What Is a Wide Local Excision?

Extensive vulvectomy

Extensive vulvectomy

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Extensive vulvectomy

The scope of this surgical resection includes the clitoris, the labia majora, the labia minora, the perineum, part of the vaginal wall or part of the lower urethra and the subcutaneous fat tissue at the corresponding site, with a depth reaching the fascia and myometrium.

Chinese name

Extensive vulvectomy

Foreign name

radical vulvectomy

Indication

Genital invasive carcinoma

Anesthesia method

Continuous epidural block anesthesia

Postoperative considerations

Prevent infection

1. Posture lithotomy position, or "herringbone" position-this position facilitates simultaneous inguinal lymphadenectomy.

2. Mark the incision. The incision starts from 3cm above the pubic symphysis of the genitals, along the outer edge of the labia majora on both sides (more than 2cm from the outer edge of the tumor), and meets the posterior and perineal union. The internal incision starts from the upper edge of the vestibular urethral opening and converges behind the vaginal opening along the vestibular and vaginal sides (). However, the border of the incision should be determined according to the condition of the tumor. Generally, it should be more than 1cm from the edge of the tumor, and if necessary, some urethra and vagina are removed. Cover the surface of the tumor with gauze before operation, and fix it with silk suture.

3. Isolate the skin flap from the yin fu, cut the whole layer of skin along the external incision, lift the skin of the external margin, and subcutaneously isolate the subcutaneous tissue. The thickness of the skin flap should be within 0.5 cm of subcutaneous fat (). The outer edge of the two skin flaps is separated, and the pubic symphysis is up to 2 ~ 3cm, and the pubic nodules and adductor surface are both sides.

4. After removing the upper and lower skin flaps on both sides of the vulva, remove the fat pad of the vulva and the lymphatic fat tissue in the upper part of the vulva from top to bottom. When cut to the lower edge of the pubic arch, the clitoris feet are separated and exposed on both sides of the urethra, clamped, cut and stitched. The depth of the pubic fascia and the genitourinary fascia were removed.

5. The middle part of the vulva is removed along the pubic tubercle, and the lymphatic fat tissue outside the labia majora and in front of the adductor fascia is removed in one piece to reach the vaginal wall ().

6. Cut off the perineum flap under the external incision and separate the inferior perineum flap. Note that at this time, you should not submerge backwards and downwards, but should be separated forward and upward, that is, the direction of the vaginal wall, so as not to accidentally damage the rectum. If necessary, use your left index finger to reach the anorectum Be instructed. The peeling depth is 1 to 2 cm in the hymen, or it depends on the depth of vaginal invasion. Here the blood vessels between the tissues are rich and easy to bleed, and attention should be paid to hemostasis ().

7. The internal incision cuts the vestibular mucosa in an arc from above the outer opening of the vestibular urethra (), cuts down the vaginal mucosa along both sides of the vagina, and converges on the posterior wall of the vagina (). If the tumor is above or invades the urethral orifice, the urethra should be exposed under the pubic arch (A) and a part of the urethra should be removed (B). Urinary incontinence does not occur when the lower segment of the urethra is removed less than one-third of the length of the urethra. Finally, the entire vulvar tissue was excised along the internal and external incisions (0).

8. Wash the surgical field. Wash the surgical field with a large amount of warm water. If necessary, dilute it with 10 mg of nitrogen mustard (HN2) and apply a wet dressing for 5 minutes.

9. Suture and drainage

From the yin fu, the subcutaneous tissue and the skin are interrupted in two layers to the upper edge of the outer urethra. The outer edges of the left and right skin incisions were sutured intermittently with the vestibular mucosa and vaginal mucosa around the corresponding urethral orifice. If the skin defect is large, transfer flaps can be used for repair. One film drainage was placed on the wound surface on each side, which was drawn from the lower part of the vulva and stayed in the ureter.

In cases of lame urethral resection, in order to prevent urethral contraction, a suture is made about 1 cm above the urethral opening and fixed on the pubic periosteum. The urethra is then freed up 2 to 3 cm, and then the upper and lower edges of the stump of the urethra and the anterior wall of the vagina are sutured separately.

10. Wound dressing is completed to block the red mercury gauze in the vagina to stop bleeding. Bandage or elastic bandage is used to pressure the entire vulvar wound, so that the skin flap can be tightly attached to the fascia, which is conducive to wound healing.

After extensive vulvectomy, due to the large number of skin defects and large wound tension, and the vulva area is susceptible to contamination by urine and feces, wound healing is difficult, and correct postoperative treatment is particularly important.

1. Anti-infective treatment routinely use antibiotics for 5-7 days.

2. Postoperative urination To prevent postoperative urination from contaminating the vulvar wound, oral opioids are routinely taken for 3 to 5 days to postpone defecation. Stay in the ureter for 7 to 10 days. When the patient begins to relieve the urination, care should be taken to clean the wound in time, and do not take a squatting position when defecation, so as to prevent the wound from cracking.

3. The vulvar wound is usually bandaged continuously for 3 days, and the dressing is removed and replaced every day to check the healing of the flap. The film drainage and vaginal gauze are removed 24 hours after the operation. The vulvar wound was opened on the fourth day, and the wound was irradiated with heat every day for 15-30 minutes, twice a day.