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I need to know the tributeries of great saphenous vein that should be ligated during trendlenberg procedure

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I now have comprehensive information from Bailey & Love's Surgery (28th edition) and the Imaging Anatomy Atlas. Here is the complete answer:

Tributaries of the Great Saphenous Vein Ligated During the Trendelenburg Procedure

The Trendelenburg procedure (saphenofemoral ligation) involves making an oblique groin incision, dissecting the GSV to the saphenofemoral junction (SFJ), and ligating all tributaries at that junction before performing a flush SFJ ligation. The anatomy is often variable, but six tributaries are classically encountered close to the SFJ and must be ligated distal to their divisions:

Lateral Tributaries

  1. Superficial inferior epigastric vein - runs superiorly toward the anterior abdominal wall
  2. Superficial circumflex iliac vein - runs laterally toward the iliac crest

Medial Tributaries

  1. Superficial external pudendal vein - runs medially to the external genitalia
  2. Deep external pudendal vein - also medial, draining the deeper genital structures

Distal Tributaries

  1. Anterior accessory great saphenous vein (AA-GSV) - runs along the anterior thigh
  2. Posteromedial thigh vein (Posterior accessory GSV / Leonardo's vein) - runs along the posteromedial thigh

Key Surgical Points

  • These tributaries are ligated distal to their divisions (i.e., each one is tied off before it enters the main GSV trunk).
  • After all tributaries are secured, a flush SFJ ligation is performed - the GSV is divided right at its junction with the femoral vein to leave no stump, which is the hallmark of the Trendelenburg operation.
  • The GSV is then retrogradely stripped to around the knee.
  • Closure of the cribriform fascia over the ligated SFJ does not reduce groin recurrence.

Why Complete Ligation Matters

Leaving any tributary unligated is the most common cause of recurrent varicose veins after surgery. If a tributary is missed, it can develop collateral reflux back into the leg, negating the procedure.
Saphenofemoral junction ligation diagram showing the femoral vein, ligature, great saphenous vein, and point of division
Diagram showing flush SFJ ligation - note the ligature placed at the junction with the femoral vein and the point of division of the GSV.
Source: Bailey and Love's Short Practice of Surgery, 28th Edition, p. 1058-1059
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