Prelims_2.pdf Chapter-01_Introduction.pdf Chapter-02_Bartholinectomy.pdf Chapter-03_Bartholin gland duct-Incision and Drainage.pdf Chapter-04_Marsupialisation.pdf Chapter-05_Operative Technique Bartholinectomy.pdf Chapter-06_Postoperative Complications.pdf Chapter-07_Introduction.pdf Chapter-08_Operative Technique Marsupialisation.pdf Chapter-09_Postoperative Care.pdf Chapter-10_Introduction.pdf Chapter-11_Preoperative Evaluation.pdf Chapter-12_Operative Technique Labial Fusion.pdf Chapter-13_Vulval Cyst.pdf Chapter-14_Operative Technique Vulval Cyst.pdf Chapter-15_Introduction.pdf Chapter-16_Operative Technique Labial Polypectomy.pdf Chapter-17_Labial Hypertrophy.pdf Chapter-18_Excision of a Hypertrophied Labial Hypertrophy.pdf Index.pdf Single Surgical Procedures in Obstetrics and –01 A Colour Atlas of Surgeries of the

Single Surgical Procedures in Obstetrics and Gynaecology–01 A Colour Atlas of Surgeries of the Vulva

Series Editors Arun Nagrath MS MAMS FICOG Professor and Head Department of Obstetrics and Gynaecology Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India Erstwhile Professor and Head Department of Obstetrics and Gynaecology SN Medical College, Agra, Uttar Pradesh, India Senior Clinical Training Consultant Johns Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO), Baltimore, USA

Narendra Malhotra MD FICOG FICMCH President, FOGSI 2008 Dean, ICMU 2008-2009 Director, Ian Donald School of Ultrasound Consultant and Director Malhotra Nursing and Maternity Home (P) Ltd., Agra, Uttar Pradesh, India Apollo Pankaj Hospital (P) Ltd., Agra, Uttar Pradesh, India Associate Editor Pooja Gupta MD Associate Professor Department of Obstetrics and Gynaecology Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India

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Single Surgical Procedures in Obstetrics and Gynaecology–01: A Colour Atlas of Surgeries of the Vulva First Edition: 2013 ISBN 978-93-5025-587-2

Printed at Dedication

One of the legendry artists' surgeons of India who excelled and afforded respect to a newly formed specialisation Gynaecological and Obstetrical Surgeries.

Famous in the 50s, 60s and 70s fondly called Teacher of Teachers.

Through this great master, I see a glimpse of his surgical mannerisms in my work trying to achieve surgical perfection which came so naturally to him.

Lest he be forgotten in the footprints of time, a humble effort to propagate his excellence through this organisation for posterity.

... lest the coming generations be starved of the magical art of gynaecological and obstetrical surgery. Arun Nagrath

... At the lotus feet of my master Late Professor Nawal Kishore MS FICOG FACS (Rockefeller Foundation Fellow)

Preface

Anything that simplifies our medical education and clinical practice has this serving as a source of basic information illustrating the surgical always been welcomed. This series, “Single Surgical Procedures in Obstetrics technique. and Gynaecology” is organised into multiple volumes on all gynaecological We hope that the resident gynaecologic surgeon will find this series and obstetrical surgical procedures related to the female genital organs. of books on surgical procedures very useful as he or she prepares for a Special sections are dedicated to patient positioning, type of incisions, career in this area of medicine and begins to perform these procedures. their closures along with proper use of drains, suture choices, etc. We believe that the experienced gynaecologic surgeon will also find The vulva presents complex clinical pathologies as it is composed of this a useful reference with many new approaches and helpful notes for the hair-bearing skin and the inner lined mucosa. The skin and mucosa commonly performed operations. bearing the complex glandular tissues also contribute to the vulval Series Editor, Dr Arun Nagrath is one of the accomplished and pathology. New growths over the vulval and perineal skin are renowned Obstetrics and gynaecology surgeon. He has gained excellence objectionable for disturbing the aesthetic appearance of the external especially in non-descent vaginal . Based on his merits and genitalia and also producing coital problems. Varied surgical techniques rich expertise, John Hopkins University inducted him as a consultant. of the benign pathologies of the vulva are presented in this section.We as In case, you want to give any suggestion or feedback you may contact editors of this Colour Atlas of Gynaecologic Single Surgical Procedures him on the following address: in Obstetrics and Gynaecology have set out to simplify surgery by creating Permanent Address a step-by-step procedural process, illustrated to emphasise those surgical 4/16, Lala Lajpat Rai Road, Civil Lines steps, which are critical to the individual procedure under consideration. Agra – 282002 (UP), India We have also provided important notes in an effort to aid the surgeon Present Address: in reducing blood loss, minimising complication rates and improving their 103 A, Varishtha Chikitsa Adhikari Awas surgical skills. All the commonly done obstetrical and gynaecological UPRIMS & R, Saifai, Etawah 206301 (UP), India procedures are illustrated in this series. Nevertheless, some rarely done procedures required by very selected group of cases are also discussed in Contact Numbers: 09319112861, 09410666674 different volumes so that one can assist the experienced surgeon with E-mail ID: [email protected]; [email protected]

Arun Nagrath Narendra Malhotra Pooja Gupta

Acknowledgements

We are grateful to Director, Brig T Prabhakar, who has a fixation for quality me to 'keep up' my endeavours and see this work through completion. A and continued progress, dedicated to his institution. He has always cajoled gynaecologist herself, she has always been by my side helping me at every his staff to move forwards and do something that 'makes a difference'. step through the completion of this volume. Though he is not heading the institution today, his infectious zeal of toil The preparation of the book of this magnitude involves many and excellence continues to inspire us. individuals who play an important role in its creation. We are especially This book is an attempt in this direction. All through our hours of toil proud of the quality of the photographs and it would be in place to put on he always helped us in smoothening the rough edges and this work carries record the contribution of Mrs Geeta Jha, nursing sister in charge, who the hallmark of his 'quality'. has shouldered the additional responsibility of helping us in the We are thankful to all the staff of the Department of Obstetrics and photography apart from providing facilities in the "State of Art" operation Gynaecology of UP Rural Institute of Medical Sciences and Research, theatre in the Department of Obstetrics and Gynaecology, UP Rural Saifai, Etawah, Uttar Pradesh, India for their contribution in this project. Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, My better half, Dr (Mrs) Manju Nagrath, Department of India. Radiodiagnosis, UP Rural Institute of Medical Sciences and Research, To our patients who have very kindly consented to allow the use of Saifai, Etawah, Uttar Pradesh, India, who has stood by me, tolerating my their operative sequences for the purpose of advancement of medical hours of frustration and its manifestations and constantly encouraging education.

Arun Nagrath Narendra Malhotra Pooja Gupta

All Volumes in the Series “Single Surgical Procedures in Obstetrics and Gynaecology”

This book is one of the titles in the series of Single – C NDVH - Debulking by Coring Surgical Procedures in Obstetrics and Gynaecology, a VOL-6 Biopsy of cervix NDVH - Debulking by spiral incision series which will eventually have 36 volumes. Cervical conisation NDVH - Debulking by cervical amputation If you wish to be kept informed of new additions Endocervical curettage at NDVH - Debulking by cervical wedge to the series and receive details of our other titles, Conisation of cervix by LEEP *VOL-12 Ward Mayo's hysterectomy please write to Jaypee Brothers Medical Publishers Electrocauterisation of cervix Modified Ward Mayo's hysterectomy— (P) Ltd at [email protected]. Cervical cryocauterisation Dr Nagrath's modification VOL-7 Trachelorrhaphy Clampless vaginal hysterectomy We list below a few of the other titles in print and in Abdominal excision of cervical stump VOL-8 Correction of incompetent cervix by -D3 preparation in the Single Surgical Procedures series. Shirodkar's technique VOL-13 Dilatation and curettage Titles already published are marked (*); those titles Correction of incompetent cervix by Suction curettage for abortion to be published during the coming months are marked McDonald's operation Dilatation and (#). Correction of incompetent cervix by Fractional curettage Lash operation VULVA – A *VOL-14 Upper segment caesarean section *VOL-1 Bartholin's gland excision UTERUS: ABDOMINAL HYSTERECTOMY-D1 Lower segment caesarean section Marsupilisation of Bartholin cyst VOL-9 Total abdominal hysterectomy UTERUS: DISPLACEMENTS-D4 Release of labial fusion Total abdominal hysterectomy with *VOL-15 Cervicopexy (Purandare's) VOL-2 Hymenectomy (Imperforate hymen) bilateral salpingo- *VOL-16 Supravaginal cervical amputation (Nadkarni's) Simple Nagrath's minilap hysterectomy VOL-17 Manchester's operation VOL-10 Abdominal subtotal hysterectomy Fothergill's repair – B Obstetrical hysterectomy VOL-3 Anterior colporrhaphy and Kelly's plication VOL-18 Shirodkar's anterior sling Posterior colpoperineorrhaphy UTERUS: VAGINAL HYSTERECTOMY-D2 Shirodkar's posterior sling Vaginal repair of enterocoel VOL-11 NDVH - Conventional approach VOL-19 LeFort's operation Abdominal repair of enterocoel NDVH - With salpingo-oophorectomy Gilliam's operation *VOL-4 Complete perineal tear repair NDVH - Debulking by uterine bisection Modified Gilliam's operation VOL-5 Fenton's operation NDVH - Debulking by wedge excision William Richardson's operation Episiotomy NDVH - Debulking by myomectomy *VOL-20 Ventral suspension of vaginal vault Schuchardt's operation NDVH - Debulking by morcellation Abdominal sacro-colpopexy UTERUS: MYOMECTOMY-D5 FEMALE STERILISATION-E3 Marshall Marchetti Krantz operation VOL- 21 Myomectomy for Fundal fibroid, Hood's VOL-26 Laparoscopic sterilisation by silastic bands Burch suspension operation operation Sterilisation by minilaparotomy technique Myomectomy for anterior wall fibroid Sterilisation by Pomeroy's operation CONGENITAL ANOMALIES-HI VOL-30 Strassmenn's utriculoplasty Myomectomy for isthmic fibroid Sterilisation by modified Pomeroy's Jone's utriculoplasty Myomectomy for anterior cervical fibroid operation Tompkin's utriculoplasty Myomectomy for posterior wall fibroid Sterilisation by Irving's method *VOL-31 Excision of transverse vaginal septum Myomectomy for intracavitary fibroid Sterilisation by Uchida's method Excision of longitudinal vaginal septum Myomectomy for fibroid polyp Sterilisation by Madlener's method VOL-32 Mc Indoe's vaginoplasty Myomectomy for broad ligament fibroid Sterilisation by Parkland's method Sterilisation by Aldridge method Modified McIndoe's vaginoplasty Myomectomy for round ligament fibroid William's vulvo-vaginoplasty Sterilisation by Kroener's method Myomectomy for multiple fibroids VOL-33# Ileal neovagina Sterilisation by Oxford's method FALLOPIAN TUBES AND -E1 Sterilisation by Shirodkar's method FISTULA OPERATIONS VOL-22 Salpingo-oophorectomy Fimbriectomy VOL-34# Layer method of RVF A Colour Atlas of Surgeries of the Vulva of Surgeries A Colour Atlas Wedge resection of ABDOMINAL WALL-F Sim's Moir saucerisation Latzko's operation Ovarian cystectomy *VOL-27 Infra-umbilical midline laparotomy VOL-35 Urethral reconstruction Ovariotomy Paramedian abdominal incision Vesicovaginal fistula VOL-23 Enucleation of broad ligament cyst Pfannenstiel's incision Vesicocervical fistula Ectopic pregnancy Kustner's incision Ureterivaginal fistula Maylard's incision RECONSTRUCTION-E2 Cherney's incision MISCELLANEOUS OPERATIONS-J VOL-24 Salpingolysis VOL-28 Abdominal closure VOL-36 Intestinal loop urinary diversion Fimbriolysis Single layer abdominal closure Urinary diversion cutaneous ureterostomy Salpingo-ovariolysis Skin closure methods Urinary diversion uretero-sigmodostomy Salpingostomy Use of drains Ureterovesicle anastomosis (psoas hitch) Incisional hernia repair Posterior colpotomy VOL-25 Cornual reimplantation Insertion of suprapubic catheter Fimbrioplasty URINARY STRESS INCONTINENCE-G Demonstration of tubal patency via Tuboplasty—Microresection and VOL-29 Retropubic urethropexy laparoscopy anastomosis Kelly's operation Demonstration of tubal patency by HSG

