The patient is placed in the dorsal lithotomy position with her buttocks at least 3 inches off the end of the table.

An outline of the lesion is made with a brilliant green ink preparation. An elliptical incision is made down to the subcutaneous fat. The incision starts from above the labial folds on the mons pubis and is extended down the lateral fold of the labia majora and across the posterior fourchette. A dry pack is used to occlude the small bleeding vessels in the skin until this incision is completed.

As the 3 and 9 o'clock positions on the vulva are approached, the pudendal artery and vein are encountered. These vessels, before being incised, should be clamped to avoid major blood loss. For maximum exposure, the specimen should be kept on tension by placing multiple Allis clamps around the edges of the skin.

The pudendal vessels are securely tied, and the incision is continued around the entire circumference of the lesion, as shown in Figure 2.

Exposure to the vaginal orifice and urethra is made by retracting the labia laterally. The line of incision around the urethra and vaginal orifice has been marked with brilliant green surgical ink. The incision is started above the urethral meatus and carried around the vaginal introitus with an adequate margin around the lesion.

By palpating the incision above the urethral meatus with the finger and placing a small hemostat behind the suspensory ligaments of the clitoris, the surgeon makes an opening above the urethra to ensure that damage to the urethral meatus is avoided. A similar technique is used laterally to perforate the cutaneous tissue from the lateral incision to the vaginal incision.

This technique can also be used inferiorly to avoid damaging the rectum. The surgeon may place a finger in the rectum while retracting the specimen superiorly and perforating the dermis tissue between the inferior skin margin and the vagina along the lines of the incision made in both structures. After the dermis has been permeated, one blade of curved Mayo scissors may be inserted to cut between the perforations.

The specimen has been transected between the perforations made in the vaginal mucosa, leaving the specimen attached only to the fat pad in the mons pubis and to the vascular plexus surrounding the suspensory ligaments of the clitoris. This area should be clamped and tied before it is transected with scissors.

Primary closure of the wound is begun. First, the posterior wall of the vaginal mucosa is undermined and brought out to the posterior fourchette so that contracture of the vaginal introitus is avoided. After hemostasis is achieved, closure of the wound is continued superiorly in the mons pubis by closing the subcutaneous tissue with interrupted 2-0 synthetic absorbable suture.

Three or four 2-0 synthetic absorbable sutures are placed in the levator ani muscles, which are plicated in the midline after the posterior vaginal mucosa has been mobilized. Note that the subcutaneous tissue of the mons pubis has been closed almost down to the urethral meatus.

A close-up of the plicated levators, the pudendal vessels, and the mobilized posterior wall of the vagina is shown.

Closure of the subcutaneous tissue of the perineal body is begun with interrupted 2-0 synthetic absorbable sutures. The subcutaneous tissue remaining superiorly is then closed.

A catheter is inserted into the urethral meatus, and the periurethral mucosa is sutured to the skin with interrupted 3-0 synthetic absorbable sutures. The vaginal mucosa is likewise sutured to the skin with interrupted 3-0 synthetic absorbable sutures.

Skin closure is begun in a subcuticular fashion over the mons and the perineal body, respectively, with interrupted 3-0 synthetic absorbable sutures. The remaining vaginal mucosa is sutured to the skin with interrupted 3-0 synthetic absorbable sutures.

Final closure of the simple vulvectomy is made by using synthetic absorbable sutures, making permanent sutures unnecessary. During closure of this incision, it is most important to eliminate tension on the suture line. The surgeon should mobilize the perineal tissues until the margins of the wound come together without tension. The Foley catheter is left in place for 24 hours and then removed. The patient is ambulated immediately. Laxatives and stool softeners are administered on the third postoperative day.