Management of Varicose Veins with Special Reference to the Stripping Operation

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Management of Varicose Veins with Special Reference to the Stripping Operation THOMAS T. MYERS

THE rationale of the stripping procedure in the treatment of varicose veins is that every vein interrupted or removed will help delay the return of varicosities. Treatment of varicose veins by stripping at the Clinic was begun by Dr. C. H. Mayo in the early years of the century and he reported the results and technique in 1906. Stripping gave way to sclerosing therapy between 1927 and 1930. In 1937 high ligation was combined with sclerosing therapy. This form of treatment was continued exclusively until 1947. From 1947 to 1949 at the Clinic a gradual swing occurred from ligation and injection therapy to partial stripping, and ultimately complete stripping. In 1949 stripping was employed in 91 per cent of the surgical procedures on the great saphenous vein and in 87 per cent of those on the small saphenous vein. By 1950 stripping was used in 99 per cent of all procedures, and since 1951 in 100 per cent. By January, 1955, 4550 stripping procedures had been done at the Clinic. RECENT SURVEY OF RESULTS

In order to determine the true value of the stripping procedure in the treatment of varicose veins, results of stripping operations performed at the Clinic in the five years from 1947 to 1951, inclusive, were studied by Smith and me. In this study we included only patients who were seen and checked in person at least 12 months after operation was performed. Of the 2660 stripping operations performed in the five years, 1189, performed on 711 patients (231 men and 480 women), were included in the study of results. The average length of follow-up after operation was 25.1 months. The longest was 62 months. Data concerning patients who had primary varicose veins and concerning those who had secondary varices associated with deep venous insufficiency are included in the results. In the first two years under consideration, 1947 and 1948, many incomplete stripping operations, stripping from the thigh or slightly be1147

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Thomas T. Myers

low the knee to the first bifurcation, were used; sclerosing solution was injected into the distal veins. Gradually more and more complete stripping procedures were performed, until at present, an extensive and radical operation is done with removal of every possible varicose vein either by stripping or direct dissection. Since the two different operations for similar conditions were performed by the same men, an excellent opportunity presents itself for comparing results. Of the 1189 stripping operations on the lower extremity, 1080 were on the great saphenous veins and 109 on the small saphenous veins. There was a family history of varicosities in 393 of the 711 cases (55.3 per

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Fig. 342. Results one to five years after stripping procedures. (Reprinted from Myers, T. T.: Surgical Treatment of Varicose Veins. In Allen, E. V., Barker, N. W. and Hines, E. A., Jr.: Peripheral Vascular Diseases. Ed. 2, Philadelphia, W. B. Saunders Company, 1955, pp. 744-772.)

cent). The average length of time that the patients had had varicosities was 17.2 years. The average age of the patients was 49.4 years; the oldest was 67 years; the youngest 19 years. Previous operations had been performed on 210 extremities (17.6 per cent of all extremities) and previous injection therapy without operation had been used on 358 (30.1 per cent of extremities). The results one to five years after stripping procedures are given in Figure 342. The stasis was under control in all cases. Results were classed as excellent, good, fair and poor. 1. When the over-all result was good, symptoms and signs had disappeared or were less apparent and no follow-up injection therapy was required, the result was considered excellent. 2. When conditions were the same as for excellent except that a few collateral vessels were present and from 2 to 4 cc. of sclerosing solution was required to close them, the result was

Management of Varicose Veins by Stripping Operation

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considered good. 3. When symptoms and signs showed some improvement, and 5 cc. or more of sclerosing solution was required to close collateral channels but no main channels had re-formed, the result was listed as fair. 4. When one or more of the main channels had re-formed or persisted, the result of operation was classed as poor. An average of 9.4 cc. of sclerosing solution was used to complement the stripping when stripping was done throughout the extremity and 3.6 cc. when the small saphenous vein only was stripped. For follow-up injections beginning one year after operation an average of 4.8 cc. of solution was required when stripping had been done to the knee, 1.6 cc. when stripping had been carried out throughout the extremity and 0.8 cc. when stripping was confined to the small saphenous vein. The results shown in Figure 342 prove that the more extensive the removal of the veins by operation, the longer the delay before a new venous pattern is reformed. They have pointed the way for more extensive operation also. Since 1951 the technique has been improved at the Clinic and the present technique will be described later. DIAGNOSTIC EXAMINATION

Complete physical examinations are recommended for all patients who have varicose veins because the presence or absence of constitutional diseases, infectious diseases, peripheral arterial diseases and abdominal tumors is important when treatment is being planned. A detailed history concerning the involved extremity is helpful. This should include the time that the varicosities were first noticed, how fast they have progressed and the complications, if any, such as thrombosis of the superficial veins, ulceration, hemorrhage, itching, edema, heaviness and dermatitis. For women the usual story is that the initial stage was precipitated by the first pregnancy. A special inquiry should be made concerning previous medical treatment, elastic support, sclerosing therapy, previous operative procedures, and thrombosis of the deep veins. The patient must be questioned carefully concerning old iliofemoral thrombophlebitis. Sometimes physical signs of advanced stasis are present but the patient will not give a positive history of phlebitis. Even more careful and meticulous questioning about previous deliveries, operations, fractures of the lower extremity and illnesses will be necessary before the exact diagnosis can be established in such cases. The majority of the patients, however, will recognize that they have had previous trouble in the leg and know the circumstances under which it occurred. Many patients may have obvious large varicosities and still be completely free of symptoms and signs of stasis. The patient should stand erect, preferably on a platform or stool, hold onto a fixed bar and face the source of light during examination for varicose veins. Two sources of light are frequently of value. The extremities, lower part of the abdomen, perineum and genital region should be completely exposed.

