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Anaesthesia
A general anaesthetic is required.
The operation
McIndoe’s operation
The first generally successful procedure to be described
for the formation of an artificial vagina was that of
McIndoe. The operation involves the formation of a
space between the bladder and rectum which is filled
with a mould, over which has been placed a skin graft
from the patient’s thigh.
The operation is usually performed by a gynaecologist and a plastic surgeon working together, the plastic
surgeon cutting the grafts and placing them over the
mould and the gynaecologist developing the space between rectum and bladder and suturing the mould in
place.
Developing the space for the neovagina The patient is
placed in the lithotomy position. The skin is incised
transversely at the posterior part of the vaginal dimple
(Fig. 14.7). This incision is then deepened so that the
soft areolar fascia between rectum and bladder is
Longitudinal vaginal septum
Patients who are free of dyspareunia may still benefit
from excision of a longitudinal vaginal septum, which
can cause obstruction at the time of delivery. After emptying the bladder, the septum is held with a clamp, and
gentle traction is applied. Attention is required to avoid
excess traction as this can draw the urethra, bladder or
rectum into the area of excision. The septum is then incised at its inferior and superior attachments from the
posterior and anterior vaginal walls, respectively, and
the defects repaired using interrupted or continuous
absorbable sutures.
Vaginal atresia
A superficial examination of the patient may suggest
that the vagina is present but imperforate. The hymen
can be seen at the upper part of a small vaginal dimple.
However, on rectal examination it is clear that the vagina is not developed and the uterus is present as widely
displaced streaks of tissue leading to the ovaries. A diagnostic feature is the ability to trace the uterosacral
ligaments uninterruptedly across the front of the rectum. Although the diagnosis is usually made when the
girl is in her teens, treatment may be delayed until she
wishes to embark on intercourse. The chances of producing a useful communication with the uterus are
small and the prospects for procreation infinitesimal.
However, a functioning vagina can be made using one
of two techniques
—
McIndoe’s and Williams’s.
Instruments
The instruments in the gynaecological major set will be
required, together with the plastic surgery instruments
for cutting the graft (for McIndoe’s procedure) and a
selection of vaginal moulds (Fig. 14.6).
Patient preparation
The patient is prepared as for any major vaginal procedure; shaving is essential to cut down the risk of infection, and the lower large bowel should be completely
empty.
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150
Fig. 14.6 Two types of vaginal mould. On the left the usual
shape, on the right the shape used when a functional uterus is
present.
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identified. This level is often easier to find if a finger or
blunt obturator, such as a large dilatator, is inserted into
the rectum. The plane dissects remarkably easily and
the peritoneum is rapidly reached.
Using two index fingers, the cavity is developed (Fig.
14.8) so that the chosen mould can fit easily within it. It
is important to do this before cutting the graft. Meticulous haemostasis is necessary, although if the correct
plane is found there is surprisingly little bleeding.
Cutting the graft This is carried out by the plastic surgeon removing skin from the anterior thigh (Fig. 14.9).
The leg is dressed with tulle gras and bandaged. The
graft is now draped over the mould in such a way that
there is very little overlap; excessive skin should be
trimmed away (Figs 14.10 and 14.11).
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151
Fig. 14.7 McIndoe’s operation: incising the posterior part of
the vaginal dimple.
Fig. 14.8 Stretching the cavity anterior to the rectum.
Fig. 14.9 Cutting the graft.
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Fig. 14.10 Draping the mould.
Fig. 14.11 Completing the draping.
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be touched with silver nitrate to promote rapid
epithelialization.
Williams’s operation
Although this operation is of great value to the patient
who has vaginal atresia, it is also of enormous benefit to
the patient who has shortening or stenosis of the vagina
following surgery or radiotherapy. It is a simple procedure producing a pouch of skin lying along the vulva
rather than in the axis of the vagina. The postoperative
period is short (10 days), and good results are obtained.