xii Contents

Section 1: Bartholin Cystectomy

1. Introduction ...... 3 Greater Vestibular or Bartholin Glands 3 Bartholin Gland Duct Cyst and Abscess 3 Pathophysiology 3 Clinical Features 4 Diagnosis 4 Treatment 4 2. Bartholinectomy ...... 5 Preoperative 5 Consent 5 Patient Preparation 5 Intraoperative 6 Surgical Steps 6 Postoperative 7 3. Bartholin Gland Duct—Incision and Drainage ...... 8 Preoperative 8 Consent 8 Intraoperative 8 Instruments 8 Surgical steps 8 Postoperative 9 4. Marsupialisation ...... 10 Preoperative 10 Consent 10 Intraoperative 10 Surgical Steps 10 Postoperative 11 5. Operative Technique: Bartholinectomy ...... 12 6. Postoperative Complications...... 45 Postoperative Haematoma Formation 45 Other Complications 45 Section 2: Marsupialisation 7. Introduction ...... 49 Gland/Cyst Marsupialisation 49 Physiologic Changes 49 Advantages 49 Disadvantages 49 Preoperative Preparation 49 Anaesthesia and Position on Operation Theatre Table 49 8. Operative Technique: Marsupialisation ...... 50 A Colour Atlas of Surgeries of the Vulva of Surgeries A Colour Atlas 9. Postoperative Care ...... 65 Complications 65 Postoperative Care 65 Follow-Up 65 Section 3: Labial Fusion 10. Introduction ...... 69 Synonym 69 Labial Fusion 69 Prevalence 70 Etiopathogenesis 70 Pathogenesis 70 Trauma 70 Clinical Features 71 Genitourinary 71 Complications 71 Physical Examination 71 Investigations 71 Urine 71 Imaging Studies 71 Differential Diagnosis 72 Prognosis 72 xiv Contents Management 72 Medical Care 72 Manual Separation/Lysis 72 Surgical Care 72 11. Preoperative Evaluation ...... 73 Physiologic Changes 73 Points of Caution 73 12. Operative Technique: Labial Fusion ...... 74 Section 4: Labial Cystectomy 13. Vulval Cyst...... 81 Introduction 81 Mucinous Cysts 81 14. Operative Technique: Vulval Cyst ...... 82 Section 5: Labial Polyp 15. Introduction ...... 145 16. Operative Technique: Labial Polypectomy ...... 146 Section 6: Labial Hypertrophy 17. Labial Hypertrophy ...... 165 Introduction 165 Surgical Anatomy of the Vulva 165 The Vulvo-Vaginal Complex 165 Composition 165 Aetiology 166 Diagnosis 166 Symptoms of Labial Hypertrophy 167 Labial Reduction Surgery 168 Indications of Labial Reduction Surgery 168 Over-Sized Labia 168 Sexual Reassignment 169 xv Surgical Procedures 169 Preoperative Matters 169 Operative Techniques 170 General 170 Techniques for Labial Reduction 170 Postoperative Matters 172 Convalescence 172 Follow-Up Therapy 172 Risks and Complications In Labial Reduction Surgery 172 Success of Labial Reduction Surgery 173 18. Excision of a Hypertrophied Labial Hypertrophy ...... 174 Index ...... 217 A Colour Atlas of Surgeries of the Vulva of Surgeries A Colour Atlas

xvi Section 1 Bartholin Cystectomy

 Introduction  Bartholinectomy  Bartholin Gland Duct—Incision and Drainage  Marsupialisation  Operative Technique: Bartholinectomy  Postoperative Care

1 Introduction

Greater Vestibular or Bartholin Glands considerable amounts are poured onto the vulva to act as a lubricant for These are two in number and are homologues of the male bulbourethral coitus. Contraction of the bulbocavernosus muscle, which covers the superficial surface of the gland, stimulates gland secretion. The glands or Cowper glands. They lie posterolaterally to the vaginal orifice and are in contact with and often overlapped by the posterior ends of the vestibular continue limited activity after the menopause. bulbs, one on either side. Each gland is oval in shape and approximately Bartholin Gland Duct Cyst and Abscess the size of a pea, but is impalpable unless hardened or enlarged by disease. Each gland is connected to the vestibule by an approximately 2-cm-long Mucus produced to moisten the vulva originates in part from the Bartholin duct. The ducts run downward and inward, and open in the groove glands. Obstruction of the Bartholin ducts by proteinaceous material or between the labia minora and the hymen, the vestibule, at approximately by inflammation from infection can lead to cysts of variable sizes. An 5 and 7 o'clock positions. The orifice of the ducts is not normally visible infected cyst can lead to an abscess that is drained surgically. Obstruction but, when the ducts and glands are infected, it may be indicated by a of this gland's duct can lead to cystic enlargement that accounts for nearly small red area. 2% of all new gynaecologic visits. Cysts may become infected and the The gland is lobulated and racemose, the acini being lined by a single purulent contents result in abscess development. layer of low columnar or cuboidal cells. The duct is lined by multilayered Pathophysiology columnar cells and not by transitional epithelium, as is usually stated. The impression of the latter is created by a study of pathological states. Bartholin duct cysts form in direct response to obstruction of ductal Thus the surface columnar cells become flattened when the duct is outflow. Despite this understanding, the primary reason for cyst formation distended to form a cyst; and infection may sometimes result in metaplasia. remains unknown. The secretion of the gland is colourless and mucoid and has a characteristic Abscess formation tends to develop in populations with demographic odour. It is produced mainly in response to sexual excitement when profiles similar to those at high risk for sexually transmitted infections. Historically, women with bilateral Bartholin gland duct cysts were In contrast, patients with gland abscesses typically present with assumed to have been infected with Neisseria gonorrhoeae. However, recent complaints of rapid unilateral vulvar enlargement and significant pain. studies have demonstrated a wider spectrum of organisms responsible Classically, a fluctuant mass is found on either the right or left side of for these cysts and abscesses. Recent studies demonstrated that Bartholin the introitus, external to the hymenal ring and at the lower aspect of the gland duct abscesses are polymicrobial infections, and Bacteroides species, vulva. Peptostreptococcus species, Escherichia coli and Neisseria gonorrhoeae are Bartholin Cystectomy Diagnosis ♦ found commonly on culture of purulent drainage. Less typically, Chlamydia trachomatis may be involved. A Bartholin gland enlargement can mimic several other vulvovaginal Other theories for ductal obstruction include a change in mucus masses. Most cysts are unilateral, round or ovoid and tense. Abscesses Section 1 consistency or even congenitally narrowed ducts. Mechanical trauma from typically display surrounding erythema and are tender to palpation. The poorly repaired episiotomy can also lead to such obstruction for example mass is usually located in the posterior labia majora or lower vestibule. during a mediolateral episiotomy or a posterior colporrhaphy, the sutures Whereas most cysts and abscesses lead to asymmetry of labial anatomy, can easily injure or even ligate the duct. Since mucus retention leads to some smaller cysts may only be detected by palpation. Bartholin abscesses cyst distention, the size and speed of growth are influenced by sexual on the verge of spontaneous decompression will exhibit an area of stimulation. Hence, rapid accumulation is observed during times of softening where rupture will most likely occur. heightened sexual excitement. Treatment Clinical Features Small, asymptomatic cysts require no intervention except to exclude Bartholin gland duct cysts and abscesses are common vulvar masses neoplasia in women older than 40 years. Multiple techniques exist for encountered routinely in office gynaecology. managing cysts that cause significant pressure symptoms or become Most Bartholin gland cysts are small, uninfected and asymptomatic infected. These include: except for minor discomfort during sexual arousal. They are usually found during pelvic examination. When a lesion becomes larger or infected,  Bartholin gland excision women may experience severe vulvar pain that precludes them from  Incision and drainage walking, sitting or engaging in sexual activity.  Marsupialisation

4 2 Bartholinectomy

Most Bartholin gland duct cysts can be managed with incision and Preoperative drainage (I & D) or marsupialisation. It is seldom necessary to excise a Bartholin duct cyst (Bartholinectomy/Bartholin cystectomy), particularly Consent in the younger patient, unless there is induration at the base. The latter Because of the rich venous plexus of the vestibular bulb, significant may signify deep-seated infection that is inaccessible by marsupialisation. bleeding can be encountered during bartholinectomy. In addition, gland Conversely, this may represent neoplasm in the base of the gland, an issue excision can be associated with other morbidities, such postoperative of greater concern in the patient older than 40 years of age or in patients wound cellulitis, haematoma formation, failure to remove the entire cyst with coexisting Paget’s disease. Symptomatic cysts, however, that recur wall with risk of recurrence, and pain or dyspareunia or both from repeatedly and refill following I & D or marsupialisation are typical postoperative scarring. candidates for excision. Moreover, massive cysts or multilocular cysts may be best managed with excision. Patient Preparation Many authors have suggested excision of all Bartholin gland cysts in women older than age of 40 years to exclude cancer in the gland. However, These cysts should be excised in the absence of concurrent abscess or a study by Visco and Del Priore suggests that the morbidity of gland surrounding cellulitis. Therefore, antibiotic administration typically is not excision may not be justified for this rare cancer. Instead they recommend required. I & D of the cyst with biopsy of the cyst wall. Intraoperative are placed on the medial edges and fanned out medially toward the contralateral labia. The blunt pointed Mayo scissors serve admirably for Surgical Steps sharp dissection of the cyst from its bed. Analgesia and Patient Positioning Cyst Dissection Excision of most Bartholin cysts is performed as an outpatient procedure,

Bartholin Cystectomy in an operative suite and under general anaesthesia. The patient is placed The greatest vascular structure supplying these cysts is located at the ♦ in the dorsal lithotomy position and a vaginal and perineal preparation is posterosuperior aspect of these cysts. For this reason, dissection should performed. begin at the lower cyst pole and be directed superiorly. The inferomedial cyst wall is bluntly and sharply dissected away from Section 1 Skin Incision the surrounding tissue. Dissection planes should be kept close to the cyst A gauze sponge held by a ring forceps is placed inside the vagina by an wall to avoid bleeding from the venous plexus of the vestibular bulb and assistant and pressure is directed outward along the posterior aspect of to avoid injury to the rectum. A large cyst may develop posteriorly and the cyst. This pushes the full extent of the cyst forward. The surgeon’s may approximate the rectum. fingers retract the labia minora laterally to expose the anterior surface of The rectal wall can easily be distinguished from the cyst by inserting a the cyst. finger into the rectum during dissection. Allis clamps then are placed on An elliptical incision in the vaginal mucosa is made as close as possible the lateral edges and fanned out laterally and dissection is performed to the site of the gland orifice. An incision on the mucosal side is preferable near the inferolateral cyst wall. because an incision through the vulvar skin makes it difficult to dissect Complete removal of the gland tissue adherent to the cyst wall is the cyst wall from the skin without incising or tearing the skin. If an essential because residual glandular tissue may result in the formation of opening is accidentally made through the skin, a permanent fenestration a tender nodule or recurrent cyst. If the margins of the cyst have become may result. Difficulty is not usually encountered during dissection of the obscured, the cyst can be opened and the wall dissected from the cyst from the inner surface of the vulvar skin when the incision is made surrounding tissue. on the mucosal side. Vessel Ligation Excising a small ellipse of mucosa with the cyst allows the surgeon to have a site for traction and reduces the risk of rupturing the cyst. Because As dissection is completed superiorly, the main vascular bundle to the cyst formation usually is preceded by inflammation, the wall is adherent cyst is identified and clamped with a haemostat. The bundle is cut and and cannot be easily enucleated with blunt dissection only. Allis clamps ligated with 3-0 delayed absorbable or chromic suture. 6 Chapter 2 Wound Closure Approximation of the vaginal mucosa is best accomplished with a continuous or interrupted mucosal suture of 3-0 delayed absorbable material. Directly beneath the Bartholin duct is the vestibular bulb, which is composed of anastomosing venous channels. ♦ Postoperative Bartholinectomy In the dissection of the gland from the vestibular bulb, additional care must be taken to avoid troublesome bleeding. To ensure permanent Cool packs during the first 24 hours following surgery can minimise pain, haemostasis, the entire cavity must be obliterated by approximating the walls swelling and haematoma formation. After this time, warm sitz baths, once with fine delayed absorbable suture material after excision of the cyst. or twice daily are suggested for pain relief and wound hygiene.

7 Bartholin Gland Duct—Incision and 3 Drainage

Incision and drainage (I & D) appears to be an immediate alternative for Intraoperative an acute abscess and provide immediate relief to the patient. However, Instruments unless a new duct ostium is created, the incised edges following incision and drainage will seal and mucus or pus will reaccumulate. Therefore, I As noted, the goal of Bartholin gland I & D is to empty the cystic cavity & D with subsequent steps to create a new ostium are surgical goals. and create a new accessory epithelialised tract for gland drainage. For Permanent resolution of the cyst or abscess is common following this purpose a Word catheter is used. Named after Dr Buford Word, this marsupialisation or I & D with Word catheter placement. If obstruction catheter appears similar to a small, No. 10 F Foley's catheter. Word reoccurs, however, repeating either of these procedures is preferable to catheters are constructed of a 1-in latex tube stem that has an inflatable gland excision for most patients. Bartholinectomy carries significantly balloon at one end and a saline injection hub at the other. more morbidity than either of these procedures. Surgical Steps Preoperative Analgesia and Patient Positioning

Consent Most procedures are performed as an outpatient procedure in the office Repeated obstruction of the Bartholin gland duct following initial I & D is or the emergency room. The patient is placed in the dorsal lithotomy not uncommon during the weeks and months following drainage. position and the wound is cleaned with a povidone-iodine solution or Patients should be aware of the possible need to repeat the procedure other suitable antiseptic agent. Local analgesia is sufficient for most cases should the duct obstruct again. and can be obtained by infiltrating the skin overlying the planned incision Broad spectrum antibiotics are given before the surgery. with an aqueous 1% lidocaine solution. Chapter 3 Drainage catheter to inflate the catheter’s balloon. The balloon is inflated to reach a A 1-cm incision is made using a scalpel with a No. 11 blade to pierce the diameter that will prohibit the catheter from falling out of the incision. The hub of the Word catheter then can be tucked inside the vagina to skin and underlying cyst or abscess. The incision should be made along ♦ the inner surface of the cyst or abscess and placed outside and parallel to prevent it from being dislodged by traction from perineal movement. Bartholin glandduct—IncisionandDrainage the hymen at 5 or 7 o’clock position on the surface of the vulva. This position mimics the normal anatomy of the gland duct opening and avoids Postoperative creation of a fistulous tract to the outer surface of the labia majorum. Abscesses typically are surrounded by significant cellulitis, and in such Cultures for Neisseria gonorrhoeae and Chlamydia trachomatis can be obtained cases, antibiotics are warranted. Antibiotics should be broad spectrum to from spontaneously extruded pus. Mucus drained from a Bartholin cyst treat a polymicrobial infection with aerobes and anaerobes. need not be cultured. The tip of a small haemostat is placed within the Patients are encouraged to soak in warm tub bath twice daily. Coitus drained cavity and the tips are opened and closed to lyse adhesions and should be avoided for patient’s comfort and to prevent Word catheter open loculations of pus or mucus within the cavity. removal. Ideally, the catheter is left in place for 4–6 weeks as it helps in epithelisation of the tract. Often however, a catheter will be dislodged Word Catheter Placement before this time. There is no need to try and replace the catheter if The tip of a deflated Word catheter is placed within the empty cyst cavity. displaced, and attempt to reinsert it, are typically not possible due to A syringe is used to inject 2–3 ml of sterile saline through the port of the cavity closure.