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Thomas T. Myers

The veins often will be large, near the skin and easily visible on inspection. Then in other cases they will be deep in the fatty subcutaneous tissue and not visible at all. Such veins must be detected by palpation or compression. I use the compression method in every examination for varicose veins (Fig. 343). Tracing the exact course of the vein, if done properly, serves as a rough measure of the size of the vein and will indicate whether the valves are incompetent. To trace the course of the great saphenous vein, compress the vein at the level of the knee by circling the leg with the hand with the finger tips

a b c Fig. 343. The compression test. a, Method of percussion to demonstrate an incompetent great saphenous vein at the fossa ovalis. b, Method of following course of great saphenous vein. c, Percussion of an incompetent lesser saphenous vein.

on the veins (the vein actually is compressed by the fingers over the inner surface of the condyle of the femur), and using the finger tips of the other hand to receive the impact of the ballottement, either above in the thigh and groin or below in the leg. By moving both hands along a vein a complete mapping out of the varicosities is possible. In this manner, it can be determined whether the superficial varices lead into areas of stasis changes. A big impact denotes a large vein; a small one denotes the antithesis or a badly scarred vein. Transmission of an impulse in a vein for a distance of 20 cm. by compression is usually considered an indication of incompetency. The retrograde-filling test (modified Brodie-Trendelenburg) as is shown in Figures 344 and 345 is used after the compression test to

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Fig. 344. Retrograde-filling test (modified Brodie-Trendelenburg) showing incompetency of great and small saphenous veins. a, b, Patient standing; both saphenous veins filled. c, Veins emptied; tourniquet applied; t.humb over small saphenous vein. d, e, Patient standing; tourniquet occludes great saphenous vein; thumb occludes small saphenous vein.}, g, Tourniquet is released after 15 seconds of standing. Prompt filling of veins proves incompetency of great saphenous vein. h, Veins emptied again; tourniquet and thumb applied. i,1, Patient standing; thumb removed in 15 seconds. Filling of veins proves incompetency of small saphenous vein. (a, d, f and i from Myers, T. T. and Cooley, J. C.: Varicose Vein Surgery in the Management of the Postphlebitic Limb. Surg., Gyne('. & Obst. 99: 733-744 [Dec.] 1954, and b, c, e, g and h from Myers, T. T.: Varicose Veins [Phlebectasia, Venous Aneurysm]. In Allen, E. V., Barker, N. W. and Hines, E. A., Jr.: Peripheral Vascular Diseases. Ed. 2, Philadelphia, W. B. Saunders Company, 1955, pp. 546-568.)

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Thomas T. Myers

Fig. 345. Retrograde-filling test (modified Brodie-Trendelenburg) showing competency of the great saphenous vein and incompetency of the small saphenous vein. a, b, Patient standing; both systems are filled. c, Veins emptied; tourniquet applied; thumb over small saphenous vein. d, e, Patient standing; tourniquet occludes great saphenous vein; thumb occludes small saphenous vein. j, g, Tourniquet released after

Management of Varicose Veins by Stripping Operation

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verify the imrpession of incompetency of the valves of the great saphenous veins. For this examination the patient lies on his back on the examining table with his legs raised well above the level of the thorax until all of the blood has drained from the superficial veins. He then stands erect and a careful watch is made of the rapidity and volume of retrograde filling or backfilling of venous blood. This filling can be demonstrated more dramatically if the veins are emptied as just described and a rubber tourniquet is placed at various levels, preferably at the juncture of the middle and distal third of the thigh. The patient then stands erect. An incompetent great saphenous vein will fill down to the tourniquet in a retrograde direction. After approximately 15 seconds the tourniquet can be released, and retrograde filling of the vein occurs suddenly. If it is demonstrated satisfactorily that the filling is retrograde and not gradual from below as is normal, then incompetency is established. If the vein below the tourniquet fills before the tourniquet is released, incompetency of the small saphenous vein or the perforating or deep veins must be considered. Repeated tests with the tourniquet in various positions will locate the source of abnormal filling of the vein and may disclose a perforating vein. Sometimes multiple tourniquets are necessary. However, a palpable defect through the fascia associated with bulging veins is the best evidence of an incompetent perforating vein. In an occasional case of extreme deep venous insufficiency the deep veins and superficial veins fill so suddenly when the patient stands that it is difficult to determine whether there is retrograde filling of the superficial veins. In this case the compression test will indicate whether the valves of the superficial veins are incompetent. In approximately 10 per cent of the lower extremities operated on at the Clinic for varicose veins, the small saphenous veins were incompetent. Careful examination for incompetent small saphenous veins, therefore, is important. The same plan and maneuver as for the great saphenous vein are necessary. The compression test is done by compressing the small saphenous vein with the thumb or finger tips in the popliteal space (Fig. 343, c). This point lies just lateral to the midline and is usually 2 to 3 cm. above the flexion crease behind the knee joint. If the vein is incompetent, an impulse will be transmitted to the midcalf or farther and the course of the vein may be followed. Stasis changes may occur to the lateral malleolus but a large medial branch is common,

15 seconds of standing. No filling of veins proves competency of great saphenous veins. h, Veins emptied again. i, j, Patient standing; thumb removed after 15 seconds of standing. Filling of veins indicates incompetency of small saphenous vein. (a, d, J and i from Myers, T. T. and Cooley, J. C.: Varicose Vein Surgery in the Management of the Post-phlebitic Limb. Surg., Gynec. & Obst. 99: 733-744 [Dec.11954, and b, c, e, g and h from Myers, T. T.: Varicose Veins [Phlebectasia, Venous Aneurysm]. In Allen,

E. V., Barker, N. W. and Hines, E. A., Jr.: Peripheral Vascular Diseases. Ed. 2, Philadelphia, W. B. Saunders Company, 1955, pp. 546-568.)

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Thomas T. Myers

and this incompetency may cause severe stasis changes on the medial side of the leg and ankle, or along the course of the tributary vein. A test of retrograde filling is used to verify the impression of incompetency. This is accomplished by emptying the blood from the superficial veins as previously described and placing a tourniquet at midthigh to shut out blood from the great saphenous vein. Now if the patient stands and the veins in question on the posterior portion of the leg fill, incompetency of the small saphenous vein should be suspected (Fig. 345, a). Confirmation of incompetency of the small saphenous vein shown in Figure 345, a, can be obtained by having the patient stand after the superficial veins are emptied, after the tourniquet is placed to shut out blood from the great saphenous system, and while the examiner's thumb is held firmly over the popliteal space at the t:lite of termination of the small saphenous vein (Fig. 345, d). The veins on the posterior portion of the leg do not fill. If the same veins, however, do fill on release of the thumb from the small saphenous vein, the valves of the small saphenous vein is incompetent (Fig. 345, i and j). To make a final check to determine whether the great saphenous vein is also incompetent, the veins are emptied as before and the tourniquet which has been holding out blood from the great saphenous vein is released while the examiner's thumb prevents filling from the small saphenous vein. If the vein suspected does not fill, only the small saphenous vein is incompetent, but if the vein fills after removal of the tourniquet, the great saphenous vein is also incompetent (Figs. 344 and 345). Results of these tests are accurate but a certain amount of skill must be developed in performing them. Incompetency of the great saphenous vein should be differentiated from incompetency of the small saphenous vein. To operate on both systems when only one is incompetent, without trying to differentiate, is not condoned. To operate on only one system when both are incompetent surely is not satisfactory. Differentiation is sometimes difficult for the inexperienced diagnostician; thus he may operate on the great saphenous vein when the small saphenous vein is the incompetent one. INDICATIONS AND CONTRAINDICATIONS FOR OPERATION