Arthur Williams first described the operation in 1964
and again in 1976. The authors are grateful to him for
permission to reproduce the drawings of the procedure
shown in Figs 14.16–14.20.
The patient is draped and catheterized (Fig. 14.16),
the incision in the labia is made (Fig. 14.17) and deepened. The inner edges of the incision are now sutured
together with interrupted Dexon sutures (Fig. 14.18).
An obturator is then placed in the pouch to check the
Inserting the mould The mould covered by the graft is
now inserted into the cavity, where it should lie snugly
but without any pressure contact points (Fig. 14.12).
Retention of the mould The mould must now be sutured in place. This is best done by mobilizing the labia
via an incision made as shown in Fig. 14.13. The similarities between this incision and that of the Williams’s
procedure are obvious. The inner edges of this incision
are now sutured together so as to form a shelf to retain
the mould (Fig. 14.14). This is then reinforced by suturing the outer line of the incision (Fig. 14.15).
The mould is maintained in the new vagina for
approximately 3 months; some patients demand that
it be removed earlier but this should be resisted. It is
important to keep the neovagina open and elastic;
if the patient is not regularly practising intercourse
she must dilate the vagina frequently using plastic or
glass dilators. Any areas of granulation tissue can
OPERATIONS ON THE VAGINA
153
Fig. 14.12 Inserting the draped mould.
Fig. 14.13 Incising the labia.
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154
Fig. 14.14 Suturing the inner edge of the incision.
Fig. 14.15 Suturing the outer edge of the incision.
Fig. 14.16 The draped and catheterized vulva showing the
vaginal dimple.
Fig. 14.17 Incising the labia.
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size of the vaginaplasty; if it is satisfactory, the levators
are sutured together using two interrupted stitches (Fig.
14.19). The operation is now completed by closing the
skin with a series of interrupted stitches; Williams
recommended nylon, the authors would use Vicryl
(Fig. 14.20).
Vaginectomy, partial and complete
Vaginectomy, or colpectomy, is an operation which is
rarely performed but which has very clear indications
and very significant benefits. The procedure is most
commonly indicated where there is residual vaginal intraepithelial neoplasia (VAIN) in the upper vagina after
hysterectomy.
Unfortunately, a considerable number of women will
continue to have hysterectomies performed for cervical
premalignancy without the benefit of preoperative colposcopy to localize and delineate the disease. As a consequence, in a small number of women there will be
incomplete removal of the lesion, resulting in persistently abnormal smears in the postoperative period. If
hysterectomy is indicated for cervical intraepithelial
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155
Fig. 14.18 Suturing the inner edges of the labial incision.
Fig. 14.19 Testing the neovagina’s capacity and suturing the
levators.
Fig. 14.20 Closing the outer layer of skin.
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dissector is used to apply traction to the skin flap anteriorly, while the blunted scissors are used to develop the
subepithelial plane further towards the vaginal vault
and laterally (Fig. 14.21). The skin edges are incised
further around the circumference of the mapped lesion
as the development of the tissue planes continues. Attention is required not to ‘button-hole’ the specimen, as
this will increase the possibility of leaving diseased
tissue remnants behind. Eventually, the incision is
completed around the entire lesion, with the only attachment remaining being a thin strip at the vaginal
vault with underlying scar tissue. Applying firm traction to the vaginal skin, the attachments at the vaginal
vault are now boldly cut from right to left including the
‘dog-ears’ within the specimen, eventually releasing the
entire specimen and without damage to the underlying
structures (Fig. 14.22). In leaving the scarred tissue at
the vaginal vault and ‘dog-ears’ till last, the risk of injury to the underlying rectum, bladder and ureters is
kept to an absolute minimum, whilst increasing the
likelihood of achieving complete excision of the entire
lesion with a single specimen.
neoplasia (CIN), then ideally this should be performed
vaginally in conjunction with colposcopy to reduce the
likelihood of the CIN and associated VAIN being incompletely excised. If the lesion or lesions can be seen
and fully outlined, then an excisional procedure performed vaginally is the best management method (see
below).
