For a 40‑70‑year‑old adult with CEAP (Clinical‑Etiologic‑Anatomic‑Pathophysiologic) class C2‑C3 varicose veins, duplex ultrasound showing ≥500 ms reflux at the saphenofemoral junction and a great saphenous vein (GSV) diameter ≥4.5 mm, what are the indications and step‑by‑step operative and postoperative management for a Trendelenburg (great‑saphenous‑vein ligation) surgery?

Trendelenburg Surgery: Indications and Operative Management for Saphenofemoral Junction Reflux

Critical Preoperative Assessment

For a patient with CEAP C2-C3 varicose veins, duplex ultrasound showing ≥500 ms reflux at the saphenofemoral junction and GSV diameter ≥4.5 mm, Trendelenburg surgery (high ligation and stripping) is now considered a third-line option after endovenous thermal ablation and foam sclerotherapy have been deemed unsuitable or unavailable. 1

Mandatory Preoperative Documentation

• Obtain venous duplex ultrasound within 6 months documenting: exact GSV diameter at the saphenofemoral junction, reflux duration ≥500 milliseconds, deep vein patency, extent of refluxing segments from groin to below-knee, and location of incompetent perforating veins. 1
• Document a failed 3-month trial of medical-grade gradient compression stockings (20-30 mmHg minimum pressure) with persistent symptoms including aching, heaviness, pain, swelling, or functional impairment interfering with daily activities. 1
• Confirm symptomatic presentation: the patient must report lifestyle-limiting symptoms despite conservative management, not merely cosmetic concerns. 1

Indications for Trendelenburg Surgery (When Thermal Ablation Unavailable)

• Documented saphenofemoral junction reflux ≥500 ms with GSV diameter ≥4.5 mm and persistent symptoms despite compression therapy. 1
• Patient preference for open surgery when endovenous thermal ablation (radiofrequency or laser) is contraindicated, not available, or technically not feasible. 1, 2
• CEAP classification C2 (varicose veins) through C3 (edema) with documented valvular incompetence at the saphenofemoral junction. 1

Common pitfall: Proceeding with Trendelenburg surgery without first offering endovenous thermal ablation, which has 91-100% occlusion rates at 1 year, fewer complications (reduced bleeding, hematoma, wound infection, paresthesia), and faster recovery compared to open surgery. 1

Step-by-Step Operative Technique

Patient Positioning and Anesthesia

• Position the patient supine with the operative leg slightly abducted and externally rotated. 2
• Administer general or regional anesthesia; local anesthesia alone is insufficient for complete stripping. 2
• Mark the course of the GSV preoperatively with the patient standing, using duplex ultrasound guidance to identify the exact saphenofemoral junction location. 1

Saphenofemoral Junction Ligation (Trendelenburg Procedure)

• Make a 4-6 cm oblique or transverse groin incision 2-3 cm below and lateral to the pubic tubercle, centered over the marked saphenofemoral junction. 2
• Dissect through subcutaneous tissue and Scarpa's fascia to expose the saphenofemoral junction where the GSV joins the common femoral vein. 2
• Critical step: Identify and individually ligate ALL tributaries entering the proximal GSV (typically 5-7 branches including superficial epigastric, superficial circumflex iliac, superficial external pudendal, and anterior/posterior accessory saphenous veins) before ligating the main trunk. 1, 2
• Flush-ligate the GSV at its junction with the femoral vein using 2-0 or 3-0 non-absorbable suture, leaving a stump <1 cm to minimize recurrence from neovascularization. 2
• Doubly ligate the GSV stump and consider transfixing the stump with a suture-ligature for added security. 2

Critical pitfall: Incomplete ligation of saphenofemoral tributaries leads to 20-28% recurrence rates at 5 years through neovascularization and persistent reflux pathways. 1

GSV Stripping (If Performed)

• Make a second incision at the knee level (medial aspect, just below the tibial tuberosity) or at the ankle (anterior to the medial malleolus). 2
• Pass a flexible stripper (disposable or reusable) from groin to knee or ankle through the GSV lumen under gentle traction. 2
• Secure the stripper to the vein distally with a heavy ligature, then withdraw the stripper proximally, inverting and avulsing the vein. 2
• Alternative approach (GSV-sparing): Perform flush ligation alone without stripping if the below-knee GSV diameter is <4.5 mm and shows no reflux, preserving the vein for potential future bypass grafting. 3, 4

Tributary Varicosities (Stab Phlebectomy)