9 4 Marsupialisation

High recurrence rates follow simple incision and drainage (I & D) of a Intraoperative Bartholin duct cyst or abscess. As noted earlier, a new duct ostium must Surgical Steps be created to prevent the incised edges from adhering and allowing mucus or pus to reaccumulate. For this reason, marsupialisation was developed Anaesthesia and Patient Positioning as a means to create a new accessory tract for gland drainage. The Marsupialisation is an outpatient procedure typically performed in an procedure makes it possible to avoid excising the gland with the cyst and operating suite using a unilateral pudendal nerve block or general to preserve the secretory function of the gland for lubrication. anaesthesia. Some authors, however, have described performance of the Preoperative procedure in an emergency room setting. The patient is placed in the dorsal lithotomy position and the vagina and vulva are surgically prepared. Consent Skin Incision The consent for marsupialisation mirrors that for Bartholin gland I & D. Accordingly, patients should be aware of the risk for repeated obstruction A wedge-shaped, vertical incision measuring 2–3 cm is created using a of the Bartholin gland duct following marsupialisation. Patients should scalpel with either a No. 10 or No. 15 blade. The incision is made on be aware of the possible need to repeat the procedure if ductal obstruction the vaginal mucosa over the centre of the cyst just outside the hymenal recurs. ring. Chapter 4 Cyst Incision As a result of closure and secondary fibrosis of the orifice after The cyst wall then is incised with a scalpel and the incision is extended marsupialisation, 10–15% of cysts recur. Abscess formation is another occasional sequel of marsupialisation. Marsupialisation requires a greater with scissors. After the cyst wall is opened and the cyst is drained of its ♦ contents. degree of analgesia, a larger incision, placement of sutures and longer Marsupialisation The tip of a small haemostat is placed within the drained cavity and procedure time. Marsupialisation has had limited use since the Word the tips are opened and closed to lyse adhesions and open loculations catheter was introduced. The Word catheter placement following I & D within it. The cavity is rinsed with sterile saline and suction is used to accomplishes the same result as surgery with minimal or no trauma. remove remaining saline and blood prior to wound closure. The nipple of the catheter can be inserted into the vagina. There is essentially no discomfort with the procedure and coitus can be resumed Wound Closure normally. This procedure can be performed with local analgesia in the The lining of the cyst is everted and approximated to the vaginal mucosa office setting and yields results comparable to those of marsupialisation with interrupted sutures of 2-0 delayed absorbable material. Drains are and other several advantages over marsupialisation, hence the use of I & not necessary. D should be encouraged. Postoperative Marsupialisation is admittedly easier to perform than radical excision; it carries the inherent possibility of recurrence of the Bartholin cyst. Victor Cool packs during the first 24 hours following surgery can minimise pain, Bonney himself practised and abandoned marsupialisation in favour of a swelling and haematoma formation. After this time, warm sitz baths, once complete excision of the Bartholin gland. Marsupialisation as a surgical or twice daily, are suggested for pain relief and wound hygiene. maneuver is essentially a shortcut and a half measure that merely releases Patients may be seen within the first week following surgery to ensure the surgeon from performing the difficult dissection required to remove that ostium edges have not adhered to each other. Within 2–3 weeks, the the primary condition. wound shrinks to create a duct opening typically 5 mm or less in size.

11 5 Operative Technique: Bartholinectomy

FIGURE 1: A Bartholin cyst. Note the prominent swelling in relation to the lower one-third of FIGURE 2: A close-up of the Bartholin cyst, seen on the left side posterolaterally to the the labia on the left side vaginal orifice Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 3: Patient is placed in dorsal lithotomy position and a vaginal and perineal prep is FIGURE 4: Skin overlying the planned incision is infiltrated with 1% lidocaine solution done

13 Bartholin Cystectomy ♦ Section 1

FIGURE 5: The vulva is freely supplied with blood vessels and therefore any incision tends FIGURE 6: An elliptical incision is made in the vaginal mucosa close to the site of the gland to bleed freely. Infiltration of tumescent fluid all around the cyst eases dissection and minimises orifice intraoperative bleeding

14 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 7: Allis forceps is applied on the lateral side of the incised edges for proper traction FIGURE 8: Blunt dissection is done with finger

Note: A pair of Allis forceps is applied to the cut edges of the incision and the cyst wall is separated from the surrounding connective tissue with the handle of the scalpel or the pulp of the operator's index finger.

15 Bartholin Cystectomy ♦ Section 1

FIGURE 9: Sharp dissection of the cyst from its bed is done using blunt pointed Mayo FIGURE 10: Blunt dissection is continued scissors

16 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 11: Thus dissection begins at the lower pole of the cyst and directed superiorly as FIGURE 12: Any vascular structure seen is held with a haemostat the vascular structure supplying the cyst is located at posterosuperior aspect

Note: Separation can be more difficult in the upper and posterior surface, and enucleation has to be completed by using fine cutting scissors. Branches of the pudendal vessels are found in this area and will need to be tied.

17 Bartholin Cystectomy ♦ Section 1

FIGURE 13: Enucleation has to be completed by using fine cutting scissors FIGURE 14: Separation of the cyst from the overlying labial skin

18 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 15: Similar dissection is done on the medial side FIGURE 16: Care must be taken not to button hole the vaginal aspect of the labium

19 Bartholin Cystectomy ♦ Section 1

FIGURE 17: The cyst is held with non-traumatic Babcok’s forceps to avoid rupture of the FIGURE 18: Further dissection is continued to remove the cyst from its bed cyst

20 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 19: Further traction is applied for proper visualisation FIGURE 20: Dissection planes should be kept close to the cyst wall to avoid bleeding from the venous plexus of the vestibular bulb

21 Bartholin Cystectomy ♦ Section 1

FIGURE 21: Dissection planes should be kept close to the cyst wall to avoid bleeding from the FIGURE 22: Apart from any arterial bleeding, it is sometimes difficult to control venous plexus of the vestibular bulb oozing from the venous plexus in the bed of the cyst

Note: Since venous bleeding is sometimes large and if not obliterated will form a pocket in which blood can accumulate. It is the best to bring its surfaces together by interrupted catgut sutures, applied inside the cavity, commencing at the bottom and gradually obliterating it.

22 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 23: Complete separation of the cyst from its medial relations FIGURE 24: Division of the small tags of connective tissue at the upper part of the cyst wall

Note: Difficulty may be experienced in enucleating the cyst if it has been inflamed, as the wall is consequently adherent to the surrounding structures or if the cyst is punctured, during its enucleation.

23 Bartholin Cystectomy ♦ Section 1

FIGURE 25: An intact cyst being enucleated from all the walls, the cyst remaining attached FIGURE 26: Gauze packed in the cavity bed to minimise intraoperative blood loss to the bed with connective tissue and the blood vessels running through it. Skeletonisation of the blood vessels in progress

24 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 27: Dissection is completed superiorly FIGURE 28: The cyst should be held very delicately towards the terminal part of the dissection to prevent its rupture defeating the very purpose of the dissection

25 Bartholin Cystectomy ♦ Section 1

FIGURE 29: Identification of the fibro-connective tissue, which holds the cyst at the base FIGURE 30: Bit-by-bit dissection of the base to prevent inadvertent retraction of the blood vessels, which may be difficult to secure

26 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 31: The base being put at a stretch while the basal structures are divided bit-by-bit FIGURE 32: Complete division of the cyst

27 Bartholin Cystectomy ♦ Section 1

FIGURE 33: Complete separation of the cyst FIGURE 34: The main vascular bundle to the cyst is identified and clamped with a haemostat

28 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 35: The cyst is now completely excised or removed from its bed FIGURE 36: The vascular bundle to the cyst is ligated with 3-0 delayed absorbable or chromic suture

29 Bartholin Cystectomy ♦ Section 1

FIGURE 37: The entire cavity is obliterated by approximating the walls with fine absorbable FIGURE 38: The bed of the excised cyst is sutured with interrupted sutures for proper suture material haemostasis

Note: Application of interrupted figure-of-eight sutures is very useful in obliterating the cavity.

30 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 39: Three to four interrupted sutures are taken FIGURE 40: Second layer is closed using same suture material

31 Bartholin Cystectomy ♦ Section 1

FIGURE 41: Second layer is closed in continuous fashion FIGURE 42: Adequate haemostasis is essential for an appropriate postoperative recovery

32 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 43: Closure of the cavity bed FIGURE 44: Closure of the cavity bed

33 Bartholin Cystectomy ♦ Section 1

FIGURE 45: Bed closed with additional stitches ensuring complete haemostasis FIGURE 46: Second layer is continued toward inferior pole

34 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 47: Closure of the bed with interrupted sutures is ideal FIGURE 48: When asepsis and complete haemostasis can be ensured, continuous sutures are time saving and provide the same results

35 Bartholin Cystectomy ♦ Section 1

FIGURE 49: The number of layers in which the bed is to be obliterated is not specific. It FIGURE 50: Too tight a suture results in tissue necrosis and too loose a suture is better left depends on the depth of the bed following enucleation of the Bartholin cyst unapplied, therefore the right tension of the sutures is imperative for adequate healing

36 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 51: Proper haemostasis is obtained FIGURE 52: The vaginal skin edges is closed with 3-0 chromic suture

37 Bartholin Cystectomy ♦ Section 1

FIGURE 53: The vaginal skin edges are sutured in interrupted fashion FIGURE 54: The labial skin being approximated with the vaginal mucosa

38 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 55: The vaginal skin edges are sutured in interrupted fashion FIGURE 56: Skin suturing is in progress

39 Bartholin Cystectomy ♦ Section 1

FIGURE 57: The choice lies between applying mattress sutures and simple sutures to close FIGURE 58: Skin suturing is in progress the skin. Both sutures work well, but simple sutures yield better cosmetic results

40 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 59: Application of the terminal skin sutures FIGURE 60: Application of the terminal skin sutures

41 Bartholin Cystectomy ♦ Section 1

FIGURE 61: One last inspection of the vulva as the last stitches are in progress, in the case FIGURE 62: Note the labia on the affected side taking shape symmetrical with the healthy of a haematoma formation it is wise to leave a corrugated drain in the wound cavity side as the skin-mucosa is approximated

42 Chapter 5 ♦ Operative Technique: Bartholinectomy

FIGURE 63: Skin-mucosal sutures are nearing completion FIGURE 64: Four to five interrupted sutures are taken

43 Bartholin Cystectomy ♦ Section 1

Note: These wounds heal exceptionally well and the end results are cosmetically very gratifying.

FIGURE 65: Final picture after completing the surgery

44 6 Postoperative Complications

Postoperative Haematoma Formation  Although blood usually reabsorbs with time, sometimes evacuation Postoperative haematoma formation is a common complication of Bartholin's and drainage are necessary  Sitz bath should be given after 48 hours of operation. It improves cyst excision, which results from persistent bleeding from the labia or vestibular bulb. This haematoma, if not noticed in time, can progress to include healing, provides soothing effect to patient and reinfection to the area. mons pubis and even to anterior abdominal wall beneath the Scarpa's fascia. Other Complications To prevent its formation the following should be kept in mind: Wound Cellulitis  Completely check for the haemostasis of the area after cyst excision  Obliterate the dead space completely by figure-of-eight stitches Risk of Recurrence  Vulval skin should be approximated by mattress sutures Repeated Ductal Obstruction and Abscess Formation  If the bleeding deep in the bed of the gland seems uncontrollable, deep mattress sutures can be placed from the skin through the Postoperative Scarring Leading to Pain or Dyspareunia bleeding bed into the vagina. The sutures should not be tied too Recovery period after removal of cyst and gland is relatively prolonged tightly because necrosis may result with fenestration of the vaginal and takes 2–3 weeks, which requires good home care of the operation outlet site. Best method of local fomentation is to take a sitz bath twice or  Ice packingis to be done over the perineal area immediately after thrice daily. At home patients are advised to put 4 inches of warm the procedure to prevent minimal oozers water at approximately 100°F along with two cups of ordinary epsom  Pressure dressing should be applied on the vulva salt/table salt/chlorine bleach, etc. in a bath tub or big tub and to sit  Sometimes when oozing is highly suspected a small drain can be in this for a period of 20 minutes, 2–3 times daily. She should rinse put at the bed and stitched to the vulval skin for drainage and to with fresh water following the soaking. The genital area may be later avoid accumulation of blood and serous fluid gently towel dried. Section 2 Marsupialisation

 Introduction  Operative Technique: Marsupialisation  Postoperative Care

7 Introduction

Gland/Cyst Marsupialisation Physiologic Changes Marsupialisation of a gland is generally indicated when there is a large If marsupialisation is successful, the epithelium within the gland will be abscess that makes surgical excision of the gland difficult. In this operation, epithelialised with squamous epithelium. the surgeon opens the wall of the abscess wide and allows the purulent Advantages exudate to drain. The membrane of the abscess is then sutured to the vaginal mucosa and to the skin of the introitus in order to effect granulation The surgery is easy to perform, quickly and provides immediate relief to and re-epithelialisation of the wound from the bottom of the abscess to the patient. the top. Disadvantages The operation is fast. Haemostasis is not difficult and can be performed The healing period is protracted and therefore the patient continues to under local anaesthesia. experience some discharge and local discomfort for many months thereafter. The purpose of marsupialisation of the cyst is to exteriorise the abscess in such a fashion that it will become epithelialised from the base. Preoperative Preparation In clinical practise usually large acute and subacute cases of The preoperative preparation is similar to any other minor surgical bartholinitis are suitable cases for marsupialisation to ensure a passage of procedure performed on the vagina. drainage of pus till the abscess cavity is completely obliterated as a process of healing and any discharge from the cyst/abscess lining completely Anaesthesia and Position on Operation Theatre Table subsides. This healing may take many months.  The patient is laid supine on the operation table in a slight reverse This series presents the operation of marsupialisation being performed Trendelenburg position for a chronic vaginal wall abscess.  The reverse Trendelenburg tilt facilitates drainage from the cyst cavity. 8 Operative Technique: Marsupialisation

In the case demonstrated that follows, a vaginal cyst surgery in which a surgery coupled with an immediate nonavailability of a case of Bartholin marsupialisation has been performed. The similarity in presentation and cyst necessitated the change.

