Differences

This shows you the differences between two versions of the page.

--- resident:christodoulos_kaoutzanis [2023/07/07 15:59] – [Facial Feminization: frontal bone contouring, brow lift] ally
+++ resident:christodoulos_kaoutzanis [2023/10/31 18:26] (current) – [Pedicled ALT Phalloplasty] haley.d
@@ Line 480: / Line 480: @@
 </WRAP>
 </WRAP>
+==== Radial Forearm Phalloplasty ====
+{{ :resident:template_for_rfff_phalloplasty.pdf |}}
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
 ==== BBL ====
@@ Line 595: / Line 606: @@
 \\
 The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. Of note, the patient was repositioned from lithotomy every 3 hours, and positioning was rechecked each time. The bladder was intermittently drained. No hematuria was noted. All counts were correct at the end of the case. Dr. Higuchi's assistance was critical to the successful completion of this surgery because of the significantly increased complexity. No qualified residents were available to assist with this technically demanding operation.
+Penile Inversion Vaginoplasty (Full Depth) Description Of The Procedure:
+The patient was taken to the operating room and positioned supine on the operating room table. Sequential compression devices were placed on both lower extremities for mechanical VTE prophylaxis. Heparin 5,000 units was administered subcutaneously for chemical VTE prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. After induction of general anesthesia, a timeout was performed with the entire team. The patient was placed in lithotomy in yellowfin stir-ups well padded. The arms were tucked. All bony prominences and pressure points were well padded. Markings were made. The abdomen, genitalia and perineum were prepped and draped in the usual sterile fashion. An 16 French Foley catheter was placed on the table in sterile fashion, and the bladder drained.
+First, a 2 cm wide by 3 cm long rhomboid flap was designed in the perineum, with the ischial tuberosities and the tip at the perineal scrotal junction as landmarks for the base of the flap. The skin of the rhomboid flap was incised with a 10 blade, and using electrocautery the perineal flap composed of skin and fat was elevated down to the bulbar urethra. Then, the scrotal skin from the base of the penis to the perineo-scrotal junction was excised leaving the tunica vaginalis intact. The remaining tunica vaginalis became incorporated into the soft tissue of the labia later. The scrotal skin was kept on the back table to be used later for vaginal reconstruction. Using a 15 blade, an incision was then made in the midline of the scrotum and along the ventral side of the penis. A circumferential incision in the penile shaft skin was also made 2 cm below the corona of the glans. This excess skin from the shaft was later used for the clitoral hood. A clamp was placed on the glans, and the penis was degloved in the plane of Buck’s fascia creating a flap that would be used to line the vulva and create labia minora. Care was taken not to injure the neurovascular bundle.
+We then proceeded with the bilateral orchiectomy. The tunica vaginalis was opened with electrocautery over the left testicle.  The right testicle was delivered and held with a penetrating towel clamp.  The surrounding tunica vaginalis and the adventitia of the spermatic cord were dissected free up to the pubic symphysis and the external ring. The spermatic cord was skeletonized. The right spermatic cord, vas deferens, vein and artery were suture ligated with a 0-Silk suture. We ensured that the remaining tissue was hemostatic. Care was taken to be sure that the cord retracted back into the canal and was not palpable. She was found to have a right inguinal hernia that we repaired primarily. The hernia sac was separated from the cord and reduced below the fascia and the fascial defect was then approximated with several 0 Prolene sutures in a figure-of-eight fashion. Then, a similar procedure was performed for the left testicle. The tunica vaginalis was opened with electrocautery over the left testicle.  The left testicle was delivered and held with a penetrating towel clamp.  The surrounding tunica vaginalis and the adventitia of the spermatic cord were dissected free up to the pubic symphysis and the external ring. The spermatic cord was skeletonized. The left spermatic cord, vas deferens, vein and artery were suture ligated with a 0-Silk suture. We ensured that the remaining tissue was hemostatic. Care was taken to be sure that the cord retracted back into the canal and was not palpable. She was found to have a left inguinal hernia that we repaired primarily. The hernia sac was separated from the cord and reduced below the fascia and the fascial defect was then approximated with several 0 Prolene sutures in a figure-of-eight fashion.
+The ischiocavernosus muscle and bulbospongiosus muscle were then dissected free from the corpora and bulb, and excised with electrocautery. Next, the urethra was elevated above the tunica albuginea of the corpora cavernosum and freed from the corpora cavernosum distally. Penectomy was then performed. The tunica albuginea was incised on the ventral side on the right and left exposing the corporal tissue. A Yankauer suction tip was used to dissect the entire corpora down to the ischium bilaterally. The corporal tissue was elevated off of the tunica with a freer elevator down to the ischium bilaterally. Care was taken to ligate the corporal vessel at the base bilaterally. The proximal base of the corpora were over sewn with a 4-0 PDS running locking suture bilaterally. Care was taken to preserve the neurovascular bundles at 10 o’clock and 2 o’clock.
+At that point, the bulb was reduced and it was plicated using 3-0 PDS sutures. The perineal portion of the vaginal canal creation was done.  The central tendon of the bulbar urethra was incised. The bulbar urethra was elevated away from the rectum up to the urogenital diaphragm.
+Next, the urethra was amputated at the level of the adductor tendon. A vertical incision was made along the ventral aspect of urethra. The urethra was then opened and widely spatulated to the level of the bulb. The excess urethra was then used to line the vulva and the space between the neoclitoris and the urethral meatus.  The urethra was then everted and rosebuded from the 3 to 9 o'clock position with 4-0 PDS sutures.