Indications for stripping incompetent superficial veins are (1) large varicosities, (2) stasis changes, such as dermatitis, ulcerations, pigmentation and chronic induration, (3) a history or evidence of a single attack or recurrent acute attacks of superficial phlebitis, (4) incompetence of both deep and superficial veins with venous stasis in which the superficial veins are a definite factor and (5) need for a prophylactic procedure. Contraindications may be classed as temporary and permanent or absolute. The temporary contraindications to stripping are (1) recent deep thrombophlebitis or acute superficial thrombophlebitis, (2) weep-

Management of Varicose Veins by Stripping Operation

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ing dermatitis anywhere on the body, (3) suppurative disease anywhere on the body, (4) acute and subacute stasis cellulitis of the leg, (5) pregnancy, (6) poor general health or poor condition after a recent operation. (7) obesity, (8) severe secondary anemia with concentration of hemoglobin of less than 10 grams per 100 cc. of blood, (9) recent extensive sclerosing therapy, (10) early asymptomatic varicosities, (11) main complaint due to other diseases of the lower extremity and (12) uncontrolled metabolic disease. The permanent contraindications to be considered are (1) marked arterial deficiency of the lower extremity, (2) normal but prominent-appearing veins, (3) asymptomatic varicosities occurring during advanced age, (4) severe deep venous insufficiency when mild varicosities do not appear to be a factor, (5) chronic lymphedema with minimal varicosities and also severe varicosities unless the patient understands that the improvement of the lymphedema cannot be expected and (6) severe constitutional disease with poor prognosis. Mter deep thrombophlebitis a period of at least a year should elapse before stripping procedures are performed. In that time deep collateral channels will be formed or deep veins reopened. Acute superficial thrombophlebitis should be quieted down by elevation of the extremity and warm packs for three days or longer before the stripping procedure is begun. Weeping dermatitis anywhere on the body or suppurative disease anywhere in the body may flare to a generalized reaction and therefore is a temporary contraindication to the operation. Before stripping procedures, acute and subacute stasis cellulitis of the leg should be quieted down by elevation of the extremity and warm packs; this usually requires seven days or longer depending on severity. Operation on the veins should not be performed during pregnancy, as a general rule, because the extensive congestion increases the technical difficulty of the operation and will permit dilatation of collateral channels during the remaining months of pregnancy. Varicosities usually can be controlled with elastic support, rest and elevation of the affected extremity. If acute superficial thrombophlebitis develops during gestation, stripping is advisable after a quieting period of a few days. It is advisable that extremely obese patients reduce to satisfactory weight before operation. Recent extensive sclerosing therapy usually produces periphlebitis and poor tissue to operate on. A patient who has early asymptomatic varicosities (borderline) may go for years without noticeable progression of the varicosities or development of venous insufficiency. Extensive operation then is too much for too little. When the main complaint is due to other disease of the lower extremities, such as arthritic pain of knees, referred pain from protruding intervertebral disk, undetermined pain in lower extremity which definitely has nothing to do with varicosities, this fact constitutes at least a temporary contraindication to operation. The patient would be dissatisfied with the

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Thomas T. Myer8

result because he would expect relief from these unrelated conditions after operation on the veins. Metabolic disease, such as Addison's disease, hyperthyroidism and diabetes mellitus, should be controlled completely before operation. Controlled diabetes is not a contraindication if arterial disease of the leg is not present. Among the permanent contraindications to stripping are marked arterial deficiency of the lower extremity and normal prominent veins. The reason for the first is obvious. Incorrect diagnosis of normal prominent veins as varicose veins occurs especially when patients have large veins all over the body and practically no subcutaneous fat. Asymptomatic varicosities developing during advanced age are ordinarily not removed. Elastic support should be used when necessary. However, stripping is indicated if symptoms or changes due to stasis are present in aged patients and their general health is good. Stripping operations are contraindicated in the presence of severe deep venous insufficiency and mild varicosities, even though superficial veins are incompetent. The incompetent superficial veins are minor factors in the stasis and their removal will not accomplish enough. Stripping should not be performed in the presence of chronic lymphedema, unless the patient understands that improvement of lymphedema cannot be expected. If varicosities are only minimal, operation should not be performed. The stripping operation is not indicated when constitutional diseases with poor prognosis such as severe renal disease, severe cardiac disease, generalized cancer or uncontrollable blood dyscrasias are present, or in general when the patient is unable to withstand general anesthesia for a long time, or is bedfast or unable to walk. Severe emphysema and poor respiratory reserve are among the contraindications to general anesthesia. If operation is urgent enough, even though general anesthesia cannot be employed, local anesthesia can be used. Among bedfast patients stasis usually is not severe, even though large varicosities may be present. Acute superficial thrombophlebitis, however, may occur and may force operation. EXAMINATION BEFORE SURGERY

The surgeon shOUld plan the procedure when the legs are being examined just before the patient enters the hospital. At this examination the distribution of the venous system is the important information to be sought as the varicosities usually are obvious. The main channels and tributaries are marked out, and special emphasis is placed on the possibility that an incompetent double system may be present. Incompetent perforating veins must be located (Fig. 346) and marked. The main channel of the great saphenous vein is constant; it courses from the dorsal vein of the foot to the saphenofemoral juncture. A com-

Management of Varicose Veins by Stripping Operation

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plete second system of veins may run the full length of the leg and thigh. Such a system usually is lateral to the main channel and starts on the outer side of the dorsum of the foot or at the ankle. A common variation of a complete second system is an accessory saphenous vein which is especially visible in the thigh. It may be a very tortuous vein with many tributaries connecting it with the main channel. It courses upward over the anterior surface of the knee cap and approaches the groin on the anterior aspect of the thigh.

Fig. 346. Incision over incompetent perforating veins.

The superficial lateral cutaneous vein courses over the outer or lateral aspect of the leg to the anterolateral aspect of the thigh, ending at the groin. The superficial medial cutaneous branch courses from the ankle upward through or over the popliteal space. It may take the place of the small saphenous vein, may course medially, circle from the posterior surface of the thigh and join the great saphenous vein slightly below the groin. Some dilated collateral vessels may join this vein to the labial veins. I reiterate that all the enlarged veins of the thigh and leg should be marked so that they can easily be followed at operation and all regions that suggest a possibility of an incompetent perforating vein must be marked for exploration. The surgeon and not the assistant should mark the veins (Fig. 347).

