This surgery is performed as a day care operation where the patient can go home the same evening and has no stitches in his legs.

LSV surgery

	Trendelenberg position with 20 - 30° head down
	Legs abducted 10 -15°
	Saphenofemoral junction (SFJ) found 2 cm below and lateral to pubic tubercle
	Essential to identify SFJ before performing flush ligation of the LSV
	Individually divide and ligate all tributaries of the LSV
Superficial circumflex iliac vein Superficial inferior epigastric vein Superficial and deep external pudendal vein
	Check that femoral vein clear of direct branches for 1 cm above and below SFJ
	Stripping of LSV reduces risk of recurrence
	Only strip to upper calf.
	Stripping to ankle is associated with increased risk of saphenous neuralgia
	Post operative care:
Elevate foot of bed for 12 hours Class 2 stockings should be worn for at least 2 weeks

	Patient prone with 20-30° head down
	Saphenopopliteal junction (SPJ) has very variable position
	Preoperative localisation with duplex ultrasound is strongly recommended
	Identify and preserve the sural nerve
	Need to identify the SPJ
	Stripping associated with risk of sural nerve damage
	Subfascial ligation inadequate

Multiple Stab Avulsion

The veins are marked pre-operatively. Stab incisions are made along the blow outs. With Phlebectomy hooks, the veins are avulsed at multiple points. Wounds are closed with glue.

Perforator surgery Significance of perforator disease is unclear Perforator disease may be improved by superficial vein surgery Perforator surgery (e.g. Cockett's and Todd's procedure) associated with high morbidity Subfascial endoscopic perforator surgery (SEPS) recently described Not indicated for uncomplicated primary varicose veins May have a role in addition to saphenous surgery in those with venous ulceration

( SEPS ) Subfascial Endoscopic Perforator Surgery

Indications for SEPS

	Incompetent perforator veins
	Lipodermatosclerosis
	Ulceration

Advantages of SEPS

	Accurate localization of perforator veins in the subfascial compartment
	Minimally invasive surgery done as day care
	Morbidity from wound complications is eliminated
	Ulcer healing rates are improved