+The clitoroplasty was then performed. The glans was split on the ventral surface through the urethra to splay open the glans. The central tip of the glans was excised and the remaining glans was thinned on the ventral surface using scissors. The 4 cm long and 1 cm wide remaining glans was then shaped into a clitoris. Horizontal mattress sutures (tunica-skin skin-tunica) were placed between the limbs half way down, bringing the limbs together. A second row of horizontal mattress sutures was placed in the clitoris to create a ridge. A cuff of penile shaft skin served as the clitoral hood.
+Using adjacent tissue transfer, the penile flap measuring 10 cm x 7 cm was then further undermined past the mons with electrocautery. The fat on the mons centrally over the symphysis was cleared with electrocautery. The tunica of the neurovascular bundle was pexied to the mons pubis with interrupted 3-0 Vicryl sutures so that the clitoris was at the level of the adductor. The limbs of the neoclitoris were sutured to the edges of the vulvar lining/urethral mucosa with interrupted 3-0 Vicryl sutures at the base and running 4-0 Chromic sutures on the sides. The rhomboid flap of the perineum was sutured to the floor of the posterior vagina with interrupted 3-0 Vicryl sutures.
+Next robotic assistance was utilized to create the vaginal canal.  First, the robotic ports were placed and the abdomen was insufflated taking care not to injure the intraabdominal organs. Five robotic ports were placed, 1 in the central upper abdomen and 4 ports in a line with that.  The abdomen was inspected with the camera and no injuries were found. We opened the peritoneum right underneath the seminal vesicles. We identified the seminal vesicles and then identified the Denonvilliers fascia. We separated Denonvilliers fascia to develop a space underneath the prostate and between the prostate and rectum.  We worked our way towards the perineal incision while staying above the rectum.  We eventually were able to palpate the robotic instruments through the perineal area. We then connected the 2 incisions from the perineal area. After these incisions were connected, we started to widen the space robotically to be able to place 4 fingers into the vaginal canal.  A peritoneal flap (7 cm x 6 cm) from anterior rectum and posterior bladder were harvested for the colporrhaphy. The excess scrotal skin was then thinned and prepared as a full thickness skin graft 8 cm x 15 cm to line the vagina. It was sewn together over the 35 mm dilator first with interrupted 3-0 Vicryl sutures followed by a running 3-0 Monocryl suture. The graft was then sutured to the penile flap using two layers, first with interrupted 3-0 Vicryl sutures and then running 3-0 Monocryl suture. At that point, Acell MicroMatrix 1000 mg was applied as powder to all the wound surfaces to assist with healing. The penile flap with the incorporated skin graft was then pulled down towards the perineum and into the canal and delivered into the vaginal canal that had been dissected with robotic assistance. The skin tube was then delivered into the canal to be sutured to the peritoneal flaps. It was clear that the penile flap was too short and some of the skin graft would be part of the external genitalia. The midline of the penile flap / skin graft construct was then marked.  An incision in the midline was made in the construct from the clitoral hood to the base of the urethral meatus. The construct was then sutured to the clitoral hood and urethral mucosa with running 4-0 Chromic sutures.  Scrotal skin flaps were then elevated laterally bilaterally and used to create the labia majora. The majority of the scrotal skin was previously excised leaving the tunica vaginalis behind. The tunica became the soft tissue of the labia. Some of it had to be excised bilaterally. The rest tunica fat was tucked in and the outer edge of the labia majora was then approximated to the inner edge of the remaining scrotal skin on each side with interrupted 3-0 Vicryl sutures for the deep dermis followed by a running subcuticular 3-0 Monocryl Stratafix suture bilaterally. The lateral aspect of the rhomboid flap of the perineum was sutured to the penile skin flap laterally with interrupted 3-0 Vicryl sutures. There was some excess tissue along the central aspect of the neolabia majora bilaterally and that was tailor tacked with staples for our planned resection. Once satisfied with the appearance it was marked bilaterally, the staples were removed, and the skin was excised with scissors. Hemostasis was obtained. Both wounds were approximated with interrupted 3-0 Vicryl sutures for the deep dermis followed by a running subcuticular 3-0 Monocryl Stratafix suture. The labia minora were then further defined by using horizontal mattress 3-0 Monocryl sutures between the medial skin and the neovulva on both sides from the level of the neoclitoris all the way down to just above the urethral meatus. While doing that, robotic assisted laparoscopic abdominal colpopexy was performed to fix the vagina into the proper position between the bladder and rectum. The anterior portion of the neovagina was reapproximated to the anterior leaf of the Denonvilliers fascia using 3-0 V-Loc suture in a running manner. The posterior aspect of the neovagina was fixed to the peritoneal reflection overlying the rectum. After this was done, the anterior and posterior leaves of the peritoneal flap were reapproximated robotically using running 3-0 V-Loc suture for closure of the neovagina. The canal was packed with antibiotic soaked Kerlix packing. The apex of the neovagina was visualized laparoscopically to confirm that the packing went all the way up to the apex. The ports were removed and the port sites were then closed. The deep dermis was approximated with interrupted 3-0 Monocryl sutures and the skin was approximated with 4-0 Monocryl suture in a subcuticular manner for all the abdominal incisions.
+The abdominal, genital and perineal skin was cleansed with normal saline. Dermabond was applied to the abdominal incisions. A wound vac was placed on the vulva and perineum over the Kerlix vaginal packing, and then connected to 125 mmHg of continuous suction without any detectable leaks.  The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. Of note, the patient was repositioned from lithotomy every 3 hours, and positioning was rechecked each time. The bladder was intermittently drained. No hematuria was noted. All counts were correct at the end of the case. Both myself and Dr. Higuchi were present for all the critical portions of this procedure.  Dr.
 \\
 </WRAP>