References

Why insert the stripper from high to low when performing a stripping procedure ?

Phlebology 1997 ; 12 : 118-119
D. CRETON
EC Ambroise Paré, rue Ambroise Paré 54100 F-NANCY

Sir, Preoperative duplex ultrasound investigation in patients with lower limbs reveals that incompetent terminal valve of the long saphenous vein may be associated with complete or partial incompetence of the long saphenous trunk. In many patients, incompetence is present only in the more proximal part of the saphenous vein (in the thigh)with normal valve in the calf. I have divided the long saphenous vein into 6 equal length, from the saphenofemoral junction (labelled zero), including the intermediate portion (labelled 3) located at the knee, to the submalleolar region (labelled 6), I found that of 274 preoperative duplex ultrasound examinations for sapheno-femoral junction incompetence, saphenous incompetence extended as far as the ankle in only a small portion of patients (Table 1). Total saphenectomy (removal of sections zero-6) was indicated in only 7% of patients. The remainder could be treated by partial saphenectomy. Others authors have reported similar findings: in 50 saphenectomies described by Sales and al [1] he found that total saphenectomy was required in 7% of operations.

When undertaking partial saphenectomy (83% of our series), we usually use the Oechs, pinstripper, 52 cm long, inserted from above downwards. Its stiff metal construction makes it easy to guide into the incompetent saphenous venous trunk. The surgeon inserts the stripper with the fingertips, via an inguinal incision, with the patient's knee flexed slightly. It often reaches zone 5 (mid-lower calf) and enables the surgeon to perform saphenectomy by a simple phlebectomy incision in the calf.

In cases where total saphenectomy is indicated (17%), the stripper can be passed either from the inguinal incision downwards or from the ankle. Theoretically, pushing the stripper upwards is more logical since this is the same direction as the valves.However, there is a greater risk of inserting the stripper into a deep vein via a perforators. When the stripper is inserted from above downwardsMoreover, when the stripper is inserted from high downwards, it is necessary to have a straight stripper such as a Vastrip 2 + (Astra-Tech, Mölndal, Sweden) which is rigid enough to steer into the saphenous trunkand avoid a posterior collateral or accessory vein.In order to determine the best method of inserting the stripper which would limit the incidence of proceeding in the wrong direction and the need for intermediate incisions, I compared two series of patients undergoing total saphenectomy (Table 2). Group I involved 1300 procedures with systematic insertion of the stripper in an antegrade direction (from the ankle upwards) undertaken in 1992-93, and group II involved 191 procedures with insertion of the stripper from an inguinal incision downwards (1994). If passage of the stripper became obstructed, a second stripper was inserted in the opposite direction to free the first one, allowing passage of one of the two strippers. In the event that this procedure was unsuccessful, an intermediate incision was made at the tip of the stripper. Results have shown that group I, the stripper passed through more easily (72.6% vs 56.0%) with less frequent use of a second stripper (5.4% vs 29.3%).When the stripper was inserted from below upwards a significantly higher number of intermediate counter-incisions was required. ( X2= 121.98, p < 0.001). Jacobsen [2] reported a very similar rate of intermediate incisions in his series ( 18% out of 200 cases ).

Although this letter describes a personal series of patients and is not a randomized study, it appears that insertion of the stripper from above downwards can reduce the number of intermediate incisions required, but when total saphenectomy is being performed this at the expence of a longer surgical procedure and requires the use of a second stripper in one out of three cases.

REFERENCES

  1. Sales CM. Bilof ML. Petrillo KA. Luka NL. Correction de l'insuffisance veineuse profonde des membres inférieurs par suppression du reflux veineux superficiel.Ann.Chir.Vasc. 1996;10:186-189.
  2. Jacobsen BH. Neostripnyt engangsinstrument til venestripping .Ugeskr Laeg 1974 ; 136 : 535-536.
Table 1: Distribution of incompetence from the sapheno-femoral junction on the long saphenous vein
  Section of
saphenous vein
% n
Icompetence of the sapheno-femoral junction to the junction of: 0 100 274
Upper third to middle third of thigh 1 4 11
Middle third to lower third of thigh (Hunter) 2 8 22
Knee line 3 15 41
Upper third to middle third of leg (Boyd) 4 46 126
Middle third to lower third of leg 5 10 28
Submalleolar 6 17 46
Table 2: Passage of stripper according to direction of insertion
  (n = 1300) 1992-93 study
From below upwards
(n = 191) 1994 study
From high downwards
Passage of stripper 72,6 % 56 %
Blockage-second stripper : Passage of stripper 5,4 % 29,3 %
Intermediate incision 21,9 % 14,6 %

Significant difference, X2 = 121.98, p < 0.001.

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