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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

Skin-Stretching System
Versus Skin Grafting

Skin grafting has been an unusual but needed procedure in gynecologic oncology surgery. The physiology of wound healing is dramatically improved if wounds are covered as soon as possible and not left granulating over a period of months.

A new instrument has been added to the gynecologic surgeons armamentarium, the skin-stretching devise known as Sure-Closure (MedChem, Woburn, Massachusetts).

The purpose of the operation is to cover an exposed defect on the abdominal wall, vulva, or sacrum.

Physiologic Changes. The predominate physiologic change is closure of the wound to prevent contraction and epithelialization. Loss of fluid and protein from open wounds allowed to granulate over a period of time is a major metabolic and nutritional problem.

Points of Caution.  Care must be taken to adequately mobilize the edges of the wound. The wound should never be covered under tension.

The air dermatome should be held at an angle of 45-60°. Holding the air dermatome at an angle of less than 45° produces (1) a split-thickness skin graft that is chopped into pieces and (2) a donor site with an irregular surface.

The technique of skin-stretching via the device known as Sure-Closure takes advantage of the processes of the "mechanical creeping" produced by the Sure-Closure device, which applies a controlled amount of tension evenly along two open wound margins of skin. The mechanical stretcher uses the vesicoelastic properties of skin to stretch in a reasonable time while minimizing the skins tendency to recoil. Repeated cycles of stretching are performed over 30-40 minute period of time until the skin margins can be brought in opposition for suturing without tension.


In an open wound of the abdominal wall with the underlying rectus fascia closed with interrupted sutures, the skin on either side of the defect is undermined for 2-3 cm with the electrocoagulation device.

An air dermatome is demonstrated taking a split-thickness skin graft. Note that the dermatome occupies a 45° angle to the level of the donor site. The graft is grasped with Allis forceps or skin hooks. The air dermatome is set to produce a graft of 0.2 cm.

The donor site is covered with a fine mesh gauze to prevent epithelial cells from growing through the pores on regular gauze, debriding the donor wound with each dressing change.

The graft is laid on the open wound, and the margins of open wound are sutured to the margins of the split-thickness graft (STSG).

The elements of the Sure-Closure skin-stretching system can be seen here. They consist of two straight needles, the two parts of the stretching device with hooks that engage the two needles under the platform of the stretching device. On one stretching device there is a strain gauge that prevents the skin from stretching too rapidly. The upper platform of the stretching device shows the needles but also shows the locking system that prevents the device from unlocking after the skin has been stretched.

The needles have been inserted along the margins of the skin parallel to the wound. The stretching system has small retained needles on the bottom of their platforms stuck under the linear needles to provide a solid stretching system. The strain gauge portion of the stretching system is engaged into the receiving end and locked in place. The wheel screw of the stretching system is turned, and the margins of the skin are stretched. The strain gauge will show when the skin is being stretched beyond its capacity. There is a clutch in the stretching system that disengages the wheel crank when too much stretching pressure has been applied to the skin; this allows for the skin to recover before further stretching is allowed.

When the margins of the wound have been approximated to each other, the wound is closed with interrupted mattress sutures.

The devices have been set in place for a radical vulvectomy incision. After stretching, tension has been removed from the skin of the inguinal node dissection. The skin of the vulva resection can be stretched to close the skin to the margins of the vagina without tension through the skin-stretcher process.

The wound is closed following the stretching process.

Copyright - all rights reserved / Clifford R. Wheeless, Jr., M.D. and Marcella L. Roenneburg, M.D.
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