FIGURE 1: A retention cyst arising from the anterior vaginal wall FIGURE 2: This tense swelling caused dysurea, dypareunea and a sensation of the swelling coming out of the vulva Chapter 8 ♦ Operative Technique: Marsupialisation

FIGURE 3: A wide-bore needle is introduced into the cystic swelling yielding pus FIGURE 4: The cyst wall is held strongly with Allis tissue holding forceps

51 Marsupialisation ♦ Section 2

FIGURE 5: A second Allis forceps applied prior to making an incision through the cyst wall FIGURE 6: Note the escape of a purulent discharge following the incision

52 Chapter 8 ♦ Operative Technique: Marsupialisation

FIGURE 7: The collection is allowed to emptying through the incision FIGURE 8: Pressure on the cyst from the outside assists in rapid emptying

53 Marsupialisation ♦ Section 2

FIGURE 9: The incision has to be widened once collected discharge ceases FIGURE 10: The initial incision of the vagina is extended in both directions

54 Chapter 8 ♦ Operative Technique: Marsupialisation

FIGURE 11: The incision is extended to expose the inner lining of the cyst cavity FIGURE 12: Note the retained pus which drains as the surgery progresses

55 Marsupialisation ♦ Section 2

FIGURE 13: The retained pus is allowed to draining FIGURE 14: The end of the incision over the cyst is held by four Allis forceps

56 Chapter 8 ♦ Operative Technique: Marsupialisation

FIGURE 15: The margins of the incision being widened to prevent postoperative adhesions FIGURE 16: Excision of the incision margins is in progress and reformation of the cyst

57 Marsupialisation ♦ Section 2

FIGURE 17: The incision margins are sutured with interrupted sutures FIGURE 18: This causes closure of the vaginal epithelium and cyst wall raw edges and prevents cicatrisation of the osteum created

58 Chapter 8 ♦ Operative Technique: Marsupialisation

FIGURE 19: Suturing in progress FIGURE 20: Suturing in progress

59 Marsupialisation ♦ Section 2

FIGURE 21: Closure of the osteal margins in progress FIGURE 22: Closure of the osteal margins in progress

60 Chapter 8 ♦ Operative Technique: Marsupialisation

FIGURE 23: At the end of the procedure the stay sutures are trimmed FIGURE 24: The abscess cavity is being flushed with normal saline to aid drainage of any retained pus and debris

61 Marsupialisation ♦ Section 2

FIGURE 25: The abscess cavity being flushed with normal saline to aid drainage of any FIGURE 26: The abscess cavity being washed with povidone iodine retained pus and debris

62 Chapter 8 ♦ Operative Technique: Marsupialisation

FIGURE 27: The completed surgery FIGURE 28: The cyst wall is being packed lightly with sterile gauze dressing

63 Marsupialisation ♦ Section 2

FIGURE 29: This dressing is removed after 24 hours

64 9 Postoperative Care

As commented earlier marsupialisation is a poor alternative for the surgical Complications management of Bartholin cyst. Difficulty may be experienced in Immediate complications following marsupialisation are few, the relief enucleating the cyst if it has been inflamed, as the wall is consequently in symptoms is immediate. In the long-term the patient may continue to adherent to the surrounding structures or if the cyst is punctured, during have an offensive discharge from the retained cyst wall, which may be its enucleation. When, owing to inflammatory adhesions, a plane of very incidious to recede. cleavage does not exist, the cyst should be incised, its contents evacuated A painful vulva with discomfort while sitting may also be a distressing and the index finger of the left hand be excised with scissors, keeping as symptom in the postoperative period. close to the wall as possible. A useful alternative technique when the cyst is accidentally opened is to pack the cavity with gauze so as to define its Postoperative Care boundaries and thus facilitate its excision. This simple procedure has an Sitz baths bring relief to the painful perineum and may need to be application much wider than the removal of an adherent Bartholin's cyst. continued for many weeks after marsupialisation. It can be equally effective in the removal of adherent retroperitoneal and vaginal cysts. Follow-Up Patients need to be followed-up at regular intervals and in the absence of relief may need excision of the cyst wall. Section 3 Labial Fusion

 Introduction  Preoperative Evaluation  Operative Technique: Labial Fusion

10 Introduction

Synonym The adhesions may also be called "bridging", as they join the right and Labial adhesion, Female phimosis, Urocolpos, Synechia vulvae. left side of the vulva. The term may also be used when labium minorum fuses with labium majorum. Labial Fusion Labial fusion may also develop in the first two years of life during which period the children are playing on the floor. The vaginal and labial Labial fusion may be secondary to a urogenital sinus deformity and in mucosa is especially amenable to infection as a result of a child playing the majority of cases the labia separate on their own or with applications on a contaminated dusty floor, resulting in vulvovaginitis of childhood. of oestrogen cream. There are, however, some cases where the fusion is Fusion of the labia results, which is inseparable and to the parents these not amenable to conservative management and surgical intervention is genital appearances present as ambiguous sex characters. required. Labial fusion may also though rarely develop in postmenopausal Adhesion or fusion of the labia is a common benign gynaecologic women who have undergone radiation therapy for some genital tract disorder in the paediatric population and is defined as partial or complete malignancy. adherence of the labia minora or majora. It is usually a midline fusion and Vulvovaginitis as a result of this radiation reaction combined with an may be visible as a thin translucent streak. This disorder is usually oestrogen deficient mucosa may result in a fusion of the two labia. The asymptomatic and may be first noticed due to repeated urinary tract cervical and vaginal secretions then accumulate in the vagina leading to a infections. mucocoel formation. Labial adhesions mean that the labia minora are stuck together In the postmenopausal women undergoing radiation therapy for some ("fused"). Adhesions rarely result in complete labial fusion; more often it genital tract malignancy, this potential complication should be anticipated is partial. and adequate local care in the form of local hygiene; daily washing of the  Local causes, such as disabling hip problems that interfere with labia and the application of a local ointment bearing a steroid, oestrogen perineal hygiene and sexual activity and a locally acting antibiotic should be encouraged. This practise to a  Labial fusion may be the presenting feature of genital lichen sclerosus

Labial Fusion large extent would help in the prevention of labial fusion in this group of

♦ patients. Pathogenesis Trauma Prevalence Section 3  According to the data in the published literature, labial adhesion is  Denudation of the superficial squamous epithelial layer of the labial occasionally seen in the newborn period minora mucosa  Age of onset: 3 months to 4 years  Fibrous tissue formation  The age at which this disorder is commonly seen (i.e. peak) ranges  Sealing of the labia minora in the midline along apposed areas of from 13–23 months with an incidence of 1.8% trauma.  It is sometimes seen in women of reproductive age group as well Types of Trauma and more commonly in postmenopausal women.

No strong evidence supports a racial predilection.  Inflammatory conditions (vulvitis, vulvovaginitis) due to: • Poor perineal hygiene Etiopathogenesis • Seborrhoea Labial adhesions may be congenital or a complication of: • Atopic dermatitis • Pinworms  Exposure to drugs, such as chlorpyrifos (Dursban), and danazol  Childhood sexual abuse (may be associated with lacerations or  Adrenal steroid 21-hydroxylase deficiency haematoma) Postnatally, they may also result from inflammation that occurs  Masturbation secondary to various causes and resultant scarring, oestrogen deficiency  Straddle injury and lack of sexual activity. Numerous causes have been cited for this, a  Labial lacerations few of these are:  Contact with irritants  Hypo-oestrogenic states as in pre- and postmenopausal women  Hypo-oestrogenism may result in a reduction in the thickness of the predispose them to developing labial adhesions labial epithelial cells increasing the risk of trauma in this area.

70 Chapter 10 Clinical Features  Labial adhesions are generally readily apparent as thin, pale, semi- Genitourinary translucent membranes cover the vaginal os. Typically the adhesions begin posteriorly and progress a variable distance anteriorly towards ♦ the clitoris.  Most girls are asymptomatic and labial fusion is often first noticed Introduction by parents or during a routine physical examination  A careful examination should also evaluate for other interlabial  Flat vulva masses or genital anomalies, such as fusion of the labia majora that  Edges of the labia minora are sealed along the midline beginning at can occur with intersex disorders. the posterior fourchette and extending anteriorly towards the clitoris  A host of other paediatric vaginal or urethral disorders, including  A thin translucent membrane obscures the vaginal introitus and an imperforate hymen or a septate vagina, must be excluded. hymen.  Signs of sexual abuse may include lacerations or haematoma.

Complications Investigations Urine  Urologic or gynaecologic morbidity, but labial fusion is not a

common cause of it  Urinalysis  Distorted urinary stream (discomfort while voiding)  Routine urine culture in children with labial adhesions.  Post void dribbling of urine  Asymptomatic bacteriuria (in 20% of patients) Imaging Studies  Repeated urinary tract infection (in 20–40% of patients) Voiding Cystourethrogramme  Urinary outflow obstruction-bladder distension-hydronephrosis  Urinary outflow deflection leading to vaginal reflux of urine and  May show urinary retention behind the fused labia, bladder subsequent vaginal leaking when the child stands after voiding distension and/or hydronephrosis (postvoid dribbling, also called vaginal voiding). Sonographic Findings Physical Examination  Labial adhesions can be adhesions of the labia minora or of the  The physical examination is aided by positioning the child in a frog- majora. The labia minora adhesions are a more common occurrence leg position and using a pull-down procedure where the labia majora and more easily rectifiable. These adhesions are usually recognised are grasped and gently retracted caudally and laterally to better easily by physical examination. However, the affected individuals might be sent for a scan due to repeated urinary tract infections. visualise the vagina. 71 Ultrasound does not usually reveal anything except, if there is a If treatment is necessary following measures can be taken: urinary collection (a urinoma) that might have occurred due to the Topical Conjugated Oestrogen Cream (Premarin) pinhole sized meatus and resultant poor stream of urine. This is  Apply a small amount of cream precisely to the fused area once or Labial Fusion also the basis of antenatal diagnosis of this condition. twice a day until the adhesion is lysed (usually in less than 1 month, ♦  In one study, where voiding cystourethrography was performed in but may take up to 2 months) children with urinary tract infections, the radiologist was the initial  Effective in 90% of cases person involved in making this diagnosis by observing collection of

Section 3  Adverse systemic side-effects from oestrogen application are rare contrast material above the labia and marked reflux into the vagina. and include local irritations, vulvar pigmentation and breast enlargement. These effects are reversible once treatment is stopped Differential Diagnosis

 Hymenal skin tags Manual Separation / Lysis  Imperforate hymen  Parental use of pull-down maneuver may also facilitate gentle  Introital cysts (paraurethral or Gartner duct cysts) takedown of the adhesions.  Ureterocoele  May be performed in office setting with a probe or with gentle action  Urethral Polyp of a finger  Urethral Prolapse  High risk of recurrence and scarring  Vaginal Atresia  Vaginal Rhabdomyosarcoma. Surgical Care Prognosis Labia majora adhesions and dense fibrous adhesions may need adhesiolysis and corrective surgery. This disorder follows a benign course and has a good prognosis. Surgery may be considered if:

Management  An oestrogen cream or ointment does not work Medical Care  A fusion is particularly thick and severe  There is any trapped urine in the vagina, which could lead to an Labia minora adhesions can often be managed with periodic observation infection. and "spontaneous resolution" occurs.

