2 Vaginal Incisions and Dissection

Victor W. Nitti, MD , Benjamin M. Brucker, MD

Videos

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2-1 Hydrodissection of the Vaginal Wall

2-2 Dissection of the Distal Anterior Vaginal Wall

2-3 Dissection of the Proximal Anterior Vaginal Wall

2-4 Inverted-U Anterior Vaginal Wall Incision

2-5 Vaginal Closure of Cystotomy

2-6 Dissection of the Distal Posterior Vaginal Wall

2-7 Dissection of the Proximal Posterior Vaginal Wall

An understanding of proper dissection planes and a thoughtful approach to the type and location of the surgical incision enhance the art of vaginal surgery. Establishing proper dissection planes helps to minimize blood loss and injury to adjacent structures. These planes may vary depending on whether the surgeon will interpose autologous or synthetic implant material or flaps. Incisions should be designed to provide maximal exposure to the area of interest while causing the least amount of trauma. In addition, the orientation of the incision is often important—for example, when one wants to close multiple suture lines in a nonoverlapping fashion (e.g., in fistula repair or urethral diverticulectomy) or provide minimal exposure of a synthetic implant to the suture line.

This chapter provides a brief description of the anatomy of the anterior and posterior vaginal walls as well as a description of several common incisions used in vaginal surgery. How best to identify appropriate dissection planes leading into a variety of avascular spaces in the pelvis is also discussed.

Anatomy of the Anterior and Posterior Vaginal Walls

The anterior and posterior vaginal walls have similar but slightly different features and composition. The vaginal wall consists of several layers. Most superficial is the vaginal epithelium, which comprises multilayered noncornified squamous epithelial cells and ranges in thickness from 0.15 to 0.3 mm. Beneath this is a stromal layer (lamina propria) composed mostly of collagen with some intermixed elastin. Beneath the stroma is a fibromuscular layer consisting of smooth muscle and collagen with some elastin. The total thickness of the vaginal wall is 2 to 3 mm. Between the vaginal wall and the underlying structures (i.e., bladder, rectum, cervix) and their supportive tissues is an adventitial layer, which varies in thickness and becomes more prominent as one moves laterally or cephalad toward the cervix. The adventitia contains discontinuous layers of collagen and elastin fibers as well as adipose tissue, nerve fibers, and blood vessels.

The vaginal wall is most densely connected to underlying structures at its most distal aspects. The distal anterior vaginal wall is firmly adherent to the posterior urethra. As one proceeds proximally, the vaginal wall is more easily separated from the bladder. Similarly, the vagina and rectum are densely fused in the distal one third of the vagina. Surgically there is no clear plane of dissection between the very distal vagina and the rectum. As one proceeds 3 to 4 cm proximally, as the adventitial layer becomes more prominent, the plane between the vagina and rectum becomes more easily identifiable.

As the dissection extends toward the proximal vagina or cervix, the preperitoneal space between the base of the bladder and anterior cul-de-sac or the anterior wall of the rectum and posterior cul-de-sac is encountered. Identifying these spaces greatly facilitates identification and entrance into an enterocele sac in patients with enterocele or apical prolapse.

The vagina is highly vascularized and becomes more so as one dissects laterally. Large venous plexus and sinuses account for this vascularity. Thus it is vital to attempt to dissect just below the fibromuscular layer when such a plane is identifiable. The lateral dissection anteriorly should extend to the inferior pubic ramus on each side and posteriorly to the pararectal gutter on each side.

Vaginal Dissection and Incisions

Hydrodissection

Some surgeons find that the dissection of the vaginal wall is enhanced by the use of hydrodissection or the injection of a liquid into the plane between the vaginal wall and the underlying structures (Video 2-1

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