Hello, and welcome to today's webinar. I am Lugmila Lukitskaya, the moderator for today's session. Before we begin, I want to make sure that I'll let you know that we will take questions at the end of the webinar, but you can submit them at any time by typing them into that question box on the left-hand side of the event window. Today's webinar is Surgical Management of the Constricted or Obliterated Vagina presented by Dr. John Gebhardt. Dr. Gebhardt is a consultant in female pelvic medicine and reconstructive surgery and a professor of obstetrics and gynecology at Mayo Clinic in Rochester, Minnesota, and is the immediate past president of FDS. He is also the cohort director of the Augsburg Stent-On Course. Please welcome Dr. Gebhardt. Thank you, Lugmila. We'll get right into it here. You know the title. And the next slide you'll see are my disclosures, nothing very pertinent to this talk. The objectives, we want to be able to recognize and evaluate these conditions. We want to understand principles that avoid constriction intraoperatively, and then ultimately understand surgical options that are available to us in dealing with postoperative obstruction constriction or obliteration. What causes constriction or obliteration? Well, we do. Surgical procedures can, especially posterior compartment procedures, have the, I think the tendency to cause the most constriction of any of the compartments. Atrophy certainly can. We've all seen people with bad atrophic conditions and sort of the walls might want to stick together. Certain dermatologic conditions will, lichen sclerosis on the outside and lichen planus, probably the two most common you might see, lichen planus involving the mucosal layer or the inner layer of the vagina, so inside obliteration. Bone conditions can, certainly congenital things, and then lastly radiation. So ask yourself if you're seeing the patient with a constriction, why does this patient have a constriction? That's going to sort of guide your differential. How do we make the diagnosis? Well, the history and surgical history are very important. I like to review prior operative notes if they've used any sort of, say, a graft or something that might have eroded and caused constriction or obliteration. If something's been done previously, does that impact what you might choose to want to do? So I, especially in a referral practice like mine, I find it very helpful to review prior operative notes. What's the physical exam showing you? Sometimes it's just everything's closed and that might lead you to say, I want some imaging on this patient to see, is there, can I see some upper vagina? Is there something going on above? If it's a congenital thing, is there an obstruction and therefore a buildup of blood behind it? What's the upper tract look like, et cetera? I've found that examination under anesthesia can be very helpful where we just go and take a look. We might do a biopsy or something if we're concerned about making a diagnosis, but it might give us an idea when we're under anesthesia and we can poke and prod and the patient isn't uncomfortable, what we might be able to do in terms of surgical planning for that patient. And then we just wake her back up. We have a discussion thereafter and formulate a plan. Lastly, you know, the common thing I see is that, well, here, here's a dilator or go buy a dilator and take it home and dilate. And I think you have to ask yourself, will dilation work or not? It doesn't hurt anything, but if it's a dense scar and you're pressing on it in the office with your finger and she's, you know, backing up and it's uncomfortable, you know, what's the likelihood that dilation is going to work? I think it's pretty small. So use that when appropriate, but also ask yourself, will conservative management work? So let's start on the outside and we'll work our way up the tract, if you will. So here's an example of a patient I saw. You know, I always would ask my fellows, normal or abnormal? Abnormal. Okay. The labia sort of stopped short. I wasn't sure if this was a high congenital perineal body or labial fusion. And it turns out it was labial fusion. That's what the original picture looks like. There's a ruler to give you a little essence of what her genital hiatus is like. And then we get her in the operating room. I get a curve inside and spread and you can see that it's sort of nice and thin there. And so I'm just going to be able to, and then you see almost now when I tent that skin, you can see where the perineum is. So very simple, straightforward, open that vertically right down the middle. And then from there, I'm going to just over-sew the edges so that I've got tissue to tissue that's going to heal well. She's probably not even going to need to dilate. This lady was, I think, 31. And so everything should stay open fine in something like this. You could use topical estrogen if you'd like, but she probably won't need a dilator because now everything's been open. It can hurt to use one, but not necessary on this particular patient. Normal or abnormal? Abnormal once again, okay? On the outside, like this, lichen sclerosis is probably my leading diagnosis if I'm seeing someone