Auer Ch 61 Vulva, Vagina, Cervix

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finochietto retractors

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persistent hymen

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Front 17

Vascular supply to vulva:

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internal pudendal

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Innervation to vulva:

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pudendal, caudal rectal

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Innervation to vestibule:

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pudendal, caudal rectal

Front 20

What is the perineal body?

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Formed by fibers of the external anal sphincter and constrictor vulvae muscle

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Location of vestibule:

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from vulva to level of transverse fold

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Location of transverse fold:

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dorsal to the external urethral orifice

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What covers lateral and ventral surface of vestibule?

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Constrictor vestibuli muscle

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What does the constrictor vestibuli muscle blend with?

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Constrictor vulvae muscle

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What forms the vestibular sphincter?

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Constrictor vestibuli muscle, pillars of hymen, floor of pelvis

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Location of vagina:

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caudal extent from transverse fold of external urethral sphincter, cranial extent vaginal fornix around cervix

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Relations of vagina:

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rectum is dorsal, bladder & urethra is ventral, pelvic wall is lateral, small cranial ventral portion and larger cranial dorsal portion is peritoneal

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Vascular supply to vagina:

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internal pudendal

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Innervation to vagina:

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no motor innervation (no muscle) only sympathetic ganglia

Front 30

What is the cervix?

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Extension of caudal portion of uterine body

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What is the caudal portion of the cervix called?

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External cervical os

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What is the function of the cervix?

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Sphincter separating caudal reproductive tract from uterus

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Protective barriers of caudal reproductive tract:

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constrictor vulvae muscle, vestibular sphincter, cervix

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Surgical approaches to pneumovagina:

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caslick, perineal body reconstruction, perineal body transection

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What are other names for perineal body reconstruction?

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Epioplasty, Gadd technique

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Goal of perineal body reconstruction?

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Restoration of integrity of the dorsal aspect of the vestibule and vestibular sphincter function

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Describe perineal body reconstruction:

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incision along mucocutaneous junction of dorsal vulvar commissure, extending cranial at dorsal commissure, submucosal dissection dorsolaterally to create 2 triangular flaps of mucosal tissue that approximate the shape of the perineal body, tissue retracted caudally until desired shape is formed, mucosa closed with absorbable suture in horizontal mattress pattern inverting mucosa into vestibule, SQ closed from cranial to caudal with absorbable suture in continuous pattern, labial skin closed as for caslick

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Sexual rest indicated with perineal body reconstruction:

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4 weeks

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Goal of perineal body transection:

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separation of muscular and ligamentous attachments between rectum and caudal repro tract

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Describe perineal body transection:

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4-6 cm horizontal incision midway between ventral anus and dorsal commissure of vulva, extending ventrally around dorsal commissure for 3-4 cm, dissection continued cranially for 8-14 cm until there is separation between the rectum and caudal repro tract and when the vulva has retained a vertical position, skin can be closed or left open to heal by 2nd intention

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Sexual rest for perineal body transection:

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3 weeks

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Surgical correction of urovagina:

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perineal body transection, Monin (caudal relocation of transverse fold), caudal urethral extension with either brown, shires, mckinnon or combined brown-mckinnon techniques

Front 43

Indications for caudal relocation of transverse fold (monin):

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only if urine reflex and abnormal perineal conformation is minimal

Front 44

Advantage/ disadvantages of caudal relocation of transverse fold (monin):

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simple but does not extend opening as far caudally as extension techniques and can make performing extension techniques harder

Front 45

Describe Monin technique (caudal relocation of transverse fold):

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horizontal incision made at transverse fold to create dorsal and ventral shelves, the fold is retracted caudally and at site of intended relocation, incisions are made at the right and left ventrolateral wall of the vestibule, transverse fold mucosa is sutures in 2 layers to the vestibular wall with absorbable suture creating an orifice that is 2-2.5 cm caudal to the original

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Complication of urethral extension procedures:

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fistula formation along suture line

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Sexual rest after urethral extension techniques:

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4 weeks

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Describe brown technique:

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transverse fold incised horizontally to dorsal and ventral flaps, incision continued caudally along vestibular wall creating dorsal and ventral shelves of vestibular mucosa, ventral flaps are apposed in continuous pattern with absorbable suture inverting into the urethral orifice lumen, submucosa closed in continuous pattern with absorbable suture, dorsal flaps are apposed with continuous horizontal mattress pattern to evert the mucosa into the vestibule

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Describe shires technique:

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foley catheter placed in bladder, interrupted horizontal mattress sutures placed apposing left and right vestibule mucosa to form a tunnel over catheter beginning cranial to orifice and ending 2-3 cm from the vulva, everted mucosa is excised, cut edge of mucosa is apposed in a continuous pattern with absorbable suture

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Advantage of mckinnon technique:

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urethral tunnel is stronger and larger than with brown or shires

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Describe mckinnon technique:

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horizontal incision in transverse fold making dorsal and ventral shelves, incision is continued caudally along vestibular wall, flaps are dissected ventrally until the flaps can be apposed on midline without tension, flaps are closed in a Y pattern with continuous horizontal pattern inverting mucosa into urethral orifice

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Where does fistula formation occur with mckinnon technique?

