The patient undergoing radical vulvectomy should be positioned on the operating table in the modified dorsal lithotomy position with the legs extended, giving adequate exposure to the lower abdomen and perineum. The hips should be abducted 30° and extended 5-10° with the knees flexed 90°.

The abdomen and perineum are surgically prepped. A Foley catheter is inserted in the bladder.

Although a variety of incisions can be used for this operation, one shaped roughly like the head of a rabbit is preferred. The proposed incision is marked with brilliant green solution, starting from the anterior superior iliac spine, sloping downward toward the mons pubis, lateral to the inguinal ligament, to a point adjacent to the pubic tubercle. At this point, it proceeds lateral to the labia majora and horizontal with a "W" incision across the perineal body, joining the incision lateral to the labia majora on the opposite side. A second incision, superior and medial to the first, slopes down toward the mons pubis and meets a similar incision from the outside.

This procedure is best carried out with two surgeons, each with an assistant, operating on both sides.

The upper portion of the entire incision is made at one time. The incision is carried from the anterior superior iliac spine down across the mons pubis, up to the opposite anterior superior iliac spine, down lateral to the inguinal ligament to the pubic tubercle. The incision is carried through the skin down to the fascia. Metzenbaum scissors are used to dissect along the fascial surface, removing en bloc the skin and its subcutaneous lymph nodes.

The inguinal ligament and rectus fascia have been cleaned of all nodal tissue. A retractor is used to deflect the skin overlying the sartorius muscle. The right and left fossae ovalis are identified. If identification of the fossae of ovalis proves difficult, the fascia covering the sartorius muscle should be reflected medially to ensure total removal of the lymph nodes without lacerating vascular structures within the fossae ovalis.

Structures within the femoral canal generally follow the code word "navel", i.e., the most lateral structure is the femoral nerve followed in order by the femoral artery, vein, an empty space, and a lymphatic space. The femoral artery should be identified, and dissection should be carried along the artery until all lymphatic tissue is removed down to the adductor canal. The femoral nerve should be preserved, although occasionally a few of its terminal cutaneous branches must be sacrificed. The femoral vein should be identified along with the saphenous vein. This can be facilitated by noting the anatomic relationship between the circumflex artery, generally 1-2 cm above the junction of the femoral artery, and the saphenous veins.

At this time, the Cloquet node is located, removed, and sent for pathologic analysis. The lymphatic dissection continues along the saphenous vein until it can be sufficiently freed for clamping and ligation.

The saphenous vein is doubly clamped, incised, and tied with a 2-0 suture.

The adductor longus muscle can now be identified and should be cleaned of all fatty nodal tissue by retracting the saphenous vein en bloc with the lymph nodes until the adductor canal is reached.

The sartorius muscle is identified, mobilized and transected at its insertion with the electrocautery.

The sartorius muscle is transplanted over the femoral artery and vein.

The sartorius muscle is sutured to the inguinal ligament with interrupted 2-0 suture. To reduce the possibility of hernia, a few 2-0 sutures are placed on the medial border of the sartorius muscle, suturing it to the adductor longus muscle.

The lymph node dissection with the sartorius transplant portion of the operation has now been completed. The saphenous vein adjacent to the adductor canal is identified for the second time. It is clamped and tied with a 2-0 suture.

The surgeon moves from the lateral side of the patient to the perineal area, and the entire surgical specimen is elevated with Allis clamps.

A careful outline of the vaginal introital incision is made with brilliant green solution. The incisions lateral to the labia majora are made down to the fascia.

The pudendal artery and vein are clamped and tied prior to transection. The specimen is retracted medially with multiple Allis clamps. The incision is extended down the lateral border of the labia majora and superficially extended across the perineal body.

The labia minora are retracted laterally with Allis clamps, and an incision is made in the vestibule around the urethral meatus, down around the posterior fourchette, and back up the other side.

The en bloc specimen is retracted downward, and the surgical dissection is made along the fascia until the perineal body is reached.

The surgeon elevates the posterior vaginal mucosa with Allis clamps and undermines it for approximately 6-7 cm with curved Mayo scissors, releasing the rectum from the posterior vaginal wall.

A Foley catheter is reinserted into the bladder. The wound is assessed to determine whether it can be closed primarily without tension by mobilizing adjacent tissue, should the Sure-Closure skin stretchers be used, or whether it requires a graft or flap.

Tissue lateral to the margin of the wound is undermined by sharp and blunt dissection. Closed suction drains are placed in the ischial rectal fossa.

Closure of the wound is begun in the perineal body by suturing the subcutaneous tissues for 3 or 4 cm up to the posterior fourchette of the vagina.

The subcutaneous tissue of the thigh is sutured to the paravaginal tissue up to the level of the urethral meatus.

No attempt is made to suspend the urethral meatus to the fascia and periosteum of the pubic symphysis or use it for wound closure. Such a course is apt to produce postoperative urinary incontinence.

The subcutaneous tissue, from both sides of the incision lateral to the labia majora up to the pubic tubercle, is closed to the paravaginal tissue with interrupted 2-0 synthetic absorbable sutures.

Closed suction drains are placed in the ischial rectal fossa and under the closure of the vagina to the skin of the thigh.

The skin of the perineal body is approximated with interrupted 3-0 nylon suture. The vaginal mucosa is sutured to the squamous epithelium around the entire introitus and vestibule with interrupted 3-0 nylon suture. The skin edges above the urethral meatus are sutured together for at least 3-4 cm with interrupted 3-0 nylon sutures.

The skin of the lower abdomen is mobilized up to the umbilicus. There must be no tension on the suture line between the incision overlying the inguinal ligament and the margin of the skin of the lower abdomen.

Suction drains are placed in the area of each sartorius muscle. These are usually sutured to the fascia with 4-0 synthetic absorbable suture to prevent accidental dislodgement. They are, however, easily removed with a gentle tug when they have ceased draining.

The mobilized lower abdomen is pulled down and sutured to the inguinal area in two layers.

The skin margins have been approximated with interrupted mattress sutures of 3-0 nylon. Suction drains have been placed in each inguinal area and through the lower abdomen. A Foley catheter has been placed in the bladder.

Intermittent pneumonic pressure cuffs are applied to the lower leg for thromboembolic prophylaxis. The patient is kept at bed rest for 10 days.