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The Management of Vacuum-assisted Closure Following Vulvectomy with Skin Grafting

Hu, Jun, MD*; Haefner, Hope K., MD

Plastic and Reconstructive Surgery – Global Open: April 2018 - Volume 6 - Issue 4 - p e1726
doi: 10.1097/GOX.0000000000001726
Ideas and Innovations
Open
SDC
United States

Summary: Vulvectomies often require removal of large areas of vulvar skin, which may result in problems with wound healing, including infections and scarring. At times, skin grafting is needed following a vulvectomy, and for large excisions, a Foley catheter and rectal tube are often required. Vacuum-assisted closure (VAC) for vulvectomy, with or without skin grafting, has been used for a variety of vulvar conditions. The difficult portion of performing these procedures, with the use of the wound VAC, is obtaining an adequate seal around the Foley catheter and rectal tube. The authors present some useful tips to optimize obtaining and maintaining an adequate seal with the use of Hollister wafers and transparent film dressing during these procedures. This technique has been performed on over 25 patients since 2006. All extensive vulvar wounds requiring split-thickness skin grafts were dressed with a VAC device. With the use of these tips, surgery time and postoperative wound VAC leak alarms have decreased.

From the *Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China

Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, Mich.

Received for publication November 13, 2017; accepted January 30, 2018.

Published online 26 April 2018.

Institutional Review Board Approval: Not applicable; this is a surgical technique article, which is not regulated by the Institutional Review Board at Michigan Medicine.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Hope K. Haefner, MD, Department of Obstetrics and Gynecology, Michigan Medicine, L 4000 Women’s Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109, E-mail: haefner@med.umich.edu

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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INTRODUCTION

Vulvectomies (partial, total, or radical) are performed for a variety of conditions. At times, many different areas of the vulva may require removal, including the mons pubis, labia majora, labia minora, perineum, perianal area, and buttocks, for conditions such as hidradenitis suppurativa, Paget’s disease, and vulvar cancers, among others. When large areas are excised, skin grafting may be required. Although cotton balls sutured over skin grafts have been utilized to optimize graft adherence in the past, the wound VAC has become a popular way to expedite healing. Since it was first developed in 1997,1 the wound VAC has been used successfully in many different anatomic locations.1–4 However, it can be difficult in patients with vulvar or perianal wounds to obtain an airtight seal, especially around the Foley catheter and rectal tube. To date, there are only a few publications on the use of the wound VAC following vulvar surgeries.5 , 6 In this article, we describe tips for optimizing the use of the wound VAC during surgeries of the vulva and buttocks.

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PATIENTS AND METHODS

We identified a specific group of patients who had large lesions of hidradenitis suppurativa (Hurley stage III) or Paget’s disease on the vulva. Due to the extensive size of the lesions, the wounds could not be closed primarily. From 2006 to 2017, over 25 of these patients underwent vulvectomy with skin grafting.

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Procedure

These extensive procedures may be performed in 1 stage (eg, Paget’s disease, vulvar cancer) or multiple stages (eg, hidradenitis suppurativa). At times, wound VACs are used for several days before skin grafting in tissue that has been infected (hidradenitis suppurativa, necrotizing subcutaneous tissue/fascia infections). In these situations, the patient undergoes wound VAC changes every 72 hours until the tissue is ready for skin grafting. Often the tissue is ready for grafting 7 days after the initial procedure. Before surgery, if the lesions are close to the anus, patients undergo a bowel preparation. When areas of the vulva near the perianal tissue require excision, a rectal tube is carefully placed to prevent stool leakage onto the wound. Similarly, when the area of excision is near the urethra, a Foley catheter is placed. After the excision of vulvar lesions, the excised area is irrigated with a Stryker irrigator covered with an x-ray bag to minimize the risk of infection. Once the wound is determined to be optimal for skin grafting, a split-thickness skin graft is obtained with a dermatome from the lateral thigh(s) and meshed. The skin grafts are then placed onto the wound and stapled and/or sutured in place, taking care not to subject them to tension. Once a skin graft is secured, nonadhering dressing is placed over the entire skin graft surface to ease the removal of the wound VAC. A black polyurethane foam dressing is placed over the nonadhering dressing, and a slit is cut in the VAC drape to allow exit of the Foley catheter and rectal tube. Large sheets of transparent film dressing with slits cut in the midline are placed around the tubes, without kinking the drains. Hollister wafers are placed around the Foley (Fig. 1) and rectal tube to prevent further leaks. The Foley is then additionally sealed with 2 overlapping intravenous (IV) transparent film dressings (Fig. 2). Two pieces of transparent film dressing are folded at 90-degree angles and placed adjacent to each other covering the Foley to provide a secure seal (Fig. 3). The wound VAC sealing around the rectal tubes is optimized with the use of Hollister wafers in the same way as the Foley catheter. Transparent film dressings are folded at 90-degree angles and placed around the rectal tube to provide an adequate seal (Fig. 4). The VAC is applied to a continuous suction at 125–150 mm Hg. One hundred twenty hours (5 days) after skin grafting, the wound VAC is removed7 (see video, Supplemental Digital Content 1, which demonstrates the wound VAC procedure. This video is available in the “Related Videos” section on PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A721).

Fig. 1

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Fig. 2

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Video

Video

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DISCUSSION

The wound VAC is a novel technique that uses controlled negative pressure to provide evacuation of excessive fluid, stimulation of granulation tissue, and neovascularization. The wound VAC converts a complex open wound into a controlled closed wound, and a good seal generally ensures a good prognosis. The key point of using a wound VAC in association with a vulvectomy is to obtain an airtight seal around the Foley and rectal tube; however, this is sometimes quite difficult, even for experienced surgeons. We have performed this technique in over 25 patients since 2006, using a VAC device to dress all the vulvar wounds with skin grafts. These tips for adequate sealing around the Foley and rectal tube have decreased both the surgery time and the postoperative wound VAC leak alarms. The wound VAC for the vulva has been performed successfully for our cases and is well tolerated by the patients—expediting the healing of complex wounds and minimizing the time to complete healing. We recommend using the wound VAC, along with the sealing techniques we developed, for surgeries involving areas near the urethra and/or the anus.

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REFERENCES

1. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38:563–576; discussion 577.
2. Bonnamy C, Hamel F, Leporrier J, et al. [Use of the vacuum-assisted closure system for the treatment of perineal gangrene involving the abdominal wall]. Ann Chir. 2000;125:982–984.
3. Webster J, Scuffham P, Stankiewicz M, et al. Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Cochrane Database Syst Rev. 2014;10:CD009261.
4. Kantak NA, Mistry R, Halvorson EG. A review of negative-pressure wound therapy in the management of burn wounds. Burns. 2016;42:1623–1633.
5. Schimp VL, Worley C, Brunello S, et al. Vacuum-assisted closure in the treatment of gynecologic oncology wound failures. Gynecol Oncol. 2004;92:586–591.
6. Narducci F, Samouelian V, Marchaudon V, et al. Vacuum-assisted closure therapy in the management of patients undergoing vulvectomy. Eur J Obstet Gynecol Reprod Biol. 2012;161:199–201.
7. Rhode JM, Burke WM, Cederna PS, et al. Outcomes of surgical management of stage III vulvar hidradenitis suppurativa. J Reprod Med. 2008;53:420–428.

Supplemental Digital Content

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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.