like this. If in doubt, you could get some biopsies and see. Please, if you take nothing else home, take this home that if you see something like this, resist the urge to open it up right away surgically. You must first make a medical diagnosis and then initiate medical management. Get the tissue better. If you operate on this and don't treat it medically, it's just going to scar right back down. So this is lichen sclerosis, and then we're going to go to a video here, if we could play the video, on labial fusion secondary to lichen sclerosis. So you see here, she presented with incontinence because essentially she's voiding into her vagina and there's just a little pinhole. So I've got a lacrimal duct probe here. I get it in that hole, and again, you can see like the other case, the tissue is thin. That's a great sign. So I can safely cut down on that probe and know that nothing's between the skin and the probe. So I can safely do that to open things up, as you see here. Once we get it opened up, then we want to have a little look around. This is an 84-year-old, just for reference sake. I get a curve in the vagina, okay, I can see the urethral meatus. I'm going to open inferiorly with a little cautery here. She doesn't desire a functional vagina because she's not sexually active, but she wants to pee better. Okay, so we've opened things up, looked in, everything thus far looks good. We're going to have a good look inside the remainder of the vagina. I don't have to completely unroof the clitoris here and open everything up anteriorly, again, because she's 84, but you certainly could get a little bit more aggressive, but I can easily get a finger in. We're going to treat. Already, she's got some topical medication. She's going to be using usually a topical steroid of some sort. Have her start that right away, going to have her dilate right away to help keep things open now that we've opened it up. And I wouldn't do any more stitching there. I would just stop there and have her dilate, and that'll heal secondarily. Okay, next slide. Some congenital things, a cribriform hymen, a little electrocautery circumferentially around this will open things up real nicely. Next slide shows sort of a bifid hymen, a midline structure there, a little electrocautery as you see. This is the same patient. We'll open that up nicely. When there's just minor little stuff like that, I wouldn't suture that any further or bring edges to edges. That'll heal in nicely. You could have her use a dilator if you wanted, but generally, they're well estrogenized and ought to do fine just healing secondarily. A little topical estrogen wouldn't hurt anything, often makes things not stick down to one another, so that's something to keep in mind. The next slide shows just another representative photo of a hymenal buildup, and so from that, you want to just resect everything laterally out to where the hymen reaches the sidewall. In that setting, we used a few little stitches here as you see to re-approximate the epithelial edges, so you have to sort of see what it looks like. Does it need a stitch or not? If in doubt, it doesn't hurt to put a few in. You just want to prevent overdoing it with stitching. Sometimes you'll get something like a transverse septum. As this illustration shows, you can see the hematocorpus. Obviously they've got a functional upper tract that's producing that blood, but they may have a completely obstructive septum there. Sometimes there'll be a little bit of a hole in the septum that allows it to drain, but they can't really have intercourse or use a tampon because of that almost obstructive septum. What I like to do there is put a needle, as the illustration shows, through that to sort of find the hematocorpus. You can certainly do it under ultrasound guidance as well if you were so inclined. I'm not a big ultrasound person, but that would certainly be helpful if you were so inclined. What this picture shows is a nice MRI view of a distal transverse septum. You can see the blood lighting up in the lighter color, filling the vagina, hematocorpus, and then you see the level of where the septum is. In my experience, most septums are relatively thin and you can resect them and not have to bridge a gap of tissue, if you will, because the septums I've seen are generally relatively thin. You can certainly get into them and drain the old blood out, which is what this shows. We use a 16-gauge spinal needle to get in and get some of that old, looks like Hershey's syrup coming out as the old blood. You know where you're at. Now I can put a knife in or scissors and open the septum up more, get all that old blood out and then be able to look up in and resect the septum, almost like the Hyman thing, resected back to the side wall and the anterior and posterior walls so that you open everything up and get rid of that. Just like the Hyman area, you'll have to decide whether you need to undermine the epithelium and bring it together or whether you could leave it alone or just put a few stitches to re-approximate. It's going to be an intraoperative decision. So you'll see in the next slide here that we simply undermined a little and re-approximated the