72 11 Preoperative Evaluation

The importance of preoperative evaluation prior to surgical management Physiologic Changes is vital to the success of the procedure. The gender of some patients may The fused labia are opened, resulting in a normal vaginal canal. be unclear. The clitoris is mistaken for a micropenis and the fused folds of the labia may be mistaken for a scrotum with undescended testes. Points of Caution Appropriate cytogenetic studies are indicated. An examination under Care should be taken to identify all genital canals within the pelvis. A anaesthesia with careful probing of all openings under the clitoris/penis silver wire probe and uterine sound should be gently inserted into the should be performed. various canals under general anaesthesia in order to identify each opening Only after the patient has been adequately evaluated, the surgical prior to making an incision into the labia. management should be started. 12 Operative Technique: Labial Fusion

FIGURE 1: In a child aged 18 months brought to the hospital by a worried mother who FIGURE 2: Note the complete fusion of the labia on both the sides, in the midline completing noticed the abnormal looking external genitalia the vaginal introitus Chapter 12 ♦ Operative Technique: Labial Fusion

FIGURE 3: Under sedation, after cleaning of the external genitalia, the adherent labia are FIGURE 4: The labia gradually separate under the pressure of the probe. Note that the labia softly separated by blunt dissection using a small cotton tipped probe as a dissection device are still fused in the upper part while the lower part adhesions yield to pressure

75 Labial Fusion ♦ Section 3

FIGURE 5: Complete separation of the fused labia revealing normal looking external genitalia, FIGURE 6: This problem results from carelessness in maintaining normal genital hygiene, including the external urinary meatus with the child playing unclothed on a dirty floor, giving rise to vulvo vaginitis of childhood

76 Chapter 12 ♦ Operative Technique: Labial Fusion

FIGURE 7: Follow-up requires frequently washing of the external genitalia with clean water and application of antibiotic creams. Addition of topical steroids helps to prevent further adhesions and refusion

77 Section 4 Labial Cystectomy

 Vulval Cyst  Operative Technique: Vulva Cyst

13 Vulval Cyst

Introduction Mucinous Cysts The most common member of this group is the Bartholin duct cyst or An occasional pedunculated or nonpedunculated cyst, mucinous cyst vulvovaginal cyst (dealt earlier in this volume). develop lateral to the clitoris or in the inner aspect of the labium minus. Epithelial inclusion cysts are common and represent the residuum of Such lesions may represent aberrant mucinous epithelium, misplaced at the chronically obstructed sebaceous "duct". The desquamated superficial time of the division of the cloaca by the urorectal fold. Another possible epithelium makes up the contents of such cysts and grossly may simulate qetiology involves the minor vestibular glands. These structures, like sebaceous material. The microscopic appearance of such lesions is Bartholin gland, have mucin secreting acini and may reflect the same characterised by a stratified epithelial lining, representative of the occlusive processes that reflect the major glands. epithelium of the hair follicle, which has been included in the final process of the occlusion of the hair follicle shaft and its associated sebaceous gland. 14 Operative Technique: Vulval Cyst

FIGURE 1: Note the prominent swelling in relation to the upper two-thirds of the labia on the FIGURE 2: The cyst is projecting through the inner surface of the labia minora left side. The swelling is multilobulated Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 3: The vulva is freely supplied with blood vessels and therefore any incision tends FIGURE 4: Infiltration of tumescent fluid all around the cyst particularly at the base reduces to bleed freely. Infiltration of tumescent fluid all around the cyst eases dissection and minimises intraoperative blood loss intraoperative bleeding

83 Labial Cystectomy ♦ Section 4

FIGURE 5: Vaginal mucosa overlying the planned incision is infiltrated with 1% lidocaine FIGURE 6: Infiltrating the base is particularly important because the arteries and veins are solution concentrated at the base and tend to bleed more in that vicinity

84 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 7: Adequate tissue oedema created by the tumescent fluid helps to reduce the FIGURE 8: An incision is made in the vaginal mucosa along the muco-cutaneous border at intraoperative mess created by blood ooze the base of the cyst

85 Labial Cystectomy ♦ Section 4

FIGURE 9: As the incision is extended note the relative blanching of the incision line resulting FIGURE 10: As the incision is extended note the relative blanching of the incision line resulting in minimal oozing of blood in minimal oozing of blood

86 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 11: Allis forceps is applied on the lateral side of the incised edges for proper traction FIGURE 12: A pair of Allis forceps is applied to the cut edges of the incision and the cyst wall is separated from the surrounding connective tissue with the handle of the scalpel or the pulp of the surgeon’s index finger

87 Labial Cystectomy ♦ Section 4

FIGURE 13: Sharp dissection of the cyst from its bed is done using blunt ended Mayo FIGURE 14: Sharp dissection of the cyst from its bed is done using blunt ended Mayo scissors scissors

88 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 15: Where the cyst wall is very thin extreme care is required to prevent puncturing FIGURE 16: Sharp pointed scissors are insinuated below the incision line to expand the of the cyst wall or buttonholing the mucosa overlying plane of cleavage

89 Labial Cystectomy ♦ Section 4

FIGURE 17: Delicate strands of tissue between the cyst wall and the vaginal mucosa are FIGURE 18: It is important to avoid puncturing of the cyst wall because collapse of the cavity carefully divided using fine sharp ended scissors following a puncture makes separation of the cyst wall very difficult

90 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 19: Stretching the cyst wall puts the fascial bands running between the cyst wall FIGURE 20: Undermining the vaginal flap while dissecting the vulval cyst and the vaginal mucosa at a stretch, thus making their division easier

91 Labial Cystectomy ♦ Section 4

FIGURE 21: The vaginal mucosa is put at a stretch, to divide the fascial fibres between the FIGURE 22: The vaginal mucosa is put at a stretch, to divide the fascial fibres between the cyst wall and the overlying mucosa cyst wall and the overlying mucosa

92 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 23: The loose strands of fascia yield under digital pressure, but the fibrous bands FIGURE 24: Care is exercised to avoid division of prominent blood vessels, which may require division with scissors have a tendency to retract inwards, making haemostasis difficult

93 Labial Cystectomy ♦ Section 4

FIGURE 25: The loose strands of fascia yield under digital pressure, but the fibrous bands FIGURE 26: The loose strands of fascia yield under digital pressure, but the fibrous bands require division with scissors require division with scissors

94 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 27: Any bleeders are secured with haemostatic clamps FIGURE 28: Pressure of gauze cleans up the operation field and puts the tissue at a stretch for better identification

95 Labial Cystectomy ♦ Section 4

FIGURE 29: Any prominent bleeding points are secured with haemostatic clamps FIGURE 30: A second incision being applied over the overlying mucosa lateral to the previous incision

96 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 31: The second incision is being deepened to just short of the cyst wall FIGURE 32: This reduces the dissection and therefore the intraoperative blood loss

97 Labial Cystectomy ♦ Section 4

FIGURE 33: Undermining of the skin margins using sharp dissection to free the overlying FIGURE 34: Fibrous strands are being separated to advance the tissue dissection skin off the cyst wall

98 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 35: Undermining of the skin edges overlying the cyst wall FIGURE 36: The second incision is being completed at its upper end

99 Labial Cystectomy ♦ Section 4

FIGURE 37: Occasional buttonholing of the overlying skin/mucosa may be inevitable. It is FIGURE 38: Further dissection of the cyst. Note that the skin margins are held with multiple best to trim the skin edges at the end of surgery Allis forceps to put the skin margins at a stretch to ease further dissection

100 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 39: Oozing from the dissected surface may be a nuisance. This can be controlled FIGURE 40: The index and middle fingers of the right hand insinuated behind the partially by mechanical pressure dissected cyst to further put the tissues at a stretch and the tissues overlying the fingers being clipped with scissors

101 Labial Cystectomy ♦ Section 4

FIGURE 41: Dissection of the fascia supported by the fingers of the right hand at the back of FIGURE 42: Division of the small tags of connective tissue at the upper part of the cyst wall the cyst

102 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 43: Separation of the cyst wall by blunt and sharp dissection FIGURE 44: Separation of the cyst wall by blunt and sharp dissection

103 Labial Cystectomy ♦ Section 4

FIGURE 45: Separation of the cyst wall by blunt and sharp dissection FIGURE 46: The lower end of the second incision being extended downwards to meet the lower end of the first incision

104 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 47: The lower end of the second incision is being extended downwards to meet the FIGURE 48: The cyst with the overlying mucosa pulled to the opposite side to free the cyst lower end of the first incision of its deeper attachments

105 Labial Cystectomy ♦ Section 4

FIGURE 49: Dissection of the deeper tissues over the index and middle fingers insinuated FIGURE 50: Dissection of the deeper tissues over the index and middle fingers insinuated behind the cyst behind the cyst

106 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 51: Dissection of the deeper tissues over the index and middle fingers insinuated FIGURE 52: With the fingers of the left hand in place the thick tissue attachments being behind the cyst divided with sharp cutting scissors

107 Labial Cystectomy ♦ Section 4

FIGURE 53: Note the overlying tissue retract away over the fingers as the overlying fascia is FIGURE 54: Tip of the left index finger visible after division of the fascia. The dissection divided being directed to the lower attachments of the cyst

108 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 55: Tip of the left index finger visible after division of the fascia. The dissection is FIGURE 56: Prominent blood vessels secured with haemostatic clamps being directed to the lower attachments of the cyst

109 Labial Cystectomy ♦ Section 4

FIGURE 57: On freeing the cyst from its lower pole the cyst with the overlying mucosa is FIGURE 58: Division of the loose tags of fascia at the upper end pulled to the opposite side to expose the cyst attachments at the upper end to aid further dissection

110 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 59: Dissection of the remaining part of the cyst attachments at the upper part FIGURE 60: Dissection of the remaining part of the cyst attachments at the upper part

111 Labial Cystectomy ♦ Section 4

FIGURE 61: Dissection of the remaining part of the cyst attachments at the upper part FIGURE 62: Dissection of the remaining part of the cyst attachments at the upper part

112 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 63: Dissection of the remaining part of the cyst attachments at the upper part FIGURE 64: Dissection of the remaining part of the cyst attachments at the upper part

113 Labial Cystectomy ♦ Section 4

FIGURE 65: Dissection of the remaining part of the cyst attachments at the upper part FIGURE 66: Dissection of the remaining part of the cyst attachments at the upper part

114 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 67: The last tag of fascia is being divided to completely separate the cyst FIGURE 68: Commencement of the wound closure

115 Labial Cystectomy ♦ Section 4

FIGURE 69: Commencement of the wound closure FIGURE 70: The vulval cysts may burrow deep into the tissues leaving a large crater (dead space) on its complete dissection. It is important to obliterate the dead spaces completely to prevent postoperative haematoma formation

116 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 71: The dead space, if small can be obliterated by a single layer of interrupted FIGURE 72: On completion of one layer of sutures, the wound should be mopped completely sutures, but when it is large or deep seated, the closure may be done in multiple layers and inspected for any bleeding from the deeper layers before venturing to apply the overlying layer

117 Labial Cystectomy ♦ Section 4

FIGURE 73: Approximation of the deeper layers in progress FIGURE 74: Approximation of the deeper layers in progress

118 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 75: Application of the second layer of the deeper tissues FIGURE 76: The index finger of the left hand is insinuated into the wound to push in the first layer of stitches while the second layer is being applied

119 Labial Cystectomy ♦ Section 4

FIGURE 77: Care must be taken to take multiple bites of the tissues to ensure complete FIGURE 78: Care must be taken to take multiple bites of the tissues to ensure complete closure of the dead space closure of the dead space

120 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 79: The deeper stitches applied should be tight enough to ensure complete FIGURE 80: The deeper stitches applied should be tight enough to ensure complete haemostasis haemostasis

121 Labial Cystectomy ♦ Section 4

FIGURE 81: Further application of the deeper stitches FIGURE 82: Further application of the deeper stitches

122 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 83: Layer by layer approximation of the tissues ensures symmetrical restoration of FIGURE 84: Layer by layer approximation of the tissues ensures symmetrical restoration of genital anatomy genital anatomy

123 Labial Cystectomy ♦ Section 4

FIGURE 85: Layer by layer approximation of the tissues ensures symmetrical restoration of FIGURE 86: Layer by layer approximation of the tissues ensures symmetrical restoration of genital anatomy genital anatomy

124 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 87: Care should be taken to completely obliterate the dead space in the deeper FIGURE 88: The ends of the threads to be embedded and should be cut short to minimise layers tissue reaction

125 Labial Cystectomy ♦ Section 4

FIGURE 89: Vascular pedicles should be separately ligated. The use of diathermy may FIGURE 90: Diathermy use is not contraindicated, but is better avoided especially in the minimise operating time, but may increase tissue reaction superficial layers

126 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 91: The persistent ooze from the raw area progressively reduces as more and FIGURE 92: The pressure of the stitch line minimises the ooze from minute bleeders more layers are stitched

127 Labial Cystectomy ♦ Section 4

FIGURE 93: Note that the stay suture on the upper end of the incision is pulled up and the FIGURE 94: Fine suture material (‘000’or ‘00’) provide a more stable knot and cause less tissue holding forceps securing the skin edge and the mucosal end are allowed to drop tissue damage resulting in a better scar down, further aligning the margins to be stitched next

128 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 95: Approximation of the skin and mucosa in progress FIGURE 96: Approximation of the skin and mucosa in progress

129 Labial Cystectomy ♦ Section 4

FIGURE 97: Approximation of the skin and mucosa in progress FIGURE 98: Approximation of the skin and mucosa in progress

130 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 99: Note the restoration of the labial anatomy as subsequent stitches are applied FIGURE 100: Note the discrepancy in the length of the skin incision, as the mucosal margins appear smaller. In these situations additional stay sutures (one or two) may be applied in the middle to ensure even distribution of the skin edges. This ensures a proper looking labial reconstruction

131 Labial Cystectomy ♦ Section 4

FIGURE 101: Stay sutures being applied in the middle of the incision line FIGURE 102: While applying the final mucosal layer care should be taken to pick up small pieces of tissue which may have been left unstitched in the previous layer

132 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 103: While applying the final mucosal layer care should be taken to pick up small FIGURE 104: Pull on the stay sutures applied at the upper and lower ends of the incision aid pieces of tissue, which may have been left unstitched in the previous layer in an anatomical approximation of the mucosal margins and avoid distortion of the labia

