Vaginectomy
Partial or total excision of the vagina is performed most often because of vaginal neoplasia. The diagnosis is suspected following an atypical cytology report. Vaginal intraepithelial neoplasia (VAIN) may follow or exist concurrently with cervical intraepithelial neoplasia (CIN) or vulvar intraepithelial neoplasia (VIN), or may occur de novo. A de facto vaginectomy may be performed as a result of treatment for extensive condyloma acuminata. The goal of vaginectomy is twofold: (1) to remove the pathology, and (2) to retain a functioning structure. The latter translates into maintaining the vagina as a supple, nonconstricted, and suitably lengthy structure. The factor most often responsible for vaginal deformity and accompanying dyspareunia is scar formation. As was noted in Chapter 50, neighboring organs are exceedingly close (2 to 4 mm) to the vaginal mucosa. The vagina itself is a rather simple structure—essentially a potential space with its anterior and posterior walls in light contact in vivo. The vagina is attached at its lower margin to the vulva and at its upper margin to the uterus, together with the uterine supports. The vagina is attached laterally to the levator ani and a mass of surrounding connective tissue (endopelvic fascia). The loose peripheral attachments allow movement as well as flexibility between the points of relative fixation. Anteriorly, the vaginal wall and the bladder and urethral walls are in apposition. Similarly, an identical set of circumstances exists between the rectal and vaginal walls posteriorly. When reduced to its lowest common denominator, the vagina is a pleated, lightly muscled, highly vascularized skin tube.
Intraepithelial neoplasia in the absence of glands occupies less than 1 mm of a vaginal wall cross-section. Treating the vagina more deeply to eradicate the disease adds nothing to the cure but may adversely influence the functional outcome. Unfortunately, VAIN is multifocal; therefore, to diminish the chances of persistence or recurrence, very wide excisional margins around visible lesions must be undertaken. This translates into dividing the vagina into thirds and removing a minimum of one third to a maximum of three thirds.
Excision
Because the vagina is highly vascular, particularly beneath the urethra and at the bulb of the vestibule, brisk bleeding should be anticipated when it is cut. The sources of much of the bleeding are sinusoidal and cavernous structures. These sites are better sutured as they are encountered rather than clamped. If substantial areas of the vagina are going to be excised, a split-thickness skin graft should be obtained before the vaginal part of the operation is begun (Fig. 63–1). The colposcope will be used throughout the intravaginal operation. Initially, the extent of the lesion is mapped (Fig. 63–2A, B).
A 1 : 100 vasopressin solution is injected subepithelially into the vaginal stroma (Fig. 63–3A). This provides some hemostasis and a convenient dissection plane (Fig. 63–3B). An axis-oriented incision is made into the anterior or posterior wall, and flaps are created to the right and left of the midline cut as a submucosal plane is created (Fig. 63–4). The dissecting microscope (colposcope) has the great advantage of providing good, bright light as well as variable magnification. Stevens (tenotomy) scissors are ideal for this type of dissection (Fig. 63–5). The lateral wall is divided into two recesses, or sulci, which create an H appearance to the vagina as viewed head on. These are located anterolaterally and posterolaterally on the right and left walls. Between the sulci lies the insertion of the levator ani muscle on the right and left sides, respectively. Above and below the insertion on the muscle is fat, through which course blood vessels, lymphatics, and nerves. The vagina is dissected across the point of levator attachment but superficial to that attachment (i.e., remaining well within the immediate submucosal plane) (Fig. 63–6). Anterior and posterior dissections meet in the anterolateral and posterolateral sulci, and the specimen is removed (Figs. 63–7 and 63–8). Care must be taken at the vaginal fornices to not damage the ureter, which is quite close to the anterior and anterolateral fornices.
Depending on the size of the removed tissue, the vagina may be closed edge to cut edge or grafted. Generally the latter approach is selected because any substantial excision will lead to constriction, should the vagina be reconstituted by primary closure, particularly if the suture lines are closed under tension.
