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Malignant Disease:
Special Procedures

Staging of Gynecologic
Oncology Patients With
Exploratory Laparotomy

Subclavian Port-A-Cath 

Peritoneal Port-A-Cath

Application of Vaginal
Cylinders for Intracavitary
Radiation Therapy

Application of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy  

Pelvic High-Dose Afterloader

Abdominal Injection of Chromic Phosphate

Supracolic Total Omentectomy

Omental Pedicle "J" Flap

Tube Gastrostomy

Total Vaginectomy

Radical Vulvectomy
With Bilateral Inguinal
Lymph Node Dissection

Reconstruction of the
Vulva With Gracilis Myocutaneous Flaps

Transverse Rectus
Abdominis Myocutaneous
Flap and Vertical Rectus
Abdominis Myocutaneous

Radical Wertheim
Hysterectomy With
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina

Anterior Exenteration

Posterior Exenteration

Total Pelvic Exenteration

Colonic "J" Pouch Rectal

Kock Pouch Continent Urostomy

Omental "J" Flap Neovagina

Ileocolic Continent Urostomy (Miami Pouch)

Construction of Neoanus
Gracilis Dynamic Anal

Skin-Stretching System Versus Skin Grafting

Gastric Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina

Control of Hemorrhage in Gynecologic Surgery

Repair of the Punctured
Vena Cava

Ligation of a Lacerated
Internal Iliac Vein and
Suturing of a Lacerated Common Iliac Artery

Hemorrhage Control in
Sacrospinous Ligament
Suspension of the Vagina

Presacral Space
Hemorrhage Control

What Not to Do in Case of Pelvic Hemorrhage

Packing for Hemorrhage

Control of Hemorrhage
Associated With Abdominal Pregnancy

Total Vaginectomy

Total vaginectomy is indicated for malignant disease of the vagina. It is frequently required in combination with total abdominal hysterectomy or radical Wertheim hysterectomy. It is the only alternative after total pelvic irradiation for recurrent microinvasive carcinoma of the vagina. The planes of dissection after irradiation are difficult, and there is a high risk of vesicovaginal and rectovaginal fistula. Preoperatively, the surgeon should advise the patient with regard to replacement of the vagina with a skin graft, and a preoperative plan should be made as the patient's sexual status indicates. Although the vagina is occasionally removed abdominally, the procedure is best initiated from the vaginal route. Frequently, an abdominoperitoneal approach is used because the operation is combined with either a radical hysterectomy or simple hysterectomy.

The purpose of the operation is to remove the vagina.

Physiologic Changes. If only the vagina is removed and no opening is made into the bladder or rectum, there is little physiologic change.

Points of Caution. The major complication of this operation, particularly after pelvic irradiation, is inadvertent vesicovaginal or rectovaginal fistula formation. Therefore, the dissection should be carried out in the most meticulous manner possible. If the surgeon can dissect within a plane outside the pubovesical cervical fascia, fistula formation will be reduced.

Meticulous hemostasis should be performed prior to introducing the split-thickness skin graft.


The patient is placed in the dorsal lithotomy position with her buttocks off the end of the table by approximately 8 cm. Adequate vaginal and pelvic examinations are performed, and appropriate biopsies are taken. The bladder is emptied by catheter drainage.

An incision is made around the circumference of the vaginal vault down to the pubocervical fascia underneath the urethra and the perirectal fascia overlying the rectum.

Since blood supply to the vagina comes predominantly from the lateral side, dissection is begun there first. The vaginal epithelium is deviated to the midline, and Metzenbaum scissors are used to dissect the vaginal mucosa from its lateral wall.

Care is taken to identify the vaginal branches of the pudendal artery, which should be securely clamped and tied.

Dissection underneath the urethra and bladder is generally bloodless as long as it is confined to the plane between the vaginal mucosa and the pubovesical cervical fascia. If the pubovesical cervical fascia becomes involved, the small vessels in the bladder wall make hemostasis difficult.

The dissection posteriorly should be performed in the plane above the perirectal fascia, or copious bleeding can occur from the hemorrhoidal plexus of vessels.

When the dissection has reached the cul-de-sac posteriorly and the vesicouterine peritoneal area anteriorly, the vagina can be removed by itself, but it is generally removed in conjunction with total abdominal hysterectomy. The vaginal canal must then be managed according to the sexual needs of the patient.

If the patient is sexually active, a skin graft can be placed after meticulous hemostasis has been achieved (see Vagina and Urethra on McIndoe Vaginoplasty), or the vaginal canal can be closed by suturing the pubovesical cervical fascia to the rectal fascia posteriorly (see Vagina and Urethra on the Le Fort operation). If a McIndoe vaginoplasty is to be performed, suction catheters should be left in the pelvic area and brought out through left and right lower quadrant stab wounds; or if closure of the vaginal space is indicated as in the Le Fort operation, they can be brought out through the lateral vaginal vault. A suprapubic Foley catheter is left in the bladder until voiding is established. B, bladder.

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