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Thomas T. Myers

Fig. 347. a, b, The marking on a left lower extremity before operation.

Marking Solution A solution of pyrogallic acid is a reliable marking solution. It consists of: 5gm. Pyrogallic acid ..................................... . Acetone ........................................... . 50 cc. Solution of ferric chloride (N.F.) ..................... . 40 cc. Ethyl alcohol, to make .............................. . 100 cc. Dissolve pyrogallic acid in alcohol; add acetone and ferric chloride solution and alcohol to make 100 cc. Make fresh every 7 to 10 days.

The marking made by this solution will remain for many days after application to nongreasy skin and will withstand vigorous preparation of . the skin for operation. PROCEDURES EMPLOYED FOR THE COMMONLY ENCOUNTERED TYPES OF INCOMPETENCY OF THE GREAT SAPHENOUS SYSTEM

The far-advanced extensive varicosity throughout the whole great saphenous system presents a difficult problem, because an extensive operation is necessary for complete removal of the main channel and

Management of Varicose Veins by Stripping Operation

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the incompetent tributaries. In some cases incompetency is only in the upper portion of the main channel of the great saphenous vein, with a. large tributary also affected, and the remaining portion of the great saphenous vein from the thigh to the foot is competent. If the main channel of the great saphenous vein only is removed from foot to groin, the large important incompetent tributaries then will be a nidus for future or persistent varicosities. In all cases when the vein is so tortuous that the stripper cannot be passed in either direction, the tortuous vein should be removed by direct dissection or evulsion. For a competent main channel of the great saphenous vein with an incompetent superficiallateral cutaneous branch, the incompetent vein should be removed together with the main channel even though it is competent. The great saphenous vein may be incompetent in the upper third of the thigh only and this may be associated with incompetency of the superficial medial cutaneous vein and varicosities connected with dilated labial veins. Varicosities of the superficial medial cutaneous vein are most frequently aggravated by repeated pregnancies. It should be removed completely along with the main channel, and direct dissection of the vein going to the labial veins and direct removal of veins in the labia majoris. The more extensively the venous system associated with varicose veins is removed and interrupted the longer the period before varicosities develop in another superficial system. Preparation

The hair is shaved from the umbilicus downward, including the perineum, thigh, leg and foot. The skin is washed carefully with soap and water. Alcohol, then ether and then a satisfactory skin antiseptic are applied to the skin. The operating table is covered with an orthopedic drape. It preferably consists of a sterile plastic sheet extending from under the hips of the patient over the end of the table. A double sterile cotton sheet is placed over this plastic sheet. A folded sterile towel is placed over the perineum. Small towels surround the groin and an extra towel is placed over the lower part of the abdomen. A full-length split sheet is placed over the patient. This sheet can cover the legs during dissection of the groins and be left over one leg while stripping on the other is carried out. The drapes should be held in place by towel clips so that there is never danger of contamination. Anesthesia and Premedication

Intravenous anesthesia with thiopental sodium has supplanted local block and nitrous oxide anesthesia for stripping operations. Approximately ~ to 1 ounce (15 to 30 cc.) of ether through a gas machine is employed to supplement the intravenous anesthesia. Premedication consists of 1/150 grain (0.4 mg.) of atropine sulfate, and 1/6 grain (0.01

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Thomas T. Myers

gm.) of morphine sulfate is given intravenously just before administration of thiopental. The patient is kept well oxygenated at all times through the anesthesia machine, and if necessary an intratracheal tube is used. s Dissection of the Groin

The incision approximately parallels the inguinal fold, as shown in Figure 348, a, 1. A long incision is best so that wide exploration can be

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I

a b c d Fig. 348. Great saphenous vein and its tributaries. a, 1 to 6 show usual sites of incisions needed for tributaries. b, c, d, Steps in the operation. See text for more details. m~de. The incision should extend at least 2 inches (5 cm.) latera.l to the femoral artery and approximately 5 inches (13 cm.) medial and downward so that the medial superficial cutaneous branch can be approached for removal or ligation. The ultimate goal is to remove and ligate all blood vessels in the region of the saphenofemoral juncture except the femoral vein and femoral artery (Fig. 349). The major vessels lie side by side, the femoral artery being lateral and slightly anterior to the vein. The deep vessels are behind the deep fascia and course laterally beneath the fossa ovalis. Pulsation in the femoral artery is strong and the femoral vein always

Management of Varicose Veins by Stripping Operation

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lies on the inner side and at this location runs practically in the same direction. These facts are helpful in identifying these vessels. The saphenous vein should be ligated flush with the femoral vein. My colleagues and I use 0 chromic catgut and a simple tie with a transfixion ligature for reinforcement. Inspection of the femoral vein for approximately 1 inch (2.5 cm.) above and below the saphenofemoral juncture will prevent overlooking important tributaries. The fossa ovalis should be opened wide if necessary. Veins coming into the femoral vein medially and laterally should be ligated but veins coming in posteriorly are not disturbed. Because the external pudendal artery is easily injured

Fig. 349. Ligation of vessels near saphenofemoral juncture.

during the dissection as it courses through the edge of the fossa ovalis, it is ligated to improve exposure and to prevent bleeding. When ligation of the tributaries is completed, the medial and lateral cutaneous branches of the great saphenous vein are exposed and prepared for stripping or ligation. The fossa ovalis is closed with interrupted sutures of plain 00 catgut. This closure supports the femoral vessels and helps wall them off from the superficial part of the operative wound which occasionally may become infected or may have delayed healing because of a hematoma. This step also prevents leaving a dead space. Dissection of the groin is exacting and must be done thoroughly. The appearance of the groin after the ligations is shown in Figure 349. Next the other groin should be operated on if a bilateral procedure is needed. The anatomy is a mirror image of that in the first groin. Only then is the stage set for dissection of tributaries and the stripping portion of the operation.

