Oncology Patients With
Cylinders for Intracavitary
of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy
Injection of Chromic Phosphate
Omental Pedicle "J"
With Bilateral Inguinal
Lymph Node Dissection
Vulva With Gracilis Myocutaneous Flaps
Flap and Vertical Rectus
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina
"J" Pouch Rectal
Omental "J" Flap
Continent Urostomy (Miami Pouch)
Gracilis Dynamic Anal
System Versus Skin Grafting
Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina
of Hemorrhage in Gynecologic Surgery
of the Punctured
of a Lacerated
Internal Iliac Vein and
Suturing of a Lacerated Common Iliac Artery
Suspension of the Vagina
Not to Do in Case of Pelvic Hemorrhage
Associated With Abdominal Pregnancy
"J" Flap Neovagina
Construction of a neovagina has been an accepted gynecologic
procedure for many years. McIndoe (see Vagina and Urethra) has described
surgical techniques for construction of a neovagina when the bladder
is in position anteriorly and the rectum and colon are in position
posteriorly. These techniques are inapplicable, however, when patients
have undergone total pelvic exenteration with or without low coloproctostomy.
Under these circumstances, Berek and Hacker demonstrated that the anterior
wall of the neovagina could be made from an omental flap.
By modifying the omental flap,
which is normally used to close off the pelvic inlet after total pelvic
exenteration with or without low coloproctostomy, the surgeon can create
a cylinder providing anterior, posterior, and lateral walls for the
neovagina. When the cylinder is sutured to the introitus and lined
with a skin graft, it becomes a satisfactory functional vagina.
Physiologic Changes. The omentum that is enervated
by the vagus nerve forms the wall of the neovagina. Normally, tugging
or pulling on the omentum does not produce a sensation of pleasure
that one would associate with sexual intercourse. Approximately 40%
of the patients who have undergone this procedure, however, report
that they experience sexual orgasm.
Another physiologic change is the
development of estrogen hormone receptors on the split-thickness skin
graft. Derived from skin on the buttocks or thigh that normally has
no hormonal properties, the graft eventually becomes indistinguishable
from normal vaginal mucosa on biopsy. At present, it is unknown whether
the maturation index of the graft can be influenced by the administration
of systemic estrogen, as can occur in normal vaginal mucosa.
Points of Caution. If the construction of the neovagina
immediately follows total pelvic exenteration, it is important to ensure
hemostasis in the pelvic wound before applying the skin graft. If hemostasis
is uncertain, the omental neovagina should be packed with gauze or
foam rubber covered by a contraceptive condom. Then, when hemostasis
is maintained, in approximately 6-12 postoperative days a skin graft
can be taken and applied to the vaginal form.
After the skin graft has
been inserted, the neovagina must remain dilated with a vaginal form
until healing is complete. Thereafter, a soft Silastic vaginal form
should be worn for 6 months except during intercourse. After this time,
the soft Silastic vaginal form is worn only at night if sexual intercourse
is not a part of the patient's life.
This sagittal view shows a patient who has
undergone a total pelvic exenteration. In this patient, the rectal
stump was left, and the descending colon was brought down for
a very low coloproctostomy. The urethra and vagina below the
levator sling remain in place. The omentum has been brought down
as a flap and has been sutured to the sacral promontory posteriorly
and the pubic symphysis anteriorly.
In the upper part of this figure can be seen
the omental flap with the intestines lying in the pelvic lid
sling. In the lower part of this figure can be seen the distal
portion of the flap rolled into a cylinder. The lateral wall
of the cylinder has been sutured with interrupted 3-0 polyglycolic
acid (PGA) sutures.
This perineal view shows the vulva and vaginal
introitus. The wall of the omental cylinder has been sutured
to the vaginal introitus with interrupted 3-0 PGA sutures.
The omental cylinder has been
completed and sutured to the vaginal introitus.
The dermatome can be seen in this view. STSG,
split-thickness skin graft.
The graft is laid out, and
a vaginal form is fashioned from foam rubber stuffed into a contraceptive
latex condom. The vaginal form has been shaped to an appropriate
size, length, and diameter. This is laid on the graft; the graft
is folded over the vaginal form, and the edges of the graft are
sutured with interrupted 4-0 PGA sutures.
The graft-covered form is inserted through
the vaginal introitus into the omental cylinder.
This sagittal section shows the omental
"J" flap as the pelvic lid and the residue of the omental flap
that forms the outer walls of the neovagina. The graft-covered
vaginal form has been introduced into the neovagina.
The labia majora have been
approximated loosely by several 2-0 nylon sutures. These remain
in place for 10 days. The stump of the condom covering the
vaginal form protrudes through the suture line.
On the tenth postoperative day,
the patient is returned to the operating room for an examination
under anesthesia. The vulvar sutures and vaginal form are removed,
and the graft covering the neovagina is inspected.
The patient is fitted with a soft
Silastic vaginal form that must be worn for approximately 6 months.
The vaginal form is removed each
day and washed, the neovagina is douched, and the form is replaced.
Failure to be sexually active and/or to use the vaginal form
as prescribed will result in contracture of the neovagina.