If the lesion cannot be fully visualized or it extends
into the ‘dog ears’ at the angles of the vaginal vault then
a more extensive surgical procedure via an abdominal
approach is the only realistic choice. Some authorities
have recommended radiotherapy, but the authors feel
that this is not indicated as there is a very significant
vaginal morbidity after treatment, often without
clearance of the vault lesion, whereas with partial
colpectomy there is a good prospect of a reasonable
return to normal function.
Colpectomy is not an adequate procedure for invasive carcinoma of the vagina but is of great value in
treating microinvasive lesions. In those patients with an
upper vaginal lesion and who have a uterus, a hysterocolpectomy is performed
—
a much simpler procedure
than colpectomy after hysterectomy.
The vaginal procedure
Instruments
The instruments in the general gynaecology set will be
required.
The operation
Identification of the lesion The patient is placed in a
lithotomy position, cleansed, draped and the bladder
emptied. A bimanual and rectal examination is performed to exclude the possibility of a discrete invasive
lesion lying above the suture line at the vaginal vault. A
colposcopic assessment of the upper vagina, as described in Chapter 4, is performed followed by mapping of the lesion using Lugol’s iodine. Infiltration of
the subepithelial tissues with a solution of 1% Xylocaine with adrenaline 1 : 200000 helps to define tissue
planes and reduce minor bleeding. Access to the vault is
best achieved by use of a large Sims’ retractor placed in
the posterior vagina, with a smaller vaginal retractor
placed in the anterior vagina which is moved laterally
during the course of the procedure as required.
The incision A 2 cm epithelial incision is made just inferior to the posterior margins of the lesion. A toothed
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Fig. 14.21 Releasing the vaginal edges.
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sion. A firm vaginal pack is essential to facilitate dissection of the vagina from the bladder and the rectum, and
an indwelling catheter with a small (5 ml) balloon
should be inserted into the bladder.
Anaesthesia
It is a great advantage if this procedure can be carried
out under epidural or spinal analgesia as a considerable
reduction in small vessel oozing can be achieved.
The operation
Frequently, adhesions from previous surgery have to be
cleared before it is possible to visualize the pelvic structures fully. As in the radical hysterectomy procedure, a
self-retaining retractor should be used but without the
lower blade, which should be replaced by a Morris
retractor held by the second assistant. This allows the
peritoneum and the bladder to be manipulated to give
better vision and access. As a result of the previous surgical intervention, there can be considerable scarring
particularly at the angles of the vaginal vault overlying
the ureters.
The incision The abdomen is opened via a longitudinal
mid-line incision; low transverse incisions give more
limited access and should not be used.
Identifying the ureters After clearing obstructions and
adhesions from previous surgery, the ureters should be
identified as they pass along the pelvic side wall behind
the peritoneum. The peritoneum at the brim of the
pelvis is opened along a line between the remnant of the
round ligament and the infundibulopelvic ligament.
Using the fingers, the retroperitoneal space is opened
and the ureter identified and separated from the overlying peritoneum (Fig. 14.23).
Dealing with the scar tissue at the angles of the vault
The uterine artery should be identified as far laterally as
possible and then divided and drawn medially (Fig.
14.24). This will have the effect of identifying the entrance to the ureteric tunnel at its lateral end. This area
is often surrounded by dense scarring from the previous
surgery; however, if the ureteric tunnel can be accurately defined, the scar overlying it can be cut with
confidence and without trauma to the ureter.
Identifying the medial end of the ureteric tunnel Now,
the uppermost point of the vagina must be palpated and
Dealing with the denuded vault If the peritoneal cavity
has been entered at the vaginal vault during the procedure, then this can be either left open or closed using a
continuous stitch. Individual vessels can be dealt with
using a combination of sutures or diathermy. Once
haemostasis is achieved, the denuded tissue at the
vaginal vault is left unsutured to regranulate, and a
bacterostatic soaked vaginal pack and indwelling
transurethral urinary catheter inserted for 24 h.