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Thomas T. Myers

Insertion of Stripper

For this procedure I use a flexible intraluminal stripper, made with various sizes of acorn tips, which I designed in 1947. Various sizes are employed so that the vein will not slip over the end of the stripper and invert but will collapse in folds on the stripper. The stripper also comes in various lengths so that an appropriate stripper may be used. 5 The stripper can be passed upward from the foot or downward from the groin or both ways from the knee or any other level. It is usually much the easiest, however, to pass it upward from the dorsal vein of the foot to the groin (Fig. 348, b, 2 to 1). The vein is tied to the stripper with fishline silk. After tying the vein slightly proximal to the acorn tip, the silk is left long enough to follow the stripper to the groin. Strippers may be placed in all the marked tributaries or the tributaries may be followed by direct dissection or undermined through multiple incisions. This is the only good opportunity in the course of the procedure to trace the tributaries to their connection with the main channel which contains the stripper. Thus, after the stripper is placed in the great saphenous vein and before removal of the vein by stripping, all regions marked for exploration for perforating veins should be investigated, the veins ligated and the fascia closed; all connections of sizable tributaries with the main channel can be isolated and severed. Dissection of Tributaries

The groin, the inner dorsal aspect of the foot and below the knee, marked 1, 2 and 3 in Figure 348, a, are the most common sites of important tributaries. At least three incisions are required for the tributaries. These are placed at the groin, inner side of the dorsum of the foot and below the knee medially at the bifurcation of the great saphenous vein (Fig. 348, b). A fourth incision on the medial surface in the distal third of the thigh is frequently necessary to pick up a commonly enlarged tributary coursing down over or medial to the knee (4 in Fig. 348, c). This tributary may also course down over the calf; it can be isolated by an incision made at 6 in Figure 348, c. At this site it can be ligated and the tributaries associated with it removed. Other incisions may be made when necessary to remove tortuous veins that cannot be removed by stripping. This is especially true of the branch of the great saphenous vein which courses superficially from the foot over the anterior surface of the leg to the bifurcation (not shown in Figure 348). If this vein is incompetent, it must be removed by whatever means are necessary. Frequently, multiple incision and evulsion with a curved forceps are used. Extra incisions, such as those shown in Figure 348, c, d, can be made to trace a tributary commonly coursing over the calf which usually connects the great saphenous vein with the small saphenous vein as well as sending another branch down to the perforating vein indicated as 5 in Figure 348, a.

Management of Varicose Veins by Stripping Operation

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Stripping of the Main Channel

After all important tributaries are ligated or removed, the easiest part of the operation is removal of the main superficial channel. The legs are elevated to help control bleeding but the torso is kept level. A homemade device, much like a headrest in reverse but much longer, may be placed under the mattress on the operating table and elevated just before the stripping. 2 Use of shoulder braces or dropping the body back on a tight wrist strap so that pressure is made on the brachial plexus should be avoided because temporary but severe nerve weakness may be caused by pressure on the brachial plexus during the operation. If the large tributaries have been isolated satisfactorily, the stripper can be pulled with both hands without any special attachment for pulling. Gauze should be placed over the shaft so that rubber gloves will not slip. It is helpful in preserving the strippers not to bend the shaft when pulling. The amount of pull necessary to break the unisolated tributaries should be noticed carefully as the acorn tip is pulled along the main channel of the vein. This gives the surgeon an idea of the size of the vein and this is important because large veins may have to be tied or removed to prevent bleeding. As the acorn tip appears in the incision below the knee (Fig. 348, b), the vein on the stripper should be inspected to be sure that it is not splitting or shredding, as it may do occasionally, especially if enough of the tough tributaries have not been ligated around the ankle. Retying will stop further shredding. Any shredded portion remaining in the leg could be removed by a modified Mayo stripper. An incision also can be made at the distal third of the thigh, but this usually is not necessary for simple early conditions without complicated venous patterns. Flash bleeding, like the bleeding associated with separation of the placenta in delivery of a child, occurs immediately after removal of the vein by stripping. If all the tributaries have been tied or are not too large and have snapped off and retracted satisfactorily, the bleeding soon stops. If bleeding continues, it can be controlled by packing gauze along the groove of the vein with curved forceps with the fishline silk thread as a guide. If bleeding persists, slight lengthening of the nearest incision usually will permit locating and tying the offending vein. If this is unsuccessful, the fishline silk thread will serve as a guide to the place where the main channel has been and other incisions can be made in appropriate locations along it. In cases in which stasis ulcers are present, stripping and skin grafting may be done at the same operation.' Closure

Great care must be taken to have the wounds and venous channel dry before closure since collection of blood in the wounds is the cause of

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delayed healing and most of the complications. The wound in the groin is best closed in layers with plain catgut. All dead space should be eliminated because blood may collect and disrupt the wound. Wounds of the thigh, leg and foot usually do not need subcutaneous sutures. Interrupted vertical mattress sutures are used to close the skin. These should not be too tight as they may cause strangulation of the tissue. This is especially true from the knee downward because orthostatic edema is responsible for the tendency for congestion of the wounds. Washing blood from the skin of the thigh and leg after closure of the wound is an essential procedure. If fresh clots are present in the main

Fig. 350. Bandage. a, Sterile dry dressings and elastoplast tape. The tape does not completely circle the leg. b, Then folded pads. c, Then 4-inch (7.6 em.) elastic bandage. (Reprinted from Myers, T. T.: Surgical Treatment of Varicose Veins. In Allen, E. V., Barker, N. W. and Hines, E. A., Jr.: Peripheral Vascular Diseases. Ed. 2, Philadelphia, W. B. Saunders Company, 1955, pp. 744-772.)

channel or wounds, they should be expressed by rolling longitudinally a rolled towel over the old channels and wounds. A curved forceps can be used to spread the sutured wounds to permit expelling of blood clots as the towel is rolled over them. Sterile dry dressings and elastoplast tape (used in the fashion of the usual adhesive tape dressings) (Fig. 350) should be applied. Then abdominal pads folded double are laid over the old channel of the vein. A 4-inch elastic bandage is applied from the toes to the groin. This requires at least two bandages for each leg and occasionally three if the thigh is extra large or long. All dressings must be made smooth and the elastic support not too tight, as too much pressure may cause sloughing of the skin in the distal third of the leg. The patient'siegs are kept elevated on the cart when he is transported to his room and when he is placed in bed. The body is kept flat.