133 Labial Cystectomy ♦ Section 4

FIGURE 105: The mucosa to skin approximation should be adequate and care should be FIGURE 106: Any raw area in the stitch line may result in a local granuloma formation and taken to avoid raw area in the stitch line delay healing

134 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 107: The superficial stitches fall on the inner aspect of the labia minora, yielding FIGURE 108: Labial reconstruction complete in its upper part better cosmetic results

135 Labial Cystectomy ♦ Section 4

FIGURE 109: Note the reformation of the labia minora as the skin edges are in curled while FIGURE 110: This ensures the restoration of the normal anatomy being approximated to the mucosa

136 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 111: Application of the terminal skin sutures. Too tight sutures may cause local skin FIGURE 112: Application of the terminal skin sutures necrosis and therefore delayed healing

137 Labial Cystectomy ♦ Section 4

FIGURE 113: The superficial stitches are intended to ensure adequate approximation, FIGURE 114: Delayed absorbable stitches work well. The ends of the stitches should be cut therefore too tight or too loose suturing is best avoided short to prevent “digging in” of the stitches and the resultant local discomfort

138 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 115: Complete obliteration of the dead space prevents postoperative haematoma FIGURE 116: Application of the terminal skin sutures formation. Note the submucosal tissue is being included along with the mucosa to achieve proper closure

139 Labial Cystectomy ♦ Section 4

FIGURE 117: Application of the terminal skin sutures FIGURE 118: One last inspection of the vulva as the last stitches are in progress, in the case of a haematoma formation it is wise to leave a corrugated drain in the wound cavity

140 Chapter 14 ♦ Operative Technique: Vulval Cyst

FIGURE 119: The completed surgery. The aesthetic results are rewarding as tissue healing is good because of a liberal blood supply

141 Section 5 Labial Polyp

 Introduction  Operative Technique: Labial Polypectomy

15 Introduction

Benign tumours of the cervix comprise of cysts, of which the Bartholin Amongst the solid benign tumours of the vulva, the text mentions cysts are the most frequently met. Epithelial inclusion cysts are common large fibromas of the vulva, while fibromyomas lipoma, angiomas, and represent the residuum of the chronically obstructed sebaceous “duct.” hidradenomas, nevus, glandular cell myoblastoma syringoma and Mucinous cysts like Bartholin cysts have mucus secreting acini and may endometriomas are described. Also mentioned are the rare reflect the same occlusive processes that affect the major glands. Cysts of lymphoangiomas and neurofibromas. the canal of Nuck may arise from the peritoneal covering carried down Considering the rarity of the polypoidal vulval benign growths, a case with the round ligament to its insertion in the labium majus. of labial polyp is described. Operative Technique: Labial 16 Polypectomy

FIGURE 1: A sessile growth arising from the labia minor, bearing a small pedicle medially FIGURE 2: A sessile growth arising from the labia minor, bearing a small pedicle medially encroached by the vaginal mucosa and laterally by the extension of the skin from the labia encroached by the vaginal mucosa and laterally by the extension of the skin from the labia Chapter 16 ♦ Operative Technique: Labial Polypectomy

FIGURE 3: Pulling the polyp anteriorly reveals the inner extreme of the growth FIGURE 4: Infiltration of the tumescent fluid at the base of the growth to constrict the blood vessels at the base of the pedicle

147 Labial Polyp ♦ Section 5

FIGURE 5: Infiltration of tumescent fluid in all directions of the pedicle FIGURE 6: Infiltration of tumescent fluid in all directions of the pedicle

148 Chapter 16 ♦ Operative Technique: Labial Polypectomy

FIGURE 7: Infiltration of tumescent fluid in all directions of the pedicle FIGURE 8: Infiltration of tumescent fluid in all directions of the pedicle

149 Labial Polyp ♦ Section 5

FIGURE 9: Infiltration of tumescent fluid at the base FIGURE 10: Infiltration of tumescent fluid anteriorly

150 Chapter 16 ♦ Operative Technique: Labial Polypectomy

FIGURE 11: Incision given at the base of the labial polyp FIGURE 12: Incision deepened at the base

151 Labial Polyp ♦ Section 5

FIGURE 13: A plane of cleavage is sought under the skin incision in a bid to skeletonise the FIGURE 14: Edges of the incision are held with Allis forceps on the labial side to undermine pedicle of the polyp the fibro fatty tissue

152 Chapter 16 ♦ Operative Technique: Labial Polypectomy

FIGURE 15: Blunt dissection done to separate the polyp from the labia FIGURE 16: Blunt dissection being done on the lower side

153 Labial Polyp ♦ Section 5

FIGURE 17: Same procedure is being done to free the overlying polyp of its basal attachments FIGURE 18: Labial polyp after completion of blunt dissection on the anterior side

154 Chapter 16 ♦ Operative Technique: Labial Polypectomy

FIGURE 19: Loose tags of skin at the lower border of the incision is being trimmed FIGURE 20: Incision given on medial side of the labial polyp

155 Labial Polyp ♦ Section 5

FIGURE 21: Incision deepened FIGURE 22: Excision of the labial polyp is being done from above

156 Chapter 16 ♦ Operative Technique: Labial Polypectomy

FIGURE 23: As much of the subcutaneous fascia is dissected to expose the pedicle containing FIGURE 24: Blunt separation of the labial tissue from the base of the polyp the blood vessels and nerves

157 Labial Polyp ♦ Section 5

FIGURE 25: Note that the pedicle is now devoid of any subcutaneous tissue FIGURE 26: An artery forceps applied at the base of the pedicle. This clamp includes the blood vessels and nerves running into the substance of the polyp

158 Chapter 16 ♦ Operative Technique: Labial Polypectomy

FIGURE 27: An artery forceps applied from above and excision of the base of the polyp is FIGURE 28: After securing the pedicle completely, the pedicle is divided just above the done artery clamps

159 Labial Polyp ♦ Section 5

FIGURE 29: An artery forceps is applied from above and excision of the base of the polyp is FIGURE 30: Excision of the polyp done

160 Chapter 16 ♦ Operative Technique: Labial Polypectomy

FIGURE 31: Transfixation suture using no. 1 vicryl is passed to prevent the slippage of the FIGURE 32: Transfixation suture is being tied vessels at the base

161 Labial Polyp ♦ Section 5

FIGURE 33: The skin incision is then closed with simple interrupted sutures

162 Section 6 Labial Hypertrophy

 Introduction  Excision of a Hypertrophied Labia Minora

17 Labial Hypertrophy

Introduction lips) extend from the mons pubis to the rectum. The vascularized labia Enlargement of the labia minora (inner vaginal lips) is a true medical minora (the small inner lips) are within the labia majora; however, in some condition that affects many women. The medical term for this is called women, the minor lips are short and thin and hidden by the labia majora; labial hypertrophy. Many women that have enlarged labia minora, that and in some women, the labia minora are longer, thicker and wider and are much larger and protrude beyond the labia majora (the typically larger extend beyond the labia majora. outer lips) may suffer from multiple symptoms because of this or just may not be comfortable with their appearance. Labial hypertrophy may Composition be congenital in nature and therefore affect young women in their late The labia minora consist of two connective folds of flesh that contain some teens or early twenties or it may develop later in women after pregnancy adipose tissue; at the front and upper portions of the pudendum and/or vaginal childbirth. The labia may become elongated or stretched femininum (vulva), the labia minora divide into two parts. out due to hormonal changes or because of the process of one or more The first part passes over the clitoris and forms the “prepuce of the vaginal deliveries. In some cases, the labia are very asymmetrical with clitoris” (clitoral hood); the second part of the labia minora joins beneath one labium being much larger than the other one. Regardless of the cause, the clitoris and forms the "fourchette" (labial frenulum), a transverse fold this condition can be fixed through surgery. of tissue that occasionally unites the labia minora to the labia majora at Surgical Anatomy of the Vulva their posterior extensions. The skin and the mucosa of the labia minora are rich in sebaceous glands and nerve endings, thus the labia are very The Vulvo-Vaginal Complex sensitive to the touch. These folds of vulvo-vaginal skin have a core of The external genitalia of a woman are collectively denoted the vulvo- connective, erectile tissue (analogous to the corpus spongiosum penis) vaginal complex, which comprises the labia majora, the labia minora, the and are covered by stratified, squamous epithelium thus the labia minora clitoris, the urethra and the vagina. The fatty labia majora (the large outer moisten and swell with extracellular fluid during sexual arousal. Furthermore, during urination, the labia minora function to direct the urine stream away from the pudendum femininum. The size, the shape and the skin colouration of the labia minora vary according to the woman, thus, like most paired structures of the human body, the labia are not anatomically symmetrical-one “labium minus”

Labial Hypertrophy (minor lip) is usually greater (longer, wider, thicker) than its pair-yet the ♦ asymmetry is usually not notable. Moreover, the length and the width of the labia minora determine if they protrude from or are hidden by, the labia majora. Further increases in the sizes of the labia (majora and minora) Section 6 occur when the woman is sexually aroused-in preparation for coitus- wherein the labia become engorged with blood and increase the labial diameters 2–3 times. FIGURE 1: Normal labia and vulvar anatomy Labial hypertrophy usually affects the inner labia called the “labia minora”, but it can also affect the outer labia or "labia majora". The labia can be enlarged on one side or both sides. Most young women who have this condition, have bigger than average size labia. Some young women childbirth causes the development of labial hypertrophy by means of the may have been born with bigger labia, while others may have noticed formation of a haematoma during the parturition. Moreover, the cultural that their labia got much bigger during puberty (Fig. 1). practise of genital piercing can cause labial hypertrophy and asymmetry, because of the heavy weight of the metal ornaments inserted to the labium Aetiology or to the labia. Furthermore, the studies indicated the occurrence of labia The causes of labial hypertrophy, the over-development of the labia minora of the same size in identical-twin women treated for labial minora, are aetiologically varied and can derive from factors, such as the hypertrophy, which indicated a possible genetic determination of the size woman, having been born with over-sized labia (genetic inheritance) or of the labia minora. having been caused by the mechanical stresses (stretching, pulling and tearing) characteristic to coitus (sexual intercourse), masturbation, Diagnosis childbirth, urinary incontinence, lymphatic congestion (stasis), chronic There are no standard diagnostic criteria for the diagnosis of labia minora dermatitis, granulomatous disease, myelodysplastic disease and by the hypertrophy. Clinicians generally use labial width measurements or the application of topical and systematic hormones. In some women, vaginal presence of symptoms to determine treatment options. 166 Chapter 17 Labial width—labia minora hypertrophy is generally described as protuberant labial tissue that project beyond the labia majora. However, there is no consensus among gynaecologists, paediatricians or plastic surgeons regarding the use of objective clinical measurements to confirm ♦ Labial Hypertrophy the diagnosis. In an early description of this condition, Friedrich classified labia minora as hypertrophic when the maximal width between the midline and the lateral free edge of the labia minora (when the labia were extended laterally by the examiner) measured greater than 5 cm. Others have proposed that the normal width of the labia minora should be less than 3– 4 cm.

The dimensions of over-sized labia minora are established by: FIGURE 2: Enlarged labia minora  Horizontally measuring the size of each labium minus, from the midline Symptoms of Labial Hypertrophy  Vertically measuring the size of each labium minus between the base and the free-edge of the labium Enlarged labia minora can cause symptoms, such as pain or discomfort  Applying a 3–5 cm range of measure as "hypertrophy" of the labia with activities, such as exercise, sexual intercourse or even just with minora wearing tighter fitting clothes, such as jeans. Many women have discomfort with this condition because the enlarged labia rub against tight The degree of labial hypertrophy is characterised as: fitting clothes, get pulled in or out during intercourse or get irritated when  No hypertrophy: the labia minora are concealed within or extend doing activities such as riding a bicycle. to, the free edge of the labia majora Sometimes the enlarged labia can actually have an abnormal  Mild-to-moderate hypertrophy: the labia minora extend appearance and protrude out in tighter fitting clothes or bathing suits. approximately 1–3 cm beyond the free edge of the labia majora This can be very bothersome and distressful to the woman and can affect  Severe hypertrophy: the labia minora extend an approximate her self-esteem. This may be especially true in younger women who are distance greater than 3.0 cm beyond the free edge of the labia majora born with larger labia and become very self-conscious because of their (Fig. 2). appearance through their high school or college years. This can cause

167 insecurity or embarrassment with sexual partners as well. Many women Women with exceptionally long or unequal lengths of the labia minora prefer that the inner lips do not protrude past the labia majora at all, giving can have them aesthetically reshaped. If one feel that their inner labial them a much more appealing shape and eliminating many of the lips may be excessively long and therefore cause discomfort (such as symptoms of enlarged labia. chafing) or are unsightly, then labial reduction could be a surgical The woman with over-sized labia minora often presents with labial procedure for her. Young women who have enlarged labia do not need to

Labial Hypertrophy asymmetry that causes her awkward vulvo-vaginal hygiene (e.g. toilet- have surgery. If however, one or both labia cause discomfort or emotional ♦ paper bits attaching to the labia); the catching of the labia in garment- distress, surgery may be recommended. Labioplasty involves reshaping zipper closures; pubic discomfort when wearing tight clothes; pubic-area one or both labia so they are smaller in size. This type of surgery should pain when practising sport (bicycling, running, etc.); either a disrupted be done by a gynaecologic surgeon who has expertise with this type of Section 6 or a diffused urinary stream; and dyspareunia (painful sexual intercourse). procedure. Having a labioplasty is an emotional decision for most young Generally, the woman's most common complaint of self perception is women. that, when observed in the standing position, her labia minora protrude too much beyond the labia majora, this physical condition often leads to Indications of Labial Reduction Surgery low self esteem, and subsequent difficulty in achieving emotional and Over-Sized Labia sexual intimacy in her private life. The woman afflicted with “labial hypertrophy” presents labia minora that Labial Reduction Surgery are disproportionately over-sized in relation to the size of the labia majora, Labial reduction surgery is also called labial contouring or reshaping, which to her have an aesthetically displeasing appearance and cause her cosmetic labiaplasty or labioplasty, labia minora reduction. problematic hygiene, commonly reported as a diffused or a disrupted Labiaplasty is a plastic surgery procedure for altering the labia minora urinary stream; chronic irritation of the pudendal skin; painful sexual and the labia majora, the paired tissue structures bounding the vestibule intercourse and pubic pain when wearing tight clothes. Anatomically, of the vulva. like all the paired structures of the human body, it is uncommon for the Every woman is constructed slightly differently. It is not uncommon labia minora to be perfectly symmetrical. Usually, the size discrepancy is for a woman to feel dissatisfied with her labia minora (inner lips of the slight, yet some women present one labium minus (minor lip) considerably vagina), especially if they are particularly long. In many cases women are larger (longer, wider, thicker) than its pair; some women also present just not happy with parts of their genitalia. This can be embarrassing, redundant folding (either unilateral or bilateral webbing) between the uncomfortable and can even lead to sexual dissatisfaction or difficulty. labia majora and the labia minora that can be surgically resolved.