epithelial edges with some stitches there. And often you'll see, as you see in the anterior vaginal wall there, a little petechial hemorrhage. Often you'll see that from the old blood and sort of irritation that's up within the vagina. It's good to have a good look around in the vagina because no one has at this point, just to make sure everything else looks normal. Okay, let's move on to a stricture and usually an overzealous posterior repair or maybe more accurately a peroneoraphy is done and there's excessive buildup of the peroneum and the patient complains of dyspareunia. So a simple way of resolving that most of the time, as this illustration shows, is making a vertical incision through all of that scar or buildup of skin all the way to the peroneal body, doing that vertically and then undermining the posterior distal vaginal wall and advancing it and closing it in a horizontal manner. That will nicely open up your diameter. And we're going to go to our next slide. This patient presents with insertional dyspareunia after prior vaginal hysterectomy and repairs. Here you see an examination being performed which shows that the vaginal opening is tight and it is difficult to insert two fingers. There has been scarring and excessive buildup of the peroneal body which has resulted in insertional dyspareunia. With counter traction, a 10 blade is used to make an incision in the peroneal body to open the area up. Electrocautery is then utilized to obtain hemostasis in the area. A cherry tip sucker which is smaller in size and diameter than the typical suction device is beneficial in areas of fine dissection. While the majority of this area is usually scar tissue, it can be highly vascular and it is critically important to obtain adequate hemostasis. The diameter of the vagina is checked and the vagina is examined further. We now begin to mobilize the posterior vaginal epithelium after adequately excising all scar tissue that is present. The epithelium is mobilized such that it may be advanced to the vaginal opening under undue tension. A Mayo scissors is used to free the underlying connective tissue and rectum from the overlying vaginal epithelium. Hemostasis is then obtained with an occasional suture or with electrocautery. What started as a vertical incision will now be closed in a horizontal manner, again Incorporating intervening tissue to obliterate the dead space is important. By closing a vertical incision in a horizontal manner, this will automatically improve the introidal diameter. Interrupted 2-ovicral suture is being utilized here to re-approximate the tissues at the 6 o'clock position. Again it is critical to point out that one should first mobilize the vaginal epithelium such that this can be advanced downward and then interrupted sutures are placed incorporating the underlying intervening tissue to obtain adequate hemostasis. Intervention and counter traction on the most superior sutures are utilized to set up the repair and to provide adequate visualization. It is important as the sutures are placed that the introidal diameter is examined such that we are not overly narrowing the opening as these sutures are placed. For patient comfort, the area can be infiltrated with local anesthetic at the completion of the procedure and this may be performed in an outpatient setting. The diameter is then inspected to be certain that it is adequate for sexual function. Okay so I hope that was helpful, that's something you're definitely going to see in your practice. Let's talk about the vagina. We'll move in a little bit if you will and the next video is sort of an interesting one and I'll voice this over for you. Please go ahead. So this is a young 14-year-old from the Middle East who essentially has no vagina but has a functional upper tract but no obvious cervical connection at least on imaging. We're in the operating room and she has a little incontinence too and interestingly you see this little area of granulation tissue that I'm probing and she's got a congenital urogenital sinus that communicates to the urethra. It was just an interesting finding. We left it alone at this point. We were there to open up the vagina to allow her a chance to try to salvage that. So we made a little mini laparotomy, I put a uterine sound in here, get into the uterine cavity and I'm going to bring that down through the cervix that hasn't fully formed but I'm going to need to dissect vaginally to get to that area. So I always like to put a catheter in to drain the bladder during the dissection and then I've learned if you stay just beneath the urethra is probably preferable, I'd rather air and getting into the bladder than I would the bowel in these settings if I'm going to be off. But just sort of hugging, staying beneath the bladder, dissecting that, that first couple centimeters is the toughest and then it'll open up rather nicely. So there I've brought the probe down through the cervix. There you see the cervix, we just finished cannulizing it. I've got some stitches there that are going to hold a red rubber catheter in place and that's what you see. Rubber and silicone, the vagina will sort of mold around. The little blue catheter runs