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Postoperative Care

At least 1000 cc. of 5 per cent solution of glucose is given intravenously, usually in the latter part of the operation. For the first 12 to 18 hours after operation morphine sulfate is given freely, but it usually is....not needed for more than eight hours. Since early ambulation is desirable, depressants must be avoided. Pain is caused most commonly by tootight wrapping around the ankle and foot and loosening the bandage will correct this. Pain referred from the lower extremities to the.lumbar region can be controlled by codeine. A board put under the mattress and elevation of the foot of the bed without bending the hips often give relief too. Antibiotics are used only in cases of extreme obesity or when the patient has had a long, difficult and traumatic operation. Avoidance of hematomas, especially in the region of incisions, is the most important measure influencing complications. Ambulation is begun 18 to 24 hours after operation, at first only for one or two minutes, then for five minutes each hour for 12 hours a day. The stay in the hospital is usually five days. However, too much ambulation should be avoided as it causes edema of the legs and delayed healing. Orthostatic edema occurs to a certain degree when the patient begins to ambulate, in spite of the fact that the legs and thighs are well supported with pads and elastic bandages. An adjustable bandage seems to be the best. Sclerosing therapy can begin one week after the patient is dismissed from the hospital. Only minimal injections of the tributaries probably will be needed, but when many small tortuous tributaries are present, more extensive injection therapy will be needed. Sutures in the groin usually are removed in one week and the remaining sutures in nine or ten days after operation. If healing is delayed, a wet dressing of 0.25 per cent solution of aluminum subacetate is used. If a blood clot is present, the wound is irrigated with sterile physiologic saline solution. Infection of wounds is rare but when there is evidence of infection, antibiotics are used along with irrigation and moist dressings. Usually, all therapy is finished two weeks after operation. Elastic Support

The proper use of support is important. When the patient is dismissed from the hospital about the fifth day, the abdominal pad is exchanged for a foam-rubber pad which extends from the dorsum of the foot to the knee. This is supported by a good elastic bandage. When there is an incision on the inner surface of the distal third of the thigh, the compression bandage is extended to the middle third of the thigh. In approximately two weeks the foam-rubber pads are removed and the elastic bandage only is worn for six to eight weeks after operation or until the edema subsides. For the patient who has chronic venous insufficiency of the deep veins, use of the elastic support and sponge pad is continued

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indefinitely. All patients are cautioned not to stand still too long and to rest the legs by elevating them for 20 minutes several times a day until they have recovered from operation. Re-exalllination

One year after operation the patient should be re-examined and a few injections may be given then if certain tortuous branches were not removed. By that time the stasis changes have regressed, the pigment has become brown instead of black and the skin and subcutaneous tissue in the distal third of the leg have become soft and pliable. On the whole these patients are extremely well pleased. Re-examination every two years is desirable for an indefinite period. Only three patients out of a group on whom 4550 operations have been performed at the Clinic since 1947 have needed reoperation. These were needed because a second system in the thigh was missed at the first procedure in one case, because an incompetent perforating vein in the upper part of the thigh was missed in the second, and in the remaining case because stripping had been carried out only between the knee and groin and perforating veins between the knee and ankle had not been ligated. More of our early patients probably will need another stripping operation because our early stripping procedures were not extensive enough. On the whole, however, results of the early stripping procedures have been good. PROCEDURE FOR INCOMPETENCY OF THE SMALL SAPHENOUS VEIN

Special attention should be given to the small (lesser or short) saphenous vein. If careful inspection is made and the compression test (modified Schwartz-Heyerdale test) and modified Brodie-Trendelenburg tourniquet tests are used, an accurate diagnosis can be made. 3 Approxmately 10 per cent of operations on superficial veins at the Clinic are on the small saphenous vein either alone or in combination with the great saphenous vein. The small saphenous vein usually courses from the arch of the dorsal vein on the foot, laterally and posteriorly to the malleolus, and up the posterior surface of the leg over the calf. It ends in the popliteal vein approximately 3 to 4 cm. above the knee fold. The variations are important. The main channel, instead of joining the popliteal vein above the knee fold, may penetrate the fascia approximately 3 to 4 cm. below the knee fold. Or the small saphenous vein may send off only a small branch to the popliteal vein at the popliteal space, and may continue through the medial superficial cutaneous branch to join the greater saphenous vein 4 to 5 inches (10 to 13 cm.) below the groin. The compression test will yield diagnostic data of this variation. If sudden firm compression is mll-de with the finger over the vein behind the knee and an impact is felt in the groin, this variation is likely to be present.

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A large tributary may originate on the inner surface of the ankle. It runs to the calf and joins the small saphenous vein in approximately the middle of the leg. The actual incompetency of the small saphenous vein in such a case may extend from the saphenopopliteal juncture down through the upper half of the small saphenous vein and into the medial branch. Even though the lower half of the main channel going to the lateral surface of the ankle may not be incompetent, incompetency of the medial superficial branch may cause stasis changes to the inner surface of the ankle. In the presence of incompetency in any of the variations, removal of the veins affected is necessary. if the small saphenous vein or its tributaries are incompetent to the groin, the great saphenous vein should also be completely removed, because the upper 10 to 15 cm. of the great saphenous vein are also incompetent in these cases. Whenever the anatomy varies so that tributaries are an important factor in the problem, the main channels should be removed completely with the tributaries even though they may not be varicose in their entirety. Preparation and Anesthesia

The course of the veins is marked the day before operation. The main channel and tributaries are outlined and the perforating veins are marked for exploration and ligation. This permits the proper surgical approach. In the hospital the patient's legs are shaved thoroughly to the upper third of the thigh, because occasionally the communicating branch in the thigh going between the small saphenous and great saphenous veins will be large enough to be removed. As preoperative medication, 1/150 grain (0.4 mg.) of atropine sulfate and 1/6 grain (0.01 gm.) of morphine sulfate are given intravenously. For operations on the small saphenous vein I have used 0.5 per cent solution of procaine hydrochloride without adrenalin chloride for local injection. The entire system can be injected easily with a long needle. Nitrous oxide may be given for stripping if desirable. If general anesthesia is desired the patient should be intubated. Thiopental sodium given intravenously with nitrous oxide and ether by inhalation gives a nice anesthesia. It is my opinion that general anesthesia is the "one" of choice for all stripping procedures. . "" . Su~~cal Technique

A transverse incision· made approximately 2.5 cm. above the knee fold and a longitudinal incisio:n, made through the fascia give the easiest approach to the termination" of tlW vein in the popliteal space (Fig. .351, a to" d).. "The vein usually can be seen as a blue line through the "fascia";" how~ver,it is well to have· the"veill marked on the skin in case "it not "visible: If the vein""is" difficult "toiQcate in the popliteal region, it can be located at the ankie (Fig. 351, bY~nd the stripper passed in the

is

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vein from the ankle to the popliteal space. The stripper inside the vein can be felt readily. All branches leading to the small saphenous vein are tied. As a rule, only one small branch (the saphenofemoral branch) goes above the popliteal space and may end in the deep or gluteal veins or in the great saphenous vein in the upper third of the thigh. The small saphenous vein is divided in the popliteal space and followed to the popliteal vein. Usually, four-way retraction with flat retractors is necessary. The small saphenous vein is ligated doubly flush with the popliteal vein at the saphenopopliteal juncture with 0 chromic catgut and a transfixion suture is inserted. In the dissection to approach

a b c d Fig. 351. a, b, Stripper may be passed either upward or downward in the small saphenous vein. c, Stripper passed into an important medial tributary. d, In the remaining portion of the small saphenous vein the stripper is passed upward.