168 Chapter 17 Therapy the labiaplasty usually is performed months after the first-stage of the

Medical: Labial hypertrophy, the over-development of the vaginal lips, is vaginoplasty. As required by the (transgender) woman's indications, after not managed medically. a one-stage vaginoplasty, the labiaplasty, which creates the labia majora and the labia minora can be an elective surgery procedure for refining the ♦ Surgical: The woman's specific clinical indications determine the Labial Hypertrophy aesthetics of the woman's vulvo-vaginal complex. appropriate labiaplasty technique. The correction of hypertrophied labia minora can be performed upon a patient either as a discrete labiaplasty Surgical Procedures (single surgery procedure) or in conjunction with a gynaecologic surgery Preoperative Matters procedure or in conjunction with a cosmetic surgery procedure ().  Rarely, hypertrophy of one or both labia majora may cause unilateral or bilateral prominence of the labial structure. Herniation of an ovary Contraindications into the labium should be easily ruled out by physical examination. Absolute: There are no absolute contraindications to labioplastic surgery, Vascular or lymphatic malformations must be ruled out in bilateral either for altering or for reducing the labia minora or the labia majora. lesions, but many unilateral cases are idiopathic Resection of the

Relative: Labial reduction surgery is relatively contraindicated for the hypertrophic tissue may be indicated when the lesion appears to be idiopathic. woman who has an active gynaecological disease (i.e. an infection or a  neoplastic malignancy); for the woman who is a tobacco smoker unwilling Therapeutically, because there is neither formal medical definition to quit (either temporarily or permanently) in order to optimise the of "labial hypertrophy", nor a standardised method for grading the degree of hypertrophy present in the labia minora of the woman capability of her body to heal a surgical-incision wound; and for the woman who holds unrealistic aesthetic goals (ideal self-image and body (patient), the surgeon gives especial consideration to the anatomic image) and expectations for the outcome. Such a woman (patient) should particulars of the vulvo-vaginal complex of the woman. Likewise, the surgeon must give especial consideration to the wide variance either be psychologically counselled or excluded from labioplastic surgery. among women's perceptions of the ideal genital body image-what Sexual Reassignment the woman (patient) considers and does not consider to be an aesthetically normal and proportionate vulva. In sexual reassignment surgery, in the case of the male-to-female transgender patient, labiaplasty usually is the second stage of a two-stage Consultation: To understand the aesthetic goals of the patient, the plastic vaginoplasty operation, wherein labiaplastic techniques are applied to surgeon evaluates the labial hypertrophy that the woman presents when create labia minora and a clitoral hood. In a male-to-female procedure, standing. Afterwards, in the operating room, with the patient in the 169 lithotomy position (as if for a urinary-bladder stone-removal surgery), proper is facilitated with the administration of an anaesthetic solution the surgeon then delineates the resection-pattern markings (incision plan) (lidocaine and epinephrine in saline solution) that is infiltrated to the labia to each side of each labium (lip) to facilitate the de-epithelialisation minora in order to achieve the tumescence (swelling) of the tissues and required for reducing its size (length and width). Afterwards an anaesthetic the constriction of the pertinent labial circulatory system, the haemostasis solution is infiltrated to the labial tissues to numb and swell them for easy that limits bleeding.

Labial Hypertrophy resection of the excess tissues. ♦ As required by the patient's health, the physician-surgeon might Techniques for Labial Reduction instruct the woman to take oral antibiotic and anti-inflammatory Edge Resection Technique medications before the operation; if not, they are intravenously Section 6 The original labiaplasty technique was simple resection of the excess administered to the patient at the start of the labiaplasty operation. tissues at the free edge of the labia minora. One resection-technique Operative Techniques variation features a clamp placed across the area of labial tissue to be resected, in order to establish haemostatis (stopped blood-flow) and the General surgeon resects the excess tissues and then sutures the cut labium minus As with every paired structure of the human body, the labia minora are or labia minora. The technical disadvantages of the labial-edge resection not perfectly symmetrical, and, although the size discrepancy usually is technique are the loss of the natural rugosity (wrinkles) of the labia minora subtle, women often present one labium minus (minor lip) considerably free edges, thus, aesthetically, it produces an unnaturally “perfect greater (longer, wider and thicker) than its pair; thus, only the over-sized appearance” to the vulva, and also presents a greater risk of damaging lip undergoes tissue resection (cutting and removal). In the woman who the pertinent nerve endings. Moreover, there also exists the possibility of presents greatly over-sized labia minora, wherein one labium is everting (turning outwards) the inner lining of the labia, which then makes considerably larger than its pair, only the over-sized lip is resected for visible the normally hidden internal, pink labial tissues. symmetry with the smaller lip. In the case of the woman who also presents The advantages of edge-resection include the precise control of all of redundant folding—unilateral webbing or bilateral webbing—between the hyper-pigmented (darkened) irregular labial edges (which the woman the labia majora and the labia minora, said condition of excess tissues can reported as either functionally or aesthetically undesirable) with a linear also be resolved by means of labioplasty. scar that can also be used to contour the redundant tissues of the clitoral In corrective praxis, the labial reduction can be performed upon a hood, when present. patient under local anaesthesia, conscious sedation or general anaesthesia, For the optimal exposure of the vulvo-vaginal complex, the patient is either as a discrete, single surgery or in conjunction with a gynaecologic positioned upon the operating table in the lithotomy position. After surgery procedure, or with a cosmetic surgery procedure. The resection confirming regional anaesthesia and labial tumescence, the surgeon then 170 Chapter 17 cuts and removes (resects) the excess tissues of the labia minora. After the De-Epithelialisation Technique resection step, the suturing of the surgical wound is the procedural step Labial reduction by means of the de-epithelialisation of the tissues involves that influences the most aesthetic outcome of the labial reduction-suturing cutting the epithelium of a central area on the medial and lateral aspects the tissues of the labia minora with a running absorbable-suture ♦ of each labium minor (small lip), either with a scalpel or with a medical Labial Hypertrophy occasionally produces a scallop-edged surgical scar-line, whereas suturing laser. This labiaplasty technique reduces the vertical excess tissue, whilst the tissues with a running buried-suture usually produces a wound closure preserving the natural rugosity (corrugated free-edge) of the labia minora, (scar-line) of natural appearance. and thus preserves the sensory and erectile characteristics of the labia. Central Wedge Resection Technique Yet, the technical disadvantage of de-epithelialisation is that the width of the individual labium might increase if a large area of labial tissue must Labial reduction by means of a central wedge-resection involves cutting be de-epithelialised to achieve the labial reduction. and removing a full-thickness wedge of tissue from the thickest portion of the labium minus. Unlike the edge-resection technique, the resection Labiaplasty with Clitoral Unhooding pattern of the central wedge technique preserves the natural rugosity A labial reduction procedure occasionally includes the resection (cutting (wrinkled free-edge) of the labia minora. Yet, because it is a full-thickness and removing) of the clitoral prepuce (clitoral hood) when the thickness resection, there exists the potential risk of damaging the pertinent labial of its skin interferes with the woman's sexual response. The surgical nerves, which can result in painful neuromas and numbness. unhooding of the clitoris involves a V-to-Y advancement of the soft tissues, F Giraldo et al. procedurally refined the central wedge resection which is achieved by suturing the clitoral hood to the pubic bone in the technique with an additional 90-degree Z-plasty technique, which midline (to avoid the pudendal nerves); thus, uncovering the clitoris produces a refined surgical scar that is less tethered and diminishes the further tightens the labia minora. physical tensions exerted upon the surgical-incision wound, and, therefore, Laser Labiaplasty Technique reduces the likelihood of a notched (scalloped-edge) scar. The central wedge-resection technique is a demanding surgical procedure and the Labial reduction by means of laser-ray resection of the hypertrophied labia difficulty can arise with judging the correct amount of labial skin to resect, minora involves the de-epithelialisation of the labia. The technical which might result in either the under-correction (persistent tissue- disadvantage of laser labiaplasty is that the removal of excess labial redundancy), or the over-correction (excessive tension to the surgical epidermis risks causing the occurrence of epidermal inclusion cysts. wound) and an increased probability of surgical-wound separation. Labial reduction by de-epithelialisation cuts and removes the excess Moreover, as appropriate, a separate incision is required to treat a tissues and preserves the natural rugosity (wrinkled free-edge) of the labia prominent clitoral hood. minora, and so preserves the capabilities for tumescence and sensation.

171 Yet, when the patient presents much excess labial tissue, a combination accumulation of blood outside the pertinent (venous and arterial) vascular procedure of de-epithelialisation and clamp-resection usually is more system. In accordance with her wound-healing progress, the woman can effective for achieving the aesthetic outcome established by the patient resume physically un-strenuous and undemanding work at 3–4 days and her plastic surgeon. postoperative. Moreover, to allow the full and proper healing of the In the case of a woman with labial webbing (redundant folding) labiaplasty surgical wounds, the woman is instructed to not use tampons,

Labial Hypertrophy between the labia minora and the labia majora, the de-epithelialisation to not wear tight clothes (e.g. thong underwear), and should not do any ♦ labiaplasty includes an additional resection technique, such as the five- activity that causes pressure or irritation on the labia, such as biking, horse flap Z-plasty (“jumping man plasty”), to establish a regular and symmetric riding, running or heavy lifting and to abstain from sexual intercourse shape for the reduced labia minora. for 4 weeks postoperative. Section 6

Postoperative Matters Risks and Complications In Labial Reduction Surgery Convalescence As with any surgery, there are potential risks for complications with cosmetic labiaplasty. The most common risks are the same risks seen in Postoperative pain and surgical-wound care are minimal, which most surgery and include bleeding, infection and scarring. Patients are conditions permit the woman to leave hospital and return home the same day she underwent the labial reduction procedure; usually, no vaginal given antibiotics prior to the labiaplasty surgery, which results in a very packing is required, although she might choose to wear a sanitary pad for low risk of infection. In most cases of labial reduction surgery, if an comfort. The physician informs the woman that the reduced labia often infection occurs postoperatively, it is minimal in nature and taken care of are very swollen during the early postoperative period, because of the with a short course of oral antibiotics. oedema caused by anaesthetic solution injected to swell the tissues. She Bleeding is also a rare risk in labiaplasty; however, it can occur with also is instructed on the proper cleansing of the surgical-wound site and any surgery or could occur postoperatively if strenuous activity or the application of a topical antibiotic ointment to the reduced labia; a intercourse is begun too early. Problems with healing, such as incision wound-care regimen observed 3 times daily for 2 days postoperative. separation, poor wound healing, under or over correction, labial asymmetry, scarring and/or pain following the surgery, are also rare risks. Follow-Up Therapy However, they can occur as with any vaginal surgery and may require The woman's initial, postlabiaplasty consultation with the surgeon is further surgery or revision. The risk of any of these problems is less than recommended at 1-week postoperative. She is advised to return to the 1% and is also decreased when experienced and competent surgeons are surgeon's consultation room should she develop haematoma, an performing the procedures of labial reduction.

172 Chapter 17 It's normal to have some swelling, bruising and discomfort after the Success of Labial Reduction Surgery procedure but this should last only a couple of days to 2 weeks. Icepacks  The labia are re-shaped, not cut off. The results are almost always are applied to the groin area for the first 24 hours to help with any swelling.

satisfying to the patient. Once the labia are healed, no one will be ♦ The discomfort should improve as the swelling goes away. able to tell they were modified or reshaped because the scar is very Labial Hypertrophy Since the top of the labia is connected to the clitoris, be sure to ask if fine and hidden in the natural folds of the skin. the clitoral hood (skin covering the clitoris) will be affected. Sometimes  Most women have a resolution of the symptoms that they may have there can be scar tissue that may make future sexual activity painful. been suffering from, such as discomfort in tighter fitting clothes and/ Additionally, it's possible that the results may not be what patient has or pain with intercourse, and are also very pleased with and feel expected. more positive about their appearance after labial reduction surgery. An over-aggressive resection might damage the nerves, which  The surgery will restore a more normal appearance to the genitalia. condition subsequently causes painful neuromas. Furthermore, In most cases the surgical scar is virtually undetectable after complete performing a flap-technique labiaplasty occasionally presents a greater healing and patients are extremely pleased with the final results. risk for necrosis of the labia minora tissues.

