Simple Excision of the Vulva
Local excision of the vulva may be required in a number of benign conditions. Sebaceous cysts, myomas, papillomas and lipomas require only local excision and are easily enucleated. Rodent ulcers require a wider excision of the normal area around the margin of the ulcer, about 2 cm of healthy skin outside the periphery of the tumour.
Simple Vulvectomy
Simple removal of the vulva is most commonly performed for Ieucoplakia vulva. Partial vulvectomy may be indicated for gross hypertrophy of the clitoris or the fabia, intractable pruritus vulvae, Bowen's disease and Paget's disease. Some chronic epithelial dysplasias totally unresponsive to local treatment may occasionally require vulvectomy.
In the chronic dermatitides, classically the eczematoid, neurogenous, seborrheic and intertriginous types, the gross picture is altered by surface keratin, which produces a whitish or greyish-white “leukoplakoid” discolouration.
Similarly, the microscopic pattern is characterised by hyperkeratosis, acanthosis and chronic inflammatory infiltrate-features that have all been associated with “leukoplakia”. The danger of basing a diagnosis on the microscopic pattern without thorough study of the gross lesion cannot be overemphasised. Furthermore, it must be stated and restated that the microscopic diagnosis of “leukoplakia” be eliminated because of the poor definition of the cellular criteria. Therefore the symptoms of whitish or greyish-white discolouration of the vulva associated with itching and supported with a positive biopsy report should prompt a simple vulvectomy.
Operation for complete excision. An oval incision is made with the scalpel through the skin and subcutaneous tissue down to the deep fascia and well clear of the diseased area. The incision extends from above the clitoris on each side to include both labia majora and ends posteriorly at the fourchette. A second incision is now made round the urinary meatus, including the vestibule and the vaginal orifice. An incision is then made in the median line at the fourchette, the outer and inner oval incisions being thus joined.
The tissue on one side of this median incision is now clamped with the pressure forceps and, as it is pulled up, the structures lying between the inner and outer incisions down to the deep fascia are then dissected 32away in a single piece, up to the level of the urethra. The same procedure is carried out on the other side. The separated portion on each side is then pulled up by the forceps attached to them and the remaining portion of the vulva is then dissected off the underlying tissues. All spouting vessels are temporarily clamped with pressure forceps and ligatured after the excision has been completed.
At times there is very free bleeding, especially from the dorsal artery of the clitoris and some of the large vestibular vessels, rendering it difficult to pick up the bleeding point. In such a case the haemorrhage can be controlled effectively by passing a mattress or figure-of-eight suture under the bleeding area.
The right and left edges of the outer incision above the level of the urethral orifice are now approximated with interrupted nylon sutures passed deep to the raw surface. Below this level, the cut edges of the skin and vagina respectively are united with No. 0 catgut /vicryl sutures.
If there is any difficulty in approximating the cut edges of the skin and vagina, the lower end of the vagina should be freed for about 2 cm so that it can be pulled down and brought into close apposition with the skin edge, thus covering the raw surface left after removal of the diseased parts.