the saphenopopliteal juncture, nerves must be avoided carefully as occasionally one of the sensory nerves may course around the saphenous vein at its juncture. The peroneal nerve (motor) rarely is visible because it goes more laterally and originates at a higher level. Perfect control of bleeding is important. Too much traction on the proximal end of the small saphenous vein should be avoided during dissection as the vein can be torn easily at its juncture. Such a tear is troublesome and might necessitate narrowing the popliteal vein to tie it securely. Also, too much traction while the tie is being placed at the juncture may result in occlusion of the popliteal vein. This is a similar situation to that which sometimes occurs in the common duct when too much traction is used as the cystic duct is being tied.

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The next step after division and ligatioil of the small saphenous vein is to pass the flexible medium-sized short stripper downward or upward (Fig. 351, a, b). It is usually easily passed but the important point is to pass it into the medial superficial cutaneous branch, if one is present, to the inner side of the ankle (Fig. 351, c). The surgeon then can remove an important branch which frequently is missed. The remaining portion of the small saphenous vein which comes from the outer surface of the ankle can be removed by passing a stripper upward from the ankle (Fig. 351, d). To make the stripping easier, the stripper coming from above should be pulled first. Thus, the stripper in the lower segment of the small saphenous vein will pass upward from the ankle to the popliteal space through the tract of the upper segment. Of course, removal of the lower portion of the vein can also be accomplished by passing the stripper downward through a new incision in the middle third of the leg where the medial branch joins the main vein. Anyway, it is frequently necessary to make an incision in this region to ligate a perforating vein associated with the medial tributary. As many branches as possible should be removed or at least tied if hematomas are to be avoided in the tract. If bleeding continues after the stripping, a tributary is open and probably will have to be tied to avoid a hematoma. At times, packing with a gauze sponge will control bleeding along the tract. When this is necessary, it is especially helpful to have a fishline in the tract. The fishline can be drawn tight, thus opening the vein tract so the packing will be much easier. The rule of isolating all large tributaries and ligating or removing them before the main channel is stripped holds here as in the surgery of the great saphenous system. Mter bleeding is stopped, the fishline is removed and interrupted sutures of plain catgut are used to close the fascia over the popliteal space. Flexing the knee will bring the fascia together and make approximation easier. Interrupted vertical mattress sutures of silk are used to close all wounds in the skin. Sterile dressings are applied and held in place -and compressed by strips of elastoplast bandage. The elastoplast bandage should not go completely around the leg. The leg and popliteal region are padded with abdominal pads and supported with 4-inch ace bandage (No.8). The knee should be flexed while padding is applied so that the patient can flex the knee when walking or lying in bed without added pressure over the incision. Postoperative care is like that after stripping of the great saphenous vein (see p. 1165). OPERATION ON INCOMPETENT PERFORATING VEINS

An important part of satisfactorily destroying the superficial venous pattern is the operation on the incompetent perforating veins. Sherman has described these adequately. I have never tried to attack these by measuring for their location as he specified in his surgical technique, nor

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have I had the satisfaction of locating perforation from using the bandage technique described by Pratt. The multiple tourniquet also cannot be relied on, nor do I believe a flap operation is necessary to locate perforating veins. The superficial veins. are usually visible and palpable and their course can be outlined easily when the patient is standing on an examining table. At that time openings in the fascia also can be felt with a high degree of efficiency. Perforating veins usually are 2 to3 cm. lateral or medial to the main channel and collateral veins of variable size connect them to the main channel. When the veins are being marked, careful inspection of the common sites of perforating veins should be done (Fig. 346). An "X" is placed on the skin wherever a defect in the fascia with a vein coursing through it is noticed. Perforating veins are especially likely to play an important part when definite stasis changes are present distal to their site and when the deep veins are incompetent. In other words, the more complicated and extensive the stasis problem, the more likely that perforating veins are a factor. The perforating vein located on the inner surface in the distal third of the leg (Fig. 346) is usually large, and its removal in the course of an operation for varicose veins is important. Failure to remove perforating veins on the inner surface of the foot near the internal malleolus will cause the veins around the ankle and foot to persist or re-form and will prevent closure of veins around the ankle by sclerosing therapy. I employ a longitudinal incision for perforating veins. The vein is ligated behind the fascia flush to the deep veins or tributaries and the fascia is closed. The communicating veins leading into the perforating vein from above the fascia are either ligated or preferably removed by stripping or evulsion. If dissection is necessary, sharp dissection is best because delayed healing of wounds may result from trauma in the distal third of the leg. Good follow-up elastic support is helpful. Lumpy dressings and padding must be avoided. Because the skin is usually of poor quality, the pressure on it must not be too great. Frequently, incompetent perforating veins are located on the posterolateral surface in the distal two thirds of the leg. They can be felt and handled in a similar manner. PERSISTENT OR RECURRENT VARICOSITffiS

So-called recurrence of varicosities is not actually recurrence but persistence. The basis of all the mistakes which may be responsible for persistence or so-called recurrence is not enough operation. The patient who has had injection treatment only is an outstanding example of this. It is impossible to inject the main channels completely from the dorsum of the foot to the saphenofemoral juncture and even if it were possible, there is a constant dissolving or wasting away of the thrombus or fibrosis whenever fresh blood comes in contact with it. Several weeks or