Postoperative care
No special attention is required, and the patient can be
discharged home the following day.
The abdominal procedure
Instruments
The instruments outlined in Chapter 2 for radical hysterectomy will be required.
Preoperative preparation
This should be as for a radical hysterectomy, with the
additional procedure of marking the inferior aspect of
the lesion with a marker stitch, which will be useful
later during the operation to confirm adequate exci-
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Fig. 14.22 Excising the vaginal skin at the vault.
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a transverse incision made in the peritoneum so that the
bladder can be separated from the anterior surface of
the vagina. It may be necessary to use sharp dissection
to identify the correct plane. Once this has been identified, the bladder should be pushed down in the midline; this will have the effect of making the scar tissue
and the fascia overlying the ureteric tunnel laterally
more prominent.
Incising the roof of the ureteric tunnel Frequently, the
ureter can be identified as it passes into the bladder. If
this is possible, Monaghan’s scissors should be gently
introduced over the upper surface of the ureter and,
using a separating movement without cutting, gently
insinuated laterally to appear at the lateral end of the
ureteric tunnel. This dissection may be performed from
medial to lateral or in the reverse direction. It is important not to kink or to nip the ureter in the edges of the
scissors; the simple manoeuvre of lifting the scissors
while in the tunnel will allow a good view of the entire
length of the ureter. A medium straight tissue forceps is
then placed over the scissors and the ureteric tunnel and
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158
Fig. 14.23 Identifying the ureter
in the right retroperitoneal space.
Fig. 14.24 Dividing the uterine artery on the pelvic side wall.
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paracolpos is grasped and clamped in Zeppelin clamps
and the chosen length of vagina removed (Fig. 14.28). If
the requirement is to remove the upper part of the vagina to excise VAIN, no further dissection is necessary
and the vagina can be opened at this point to confirm
placement of the original marker stitch and adequate
excision of tissue. If a total vaginectomy is necessary,
the abdominal dissection should be extended down the
vagina to the pelvic floor. Thereafter, the patient is put
in lithotomy position and the lower vagina dissected
free from the urethra and bladder anteriorly and the
rectum posteriorly. Great care should be exercised
when dissecting below the urethra as the fascia is very
dense and the dissection must be very accurate. Having
joined up with the abdominal dissection, the entire
vagina can be removed. A little bleeding is seen around
the pelvic floor but is not of great trouble.
Draining the vagina The space left behind after
vaginectomy will vary in size depending on the extent
of the procedure. Following partial vaginectomy there
is no need for special drainage procedures except to
leave the vaginal remnant open. However, after total
vaginectomy either a vaginal passive drain or a suction
drain should be put in place. This may be augmented by
the scar tissue incised (Fig. 14.25). The pedicle is then
tied, as it carries some veins and small arteries to and
from the bladder. At this point, there may still be a few
strands of fascia passing across the ureter; these should
be divided and the tissue plane between the ureter and
the vagina identified. The cardinal ligament is now visible below and medial to the ureter. Sharp dissection
may still be required if there has been extensive scarring
from the previous surgery. The upper vagina is revealed
very quickly and the ureters dislocated laterally.
The firm pack in the vagina greatly facilitates this
dissection.
Releasing the vagina posteriorly An incision is made in
the peritoneum at the upper posterior part of the vagina
(Fig. 14.26). This incision is then extended laterally
over the remnants of the uterosacral ligaments. The rectum is now easily pushed away from the posterior surface of the vagina by passing the fingers down into the
rectovaginal space (Fig. 14.27).
Removing the vagina At this point, having released the
ureters laterally, the bladder anteriorly and the rectum
posteriorly, the surgeon can decide just how much vagina he wishes to remove. The uterosacral and then the
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159
Fig. 14.25 Dividing the roof of the ureteric tunnel.
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