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At Y

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Describe combined brown-mckinnon technique:

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horizontal incision in transverse fold continued caudally on ventrolateral wall of vestibule to 2 cm of vulva, dissection to create dorsal and ventral vestibular flaps, midpoint of free edge of transverse fold retracted caudally, right portion of ventral transverse flap sutured to right ventral vestibular flap in continuous horizontal mattress pattern used to invert mucosa into urethral orifice, left portion of ventral transverse flap sutured to left ventral vestibular flap, right portion of dorsal transverse flap sutured to right dorsal vestibular flap in continuous horizontal mattress pattern with absorbable suture, left portion of dorsal transverse flap sutured to left dorsal vestibular flap, roof of tunnel created by suturing right and left ventral vestibular flaps in a continuous horizontal mattress pattern, right and left dorsal vestibular flaps closed in a continuous horizontal mattress pattern

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First degree perineal laceration:

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mucosa of vestibule, skin of dorsal commissure of vulva

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Second degree perineal laceration:

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vestibular mucosa, submucosa, muscle of perineal body

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Result of 2nd degree perineal laceration:

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compromise closure of dorsal labia and cause pneumovagina

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Third degree perineal laceration:

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complete disruption of rectovestibular shelf, penetrating rectum, perineal body, anal sphincter

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Difference between 3rd degree perineal laceration and rectovestibular fistula:

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fistula is perineal laceration from vestibule to rectum without disruption of anal sphincter and 3rd degree has disruption of anal sphincter

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Treatment of 1st degree perineal laceration:

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nothing or caslick

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Treatment of 2nd degree perineal laceration:

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perineal body reconstruction with caslick

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Treatment of 3rd degree perineal laceration:

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two-stage (aanes) or one-stage (aanes, modified goetze, stickle)

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When are 3rd degree perineal lacerations repaired?

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At least 3-4 weeks after injury to allow healing of tissues

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What pre-operative preparations are required before 3rd degree perineal laceration repair?

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Dietary changes to produce soft but not watery manure prior to and continuing for 2-3 weeks post-op to decrease likelihood of rectal dehiscence

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Benefits of 2-stage perineal laceration repair:

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minimizes obstipation that can lead to failure

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Describe stage 1 aanes perineal laceration repair:

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horizontal incision made between rectal and vestibular tissue forming a rectal and a vestibular shelf, dissection continued cranially for 3-5 cm and lateral and caudally along the junction of rectal and vestibular mucosa so that tissues can be apposed on midline without tension, vestibular flaps are apposed with continuous horizontal mattress pattern with absorbable suture cranially and interrupted caudally, 2nd layer closure is interrupted purse string with 4 bite [right subrectal mucosa, right subvestibular mucosa, left subvestibular mucosa, left subrectal mucosa] without penetration of rectal mucosa

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When is the 2nd stage of aanes perineal laceration repair occur?

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3-4 weeks after 1st stage when tissues are healed

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Describe 2nd stage of aanes perineal laceration repair:

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triangle epithelial surface is dissected from perineal body, tissues are apposed on midline using 4 bite purse string suture, caslick performed

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Describe modified goetze technique:

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horizontal incision made between rectal and vestibular tissue forming a rectal and a vestibular shelf, dissection continued cranially for 3-5 cm and lateral and caudal along junction of rectal and vestibular mucosa so that tissues can be apposed on midline without tension, 6 bite interrupted pattern apposed vestibular and rectal tissues with sutures place 1.5 cm apart to within 4-6 cm of the cutaneous perineum, perineal body reconstruction performed, caslick perform

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What is the 6 bite suture of the modified goetze technique:

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left vestibular ventral to dorsal, left rectal submucosa, right rectal submucosa, right vestibular dorsal to ventral, right vestibular flap axial to previous vestibular bite ventral to dorsal, left vestibular flap dorsal to ventral

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Approaches to rectovestibular fistula repair:

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horizontal through perineal body, direct suturing, U pedicle flap

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Describe horizontal approach to rectovestibular fistula repair:

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horizontal skin incision made midway between anus and dorsal commissure of vulva with sharp and blunt dissection to separate the perineal body past the fistula for 3 cm, rectal portion should be 2/3 thickness and vestibular portion should be 1/3 thickness, fistula in rectal tissue is closed in a horizontal (transverse) plane in an interrupted lambert pattern with absorbable suture, vestibular shelf closed in a longitudinal plane with continuous horizontal mattress pattern with absorbable suture, dead space between is closed with an interrupted purse string pattern or left to heal by 2nd intension, if dead space closed, skin is closed

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How are cervical lacerations treated?

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3 stay sutures placed in external cervical os to retract it caudally for access to the laceration, scar tissue excised with scalpel or scissors, inner cervical mucosa closed cranial to caudal with continuous horizontal mattress pattern, cervical muscle apposed in simple continuous pattern, outer cervical mucosa closed in simple continuous pattern

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Sexual rest after repair of cervical lacerations:

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30-45 days

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Management of urovagina in cows:

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extension techniques only (transverse fold (monin) does not work in cattle) FAS describes combination brown-mckinnon, mckinnon, shires

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Treatment of vaginal and cervical prolapse in ruminants:

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buhner suture or vaginopexy

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Benefits of buhner suture:

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provide support at the point at which initial eversion of the vaginal wall occurs

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Describe buhner suture:

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2 vertical incisions made, 1 between ventral anus and dorsal commissure of vulva and 1 ventral to vental commissure of vulva, gorlach needle used from left ventral incision coursing cranial and lateral along sacrosciatic ligament to exit left dorsal incision, umbilical tape if threaded through eye of needle and withdrawn, needle is passed similarly on the right side, tape exiting left dorsal is passed through eye and pulled through right ventral, tape is tied leave 2 finger width passage

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Options for vaginopexy:

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cranial vagina sutures to iliopsoas muscle through vaginal (blind) or caudal celiotomy (open), button pexy from vagina wall through sacrosciatic ligament and gluteal muscle, tied on skin through button; only performed on 1 side regardless of approach to prevent pneumovagina