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months'after'Spontaneou8 thrombosis of the great saphenous system the thrombus will be found to be soft and eroded at operation. Months or years after spontaneous thrombosis or sclerosing therapy, completely solid ciosure of a vein is rarely seen. The physiologic processes of the body eliminate clotting in a vein as soon as possible. Removal of the clot can be prevented only by stopping its contact with blood. This is no easy task with the collateral veins coming into the main channel all along its course. Stripping of the main superficial veins is as important as the accurate dissection of the groin. Stripping of the main superficial veins eliminates a tract which is constantly being opened by its contact with. blood through its collateral veins. It also breaks up the superficial system of veins so completely that it takes years for it to reorganize. Re-formation of the superficial venous system is difficult when the main incompetent channels are out and perforating veins are ligated. Thus, leaving the main varicose veins in the leg whether closed or not is a definite mistake. It is the same as "seeding" the lower extremities for future veins. At operation dissection in the groin is frequently inadequate. The vein is not tied at the saphenofemoral or saphenopopliteal juncture. The common error is to tie the saphenous vein about 2.5 cm. from its juncture with the deep vein. All of the tributaries then are left intact. The superficial lateral cutaneous vein is the most important tributary of the great saphenous system. If the main saphenous channel has not been removed by stripping, the superficial lateral cutaneous vein provides a direct connection from the saphenofemoral juncture to the lower half of the great saphenous system in the thigh. Even though the upper half of the great saphenous vein has been tied and sclerosed in the upper half of the thigh, the superficial lateral cutaneous vein has been found at operation to be functioning with the distal part of the great saphenous vein as a complete incompetent system. After multiple pregnancies the perineal and labial veins also may become involved in a recurrence through the medial superficial cutaneous vein. Small perforating veins frequently are associated with this vein. These are difficult to find at operation and their presence tends to make results from sclerosing therapy brief. This vein frequently is so tortuous that stripping is impossible and direct dissection and evulsion are necessary. Perforating veins are an important cause of recurrence. In my opinion, many small and competent perforating veins are never seen or suspected and apparently do not play too important a part in recurrence as long as they are competent. When one is incompetent, ligation behind the fascia is necessary. In the operation for recurrent varicosities passage of the stripper upward into the groin makes dissection easier as it helps to locate the great saphenous vein as it leads into the region of the old operation in

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the groin. Because the saphenofemoral juncture often has not been exposed at the time of the previous operation, an approach from above is helpful also. The saphenofemoral juncture must always be explored. This is usually accomplished most easily in a scarred groin by locating the femoral vein behind the fascia several inches distal to the saphenofemoral juncture and by using it as a guide to the juncture. In this way operating through difficult scarred tissue is avoided. Ligation of the tributaries at the saphenofemoral juncture in a manner similar to that which would be done in an original operation is then accomplished easily. POSTPHLEBITIC VARICOSITIES AND CAVERNOUS HEMANGIOMA

Stripping should be carried out on the postphlebitic leg, in my opinion. Varicose veins do not act as compensatory collaterals but actually transmit congestion above the deep fascia so that the subcutaneous tissue and skin deteriorate. In fact the operation must be very extensive with removal of all the varicosities and with specific emphasis on ligation of all perforating veins. Perforating veins are incompetent with especial frequency in the distal third of the leg. The incidence of incompetent small saphenous vein!'J is approximately twice as frequent following deep phlebitis as it is in primary varicosities. Operation alone is not enough; adequate elastic support must be used after operation. Many legs will improve so much that it is difficult to get the patient to wear the support indefinitely. The only logical approach to the extensive cavernous hemangioma of the lower extremity is removal of the large channels by stripping and direct dissection with ligation of the many perforating veins. A recent article by Janes and myself gave the surgical management of this condition. COMPLICATIONS

Complications in the 1189 procedures carried out at the Clinic from 1947 through 1951 consisted of four postoperative episodes of thrombophlebiti!'J, an incidence of 0.3 per cent, and three episodes of pulmonary emboli, only one of which was of a serious nature, and incidence of 0.2 per cent. Out of the 2660 stripping procedures performed in the five-year period there was one death from pulmonary emboli, an incidence of 0.037 per cent. No further fatalities have occurred to date. ADVANTAGES AND DISADVANTAGES OF THE STRIPPING OPERATION

Stripping interrupts the venous pattern efficiently. It destroys and breaks up collateral veins more extensively and offers more likelihood of solving the problem of the abnormal venous pattern than previous procedures did. It also may sever some incompetent perforating veins, even though they were not recognized preoperatively or at operation.

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Stripping also reduces sclerosing treatment required immediately after operation and for years in the postoperative follow-up. The length of the operation is a distinct disadvantage, for at least one hour or more is required for each extremity. The multiple incisions increase chances of complications and multiple examinations are timeconsuming. The surgeon who is performing a stripping operation must have a more thorough understanding of venous anatomy of the whole lower extremity than is required for ligation alone. The advantages far outweigh the disadvantages, and, therefore, stripping operations are used exclusively at the Clinic in the treatment of varicose veins. REFERENCES 1. Mayo, C. H.: Treatment of Varicose Veins. Surg., Gynec. & Obst. 2: 385-388 (Apr.) 1906. 2. Myers, T. T.: Surgical Treatment of Varicose Veins. In Allen, E. V., Barker, N. W. and Hines, E. A., Jr.: Peripheral Vascular Diseases. Ed. 2, Philadelphia, W. B. Saunders Company, 1955, p. 757. 3. Myers, T. T.: Surgical Treatment of Varicose Veins. In Allen, E. V., Barker, N. W. and Hines, E. A., Jr.: Peripheral Vascular Diseases. Ed. 2, Philadelphia, W. B. Saunders Company, 1955, pp. 744-772. 4. Myers, T. T.: Skin Grafting for Stasis Ulcers. In Allen, E. V., Barker, N. W. and Hines, E. A., Jr.: Peripheral Vascular Diseases. Ed. 2, Philadelphia, W. B. Saunders Company, 1955, pp. 780-788. 5. Myers, T. T. and Cooley, J. C.: Varicose Vein Surgery in the Management of the Postphlebitic Limb. Surg., Gynec. & Obst. 99: 733-744 (Dec.) 1954. 6. Myers, T. T. and Janes, J. M.: Comprehensive Surgical Management of Cavernous Hemangioma of the Lower Extremity With Special Reference to Stripping. Surgery. 37: 184-197 (Feb.) 1955. 7. Myers, T. T. and Smith, L. R.: Results of the Stripping Operation in the Treatment of Varicose Veins. Proc. Staff Meet., Mayo Clin. 29: 583-590 (Nov. 10) 1954. 8. Paulson, J. A.: Thiopental Sodium and Ether Anesthesia. J.A.M.A. 150: 983-987 (Nov. 8) 1952. 9. Pratt, G. H.: Test for Incompetent Communicating Branches in the Surgical Treatment of Varicose Veins. J.A.M.A. 117: 100-101 (July 12) 1941. O. Sherman, R. S.: Varicose Veins; Further Findings Based on Anatomic and Surgical Dissections. Ann. Surg. 130: 218-232 (Aug.) 1949.