedical and nursing staff are continuously alertedto the possibility of thrombosis and to maintainthe prophylactic treatment of pressure bandaging,elevation of the limb and continuous muscularactivity. Should thrombosis occur, these threeitems are continued and in addition Heparin isgiven intravenously in full doses for 48 hours;Tromexan and Dindevan are not prescribedbecause they are considered to be unnecessaryand dangerous to the blood and to the liver.Sedatives consisting of Aspirin, Phenacetin,Codeine and Papaverine are given four-hourlyuntil the pain has been subsided for 48 hours, forbodily comfort is necessary to permit the patientto exercise by day and to sleep with easy turningat night. If the swelling is marked and showssigns of creeping up the thigh then PapaverineIoo mg. is injected into the femoral artery at thegroin morning and evening until the oedema hasmanifestly subsided to the knee. The elevationof the foot of the bed so that the leg is level withthe heart is important throughout this period.

ConclusionThe stripping of varicose veins is described; it

promises to be effective and safe, but is subordinateto a complete diagnosis and efficient division ofthe incompetent connections with the deep veins,i.e. at the groin, popliteal space and variously inthe leg and thigh.

BIBLIOGRAPHYBABCOCK, W. W. (1907), 'A New Operation for Varicose Veins

of the Leg,' N.Y. med. Y., 86, I 53.BARROW, D. W. (1948), 'Clinical Management of Varicose

Veins,' New York, Hoeber.FOOTE, R. R. (I954), 'Varicose Veins,' Butterworth, London.FRATKIN, L. B., and JACKES, H. L. (I95I), 'The Treatment of

Varicose Veins,' Canad. med. Ass. J., 65, 367.LINTON, R. R. (I949), ' Surgery of Veins of the Lower Extremity,'

Minn. Med., 32, 38.MAYO, C. H. (I906), 'Treatment of Varicose Veins,' Surg. Gynec.

Obstet., 2, 385.

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