173 Excision of a Hypertrophied 18 Labial Hypertrophy

FIGURE 1: A close up of the external genitalia revealing enlarged labia minora on the right FIGURE 2: The labia minora retracted laterally to reveal the introitus and the normal looking side genitalia of the opposite side Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 3: Note the distortion of the labia minora starting from its prepusal covering FIGURE 4: Rest of the genitalia are normal in appearance with a normally placed hymen downwards to assume a polypoidal appearance. But this is not a polypoidal growth considering and the external urinary meatus, revealed on retracting the normal labia of the opposite side its broad base, extending to the whole length of the labia minora

175 Labial Hypertrophy ♦ Section 6

FIGURE 5: Infiltration of the tumescent fluid starting from the lower end of the labia minora FIGURE 6: The tumescent fluid is massaged gently into the deeper tissue as the labia inflate with the fluid contained

176 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 7: Note the progressive increase in the swelling as more and more tumescent fluid FIGURE 8: This is necessary to minimise intraoperative bleeding is injected into the subcutaneous tissue

177 Labial Hypertrophy ♦ Section 6

FIGURE 9: Labia minora are very richly supplied by blood vessels and therefore more FIGURE 10: Note the blanching of the overlying skin due to the tumescent fluid intraoperative haemorrhage

178 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 11: An incision is given along the muco-cutaneous junction on the inner aspect of FIGURE 12: This incision extends to the lower end of the labia minora the labia

179 Labial Hypertrophy ♦ Section 6

FIGURE 13: The incision is further deepened FIGURE 14: The incision is then sliced through the entire depth of the labia minora till it just hangs loose by its lateral cutaneous attachment

180 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 15: Slicing the enlarged mass of the labia minora FIGURE 16: Slicing the enlarged mass of the labia minora

181 Labial Hypertrophy ♦ Section 6

FIGURE 17: The labium is then drawn to the opposite side to reveal the outer side of the FIGURE 18: A similar incision is given joining the upper and lower ends of the previous growth incision over the muco-cutaneous junction medially

182 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 19: This delineates the hypertrophied tissue to be removed FIGURE 20: Note that the incision over the skin is applied short of the base. This helps to shape the labia minora after it is incurled to be stitched to the vaginal mucosa

183 Labial Hypertrophy ♦ Section 6

FIGURE 21: The whole mass of tissue of the hypertrophied labia minora is then separated FIGURE 22: The outer incision is being similarly deepened from its base by sharp dissection

184 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 23: Slicing of the tissues from the outer aspect of the labia minora FIGURE 24: The incision is deepened to meet the incision applied from the medial aspect of the growth

185 Labial Hypertrophy ♦ Section 6

FIGURE 25: The mass of tissue is then separated from below upwards FIGURE 26: Till the whole segment of the hypertrophied labia has been removed

186 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 27: The small tag of skin at the upper end of the labia being incised to complete the FIGURE 28: The final separation of the hypertrophied mass excision of the hypertrophied labia

187 Labial Hypertrophy ♦ Section 6

FIGURE 29: The picture after the final separation of the hypertrophied mass FIGURE 30: The bleeders are identified and secured between haemostatic clamps

188 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 31: A suture is applied at both the ends of the wound and held long to act as FIGURE 32: A similar stitch is applied at the lower end of the incision line traction and also to orient the subsequent stitches. In this picture the upper end of the incision is being stitched

189 Labial Hypertrophy ♦ Section 6

FIGURE 33: Interrupted sutures are then applied, approximating the vaginal mucosa to the FIGURE 34: Care should be taken while approximating the edges of the mucosa and the overlying skin skin that the deeper tissues that have not been stitched in the initial layers are also included so as to completely obliterate the dead space

190 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 35: This prevents postoperative haematoma formation in the stitch line FIGURE 36: The small bleeders included in the artery forceps can be tackled by the pressure of the artery forceps for a few minutes while the prominent bleeders should be independently ligated

191 Labial Hypertrophy ♦ Section 6

FIGURE 37: Where necessary additional sutures are applied to approximate the underlying FIGURE 38: Where necessary additional sutures are applied to approximate the underlying tissue before the surface stitches are applied tissue before the surface stitches are applied

192 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 39: To give the labia a proper shape, stay sutures are applied at three or four FIGURE 40: This ensures a uniform and anatomical reformation of the labia minora, which places to approximate the vaginal mucosa and the overlying skin is subsequently aesthetically acceptable

193 Labial Hypertrophy ♦ Section 6

FIGURE 41: Stay sutures are being applied FIGURE 42: Stay sutures are being applied

194 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 43: As further stitches are applied, the labia minora starts taking shape FIGURE 44: These stay sutures ensure correct placement of the intermediate sutures

195 Labial Hypertrophy ♦ Section 6

FIGURE 45: Once the stay sutures have been placed then the gaps between the stay sutures FIGURE 46: Note the inclusion of the underlying tissue in the superficial stitch are closed using simple interrupted sutures

196 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 47: Interrupted skin to mucosal stitches in progress FIGURE 48: Interrupted skin to mucosal stitches in progress

197 Labial Hypertrophy ♦ Section 6

FIGURE 49: Interrupted skin to mucosal stitches in progress FIGURE 50: Interrupted skin to mucosal stitches in progress

198 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 51: Interrupted skin to mucosal stitches in progress FIGURE 52: Interrupted skin to mucosal stitches in progress

199 Labial Hypertrophy ♦ Section 6

FIGURE 53: Interrupted skin to mucosal stitches in progress FIGURE 54: Oedema/Swelling to the right of the clitoris is due to the injected tumescent fluid and settles down in the first few days providing a normal look to the tissues

200 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 55: Intermediate gaps in between the stay sutures are being filled by additional FIGURE 56: Intermediate gaps in between the stay sutures are being filled by additional simple interrupted sutures simple interrupted sutures

201 Labial Hypertrophy ♦ Section 6

FIGURE 57: Intermediate gaps in between the stay sutures are being filled by additional FIGURE 58: Intermediate gaps in between the stay sutures are being filled by additional simple interrupted sutures simple interrupted sutures

202 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 59: The stay sutures being trimmed as the intermediate stitches have been applied FIGURE 60: The interrupted sutures should be placed at a distance of 7.5–10 mm

203 Labial Hypertrophy ♦ Section 6

FIGURE 61: The interrupted sutures should be placed at a distance of 7.5–10 mm FIGURE 62: A normal looking introitus taking shape with the application of the superficial stitches

204 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 63: Where superficial oozing is encountered, additional stitches may be required FIGURE 64: Where superficial oozing is encountered, additional stitches may be required

205 Labial Hypertrophy ♦ Section 6

FIGURE 65: The long ends of the stay sutures are being trimmed FIGURE 66: The stitches appear to be digging into the skin as a result of the stitches being tied too firmly. It should be remembered that a lot of tumescent fluid has been infiltrated into the subcutaneous fascia hence the development of tissue oedema and this particular look

206 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 67: In the postoperative period the fluid is rapidly absorbed and the stitch oedema FIGURE 68: Application of interrupted sutures settles down to give the tissues a normal appearance

207 Labial Hypertrophy ♦ Section 6

FIGURE 69: Application of interrupted sutures FIGURE 70: A pull on the stay sutures in opposite directions enables better visualisation of the incision margins

208 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 71: Once the entire dead space has been obliterated, then all that is required is an FIGURE 72: Once the entire dead space has been obliterated, then all that is required is an accurate approximation of the incision edges accurate approximation of the incision edges

209 Labial Hypertrophy ♦ Section 6

FIGURE 73: Superficial stitch is being tightened FIGURE 74: A pull on the stay sutures in opposite directions enables better visualisation of the incision margins making placement of subsequent stitches easier

210 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 75: Nearing completion of surgery FIGURE 76: Nearing completion of surgery

211 Labial Hypertrophy ♦ Section 6

FIGURE 77: The two stay sutures pulled in opposite directions pus the intermediate tissue FIGURE 78: The stay sutures are trimmed at a stretch for better recognition of the margins

212 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 79: The completed surgery FIGURE 80: The completed surgery

213 Labial Hypertrophy ♦ Section 6

FIGURE 81: The completed surgery FIGURE 82: Postoperatively a Foley’s catheter is indwelled to prevent soiling of the stitch line with urine. This ensures better healing

214 Chapter 18 ♦ Excision of a Hypertrophied Labial Hypertrophy

FIGURE 83: The postoperative specimen FIGURE 84: The postoperative specimen

215 Index Page numbers followed by f refer to figure

A Chlamydia trachomatis 4, 9 Dissection of Fine suture material 128f Chromic suture 29f cyst 100f Flat vulva 71 Advance tissue dissection 98f Closure of deeper tissues over index 106f Foley’s catheter 214f Allis cavity bed 33f fascia 102f Four Allis forceps 56f forceps 15f, 87 osteal margins 60f remaining part of cyst 111f-114f tissue holding forceps 51f Commencement of wound closure 115f, Division of Anterior vaginal wall 50f G 116f loose tags of fascia at upper end 110f Application of Gartner duct cyst 72 Complete small tags of connective tissue at upper antibiotic creams 77f Genital anatomy 123f division of cyst 27f part of cyst wall 23f interrupted sutures 207f, 208f Gland orifice 14f excision of hypertrophied labia 187f superficial stitches 204f Greater vestibular 3 separation of cyst 23f, 28f terminal skin sutures 41f, 137f, 139f, 140f E Contact with irritants 70 Atopic dermatitis 70 Correct placement of intermediate sutures Edge resection technique 170 H Bartholin 195f Elliptical incision 14f Haematoma formation 140f cyst 12f Correction of hypertrophied labia minora Enlarged labia minora 167f Haemostatic clamps 95f, 96f, 188f cystectomy 5 169 Enucleation of Bartholin cyst 36f Hymenal skin tags 72 gland 3, 11 Cyst Escherichia coli 4 Hypertrophied duct 3, 8 dissection 6 Excision of labia minora 184f excision 4 incision 11 hypertrophied labial hypertrophy 174 mass 188f marsupialisation 49 incision margins 57f B Cystic swelling yielding pus 51f labial polyp 156f I Bartholinectomy 5, 12 polyp 160f External Identification of fibro-connective tissue 26f Blunt D Imperforate hymen 72 and sharp dissection 104f genitalia 74, 76f, 174f Deeper stitches 122f Indications of labial reduction surgery 168 dissection 15f, 16f urinary meatus 76f De-epithelialisation technique 171 Infiltration of tumescent fluid 148f-150f f separation of labial tissue 157 Inner Degree of labial hypertrophy 167 F Delayed absorbable stitches 138f surface of labia minora 82f C Dissection of deeper tissues over index and Female phimosis 69 vaginal lips 165 Central wedge resection technique 171 middle fingers insinuated behind Fibrous tissue formation 70f Intraoperative Childhood sexual abuse 70 cyst 107f Final separation of hypertrophied mass 187f bleeding 177f blood loss 24f, 97f Middle fingers insinuated behind cyst 106f Separation of cyst 18f Ureterocoele 72 haemorrhage 178f Mucinous cysts 81 wall 103f, 014f Urethral Introital cysts 72 Multiple Allis forceps 100f Sexual reassignment 169 polyp 72 Sharp dissection of cyst 16f prolapse 72 L N Similar dissection 19f Urinalysis 71 Simple interrupted sutures 162f, 196f, 202f Neisseria gonorrhoeae 4, 9 Labia minora 136f, 178f Skin Normal V Labial incision 6, 10 genital hygiene 76 Vaginal adhesion 69 mucosal sutures 43f labia 166f aspect of labium 19f cystectomy 79 suturing 39f Slicing atresia 72 fusion 69, 74 P enlarged mass of labia minora 181f epithelium 58f hypertrophy 165 Pair of Allis forceps 87f of tissues from outer aspect of labia introitus 74f lacerations 70 Poor perineal hygiene 70 minora 185f mucosa 84f, 85f, 91f, 92f, 193f f polyp 151 Postoperative Sterile gauze dressing 63f orifice 12f polypectomy 146 haematoma formation 45 Straddle injury 70 rhabdomyosarcoma 72

A Colour Atlas of Surgeries of the Vulva of Surgeries A Colour Atlas reduction surgery 168, 172 matters 172 Success of labial reduction surgery 173 skin edges 39 width 167 Pressure of stitch line 127f Superficial stitch 138f, 196f Venous plexus of vestibular bulb 21f, 22f Labiaplasty Pressure on cyst 53f Surgical anatomy of vulva 165 Vessel ligation 6 technique 169 Symptoms of labial hypertrophy 167 Voiding cystourethrogram 71 with clitoral unhooding 171 R Vulval cyst 81, 82, 116 T Labioplastic surgery 169f Repeated ductal obstruction and abscess Vulvovaginitis of childhood 76f Laser labiaplasty technique 171 formation 45 Techniques for labial reduction 170 Vulvovaginal complex 165 Local granuloma formation 134f Rest of genitalia 175f Transfixation suture 161f Lower end of labia minora 176f, 179f Restoration of genital anatomy 123f Tumescent fluid 178f W Types of trauma 70 Retention cyst 50f Washing of external genitalia 77f M Word catheter placement 9 S U Wound Marsupialisation 4, 10, 50 Seborrhoea 70 Undermining vaginal flap 91f cellulitis 45 Masturbation 70 Second Allis forceps 52f Upper part of cyst wall 102f closure 7, 11

218