SIMPLE AND SKINNING VULVECTOMY
Simple vulvectomy involves the excision of vulvar skin with subcutaneous tissue, without dissection to the deep fascia of the vulva and perineum.1 This procedure is indicated for extensive in situ or microinvasion carcinoma of the vulva (< 1 mm of invasion), vulvar dystrophy, and Paget disease, where the lesions are not amenable to local excision or other forms of conservative therapy. For noninvasive lesions (except Paget disease), it may be acceptable to just remove the skin (a skinning vulvectomy) without removal of any underlying subcutaneous fat.2 A total vulvectomy includes excision of the entire vulva, clitoris, and perineal tissue. For preinvasive lesions of the vulva, total vulvectomy (simple or skinning) is rarely used now, with wide local excision or even more conservative treatments such as laser ablation being much more common.1
Box 27-1 Master Surgeon's Corner
For multifocal disease, several local excisions with primary closure may be preferable to extensive vulvectomy.
Z-plasty and rhomboid fl aps are often useful for closing larger defects. This is especially true near the perineum where primary closure may cause introital strictures and dyspareunia.
Bowel preparation is usually not required but may be used when perineal and perianal excision is required.
General or regional anesthesia using epidural or spinal anesthesia is used for extensive resections. For limited excisions, local anesthesia and deep sedation or laryngeal mask anesthesia may be adequate. The patient is placed in dorsal lithotomy position using "candy cane" or Allen stirrups. Bladder catheterization is recommended for complete vulvectomy. Prophylactic antibiotics are given. After the skin is prepared and sterile draping is applied, excision margins are marked on the vulva with a pen.
It is helpful to inject the proposed incision line lesion with a dilute lidocaine and epinephrine solution (eg, 1% lidocaine with 1:100,000 epinephrine), and then the superficial skin incision is made. 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 (Figure 27-1). The clitoris is spared when possible. A dry pack is used to occlude the small bleeding vessels in the skin until this incision is completed, and cautery may be used for simple vulvectomy. If a skinning vulvectomy is performed, the dissection should be with the scalpel or sharp curved scissors to avoid cautery artifact. If the clitoris is excised, the suspensory ligament and the crura of the clitoris are divided and ligated. Depending on the depth of the incision, as the 4 and 8 o'clock positions on the vulva are approached, the pudendal artery and vein may be identified and clamped. The periurethral and vaginal incisions are made if necessary to complete the excision. Depending on the location of the lesion, the clitoris and labia minora may be spared. If the dissection involves the perineum, care must be taken to avoid the anal sphincter. The specimen should be oriented with marking stitch for pathologic evaluation.