• Mark visible varicose tributaries preoperatively with the patient standing. 1
• Make multiple 2-3 mm stab incisions along the marked varicosities using a #11 blade. 1
• Extract tributary veins through each incision using mosquito forceps or phlebectomy hooks, avulsing 5-10 cm segments. 1
• Critical anatomic consideration: Avoid the common peroneal nerve near the fibular head during lateral calf phlebectomy to prevent foot drop. 1
• Close stab incisions with adhesive strips (Steri-Strips) rather than sutures for optimal cosmetic results. 1

Wound Closure

• Close the groin incision in layers: approximate Scarpa's fascia with 3-0 absorbable suture, close subcutaneous tissue with 4-0 absorbable suture, and close skin with 4-0 or 5-0 absorbable subcuticular suture or skin adhesive. 2
• Apply sterile dressings and a compression bandage from toes to groin. 1

Postoperative Management

Immediate Postoperative Care (Day 0-7)

• Encourage immediate ambulation within 2-4 hours post-surgery to reduce deep vein thrombosis risk (0.3% incidence). 1
• Prescribe analgesics: NSAIDs (ibuprofen 400-600 mg every 6-8 hours) for pain and inflammation; add acetaminophen or opioids for breakthrough pain. 1
• Maintain compression bandaging for 48-72 hours, then transition to medical-grade compression stockings (20-30 mmHg). 1
• Advise leg elevation above heart level when resting to minimize edema and hematoma formation. 1
• Remove groin sutures at 7-10 days if non-absorbable sutures were used. 2

Early Follow-Up (Week 2-4)

• Perform duplex ultrasound at 2-7 days postoperatively to detect endovenous heat-induced thrombosis or deep vein thrombosis (mandatory screening). 1
• Continue compression stockings for 2-4 weeks during daytime hours. 1
• Gradually resume normal activities; avoid heavy lifting (>20 lbs) or strenuous exercise for 2 weeks. 1
• Monitor for complications: wound infection (reduced vs. thermal ablation), hematoma, seroma, or persistent pain. 1

Long-Term Management (Month 2-12)

• Schedule clinical follow-up at 2 months to assess symptom resolution using revised Venous Clinical Severity Score (rVCSS), which should decrease by approximately 60-66%. 3
• Perform duplex ultrasound at 3-6 months to confirm GSV occlusion or assess for recurrent reflux. 1
• Counsel patients on recurrence risk: traditional surgical treatment has 20-28% five-year recurrence rates, primarily from neovascularization at the saphenofemoral junction or progression of disease in untreated segments. 1
• Recommend lifelong compression stockings (20-30 mmHg) during prolonged standing or travel to prevent progression of venous insufficiency in remaining veins. 1

Expected Complications and Management

• Nerve injury: Approximately 7% risk of saphenous nerve damage causing numbness or paresthesia along the medial calf and foot; most cases resolve spontaneously within 6-12 months. 1
• Hematoma/ecchymosis: Common (30-50% of cases); manage with compression, elevation, and NSAIDs; usually resolves within 2-4 weeks. 1
• Wound infection: Occurs in <5% of cases; treat with oral antibiotics (cephalexin 500 mg four times daily or clindamycin 300 mg three times daily for 7-10 days). 1
• Deep vein thrombosis: Rare (0.3%); requires anticoagulation with low-molecular-weight heparin or direct oral anticoagulants. 1
• Pulmonary embolism: Exceedingly rare (0.1%); requires immediate hospitalization and anticoagulation. 1

Why Trendelenburg Surgery Is Now Third-Line

Endovenous thermal ablation (radiofrequency or laser) has largely replaced Trendelenburg surgery as the standard of care because it achieves similar efficacy (91-100% occlusion rates at 1 year vs. 72-87% for surgery), improved early quality of life, reduced hospital recovery time, and fewer complications including reduced rates of bleeding, hematoma, wound infection, and paresthesia. 1, 2, 5

• Thermal ablation can be performed under local anesthesia in an office setting, whereas Trendelenburg surgery requires general or regional anesthesia and operating room resources. 1, 2
• Patients return to normal activities within 1-3 days after thermal ablation vs. 7-14 days after open surgery. 1
• Cosmetic outcomes are superior with thermal ablation (no groin scar, minimal stab incisions for phlebectomy). 2

However, Trendelenburg surgery remains appropriate when: thermal ablation is contraindicated (e.g., severe peripheral arterial disease preventing tumescent anesthesia), the patient has anatomical variations making catheter placement impossible, or the patient specifically requests open surgery after informed consent regarding alternatives. 1, 2, 5