up through the cervix and into cervical canal to keep that open. The red rubber is going to help keep and form the vagina around that. It was important for her to remain virginal because of her culture and so we didn't want to fully open the vagina up but this is a 30 French red rubber catheter or chest tube and we're securing it into place and that'll stay in place for six to eight weeks and the body will encapsulate around that and form a nice little channel. Think of the analogy of a breast implant and how the body walls that off. This is the same way so you'll develop a nice capsule or a nice sort of one finger vagina as a result of this. We inject a little blue dye coming up here through the fundus to make sure the balloon is where I want it to be and it is. It's running out through the bottom there and again that's holding the cervix open and the vagina open. We closed the little mini laparotomy and she did absolutely fabulous. I don't know if she'll have a functional uterus or not cervix but it was worth giving it a try. Okay, next slide. What is this? Longitudinal vaginal septum, most commonly seen with a uterine didelphys. Don't have to resect these but if there's symptomatic intercourse symptoms, tampon symptoms, simply take them back flush with the anterior wall as you've seen here. I usually do that with electrocautery but I almost always do a little running lock stitch along the way, both along the front wall as you see here and along the back wall because they tend to bleed when you don't have retractors and stuff in there so I would hesitate to just take them down with cautery. You can do it that way but then I would over sew the edges. Next slide. Normal or abnormal? Clearly abnormal. This is a patient's had four or five operations and the vagina keeps closing and this is obviously abnormal to me. We did some biopsies, she has lichen planus and that's what's caused vaginal obliteration despite multiple operations. We did biopsies, I had her see dermatology. We put her on methotrexate and prednisone systemically. She did really, really well with that. There's just an example, we've got a one centimeter vagina to work with that's been multi-operated and this is a 43, 44-year-old lady who desires sexual function. We're now three or four months later. The tissue looks a lot better, not absolutely normal but we did a mac and dough procedure on her. We re-dissected, opened up the vagina, laid in a skin graft. Here's the mold and the skin graft that we use. There it is being taken out now a week later and that's what it looks like now about eight days after implantation. Excellent take of the graft, excellent depth and diameter and she did really, really well. And I think why she did well isn't because of the surgery, it's because we made the medical diagnosis and we got her treated medically and then you're going to be much more successful surgically. Next slide just shows that if you do an A&P repair on someone, you need to see them back in the office especially if they're older or atrophic, those incision lines can fuse down and so this is pretty simple. You could take it down with a little electrocautery but always see your patient's back, make sure those incision lines haven't fused. You can always use a hinge perineal or groin flap. If you look at illustration B that shows a mid-vaginal stricture, you could open that up as is seen in illustration C, almost like a big medial lateral episiotomy incision. You got to get all the way through that scar and then see how big of an area. Then you can go out laterally and sort of outline your flap and rotate it in. You can also, if you had that mid-vaginal constriction, you could just take electrocautery and open up through that as you see here. This is along her right vaginal sidewall all the way to the apex, had a thick band, couldn't even get a finger in past it so we just took electrocautery and opened it up and you'll often get to the levators even seeing fat at times. What I would say is that most people aren't aggressive enough and it's only going to scar down again to some degree so you got to really get it when you're going to go to the operating room and open it up because it's only going to get smaller. You could leave this to heal secondarily and it will. It's just going to granulate a lot, you're going to need to see her back and treat it with silver nitrate again and again, but it works well. Sometimes you can cover that with a piece of something like a Surgicis biodesign and I'll talk a little bit more about that at the end. It maybe allows it to heal a little quicker with less granulation tissue, but it's sometimes depending where it's at can be a little bit challenging to put in place, but we'll talk about that at the end. Let's go back to the hinge flap as you see here. What you want to do is open that constriction up, measure out what you want to do in terms of a flap, and then you want to rotate that flap in as the illustration shows. Here's what it looks like in the operating room. We've already done the vaginal dissection and opened it up. We've done our measurements. I've taken this now from her left groin area and you rotate it in to the vagina, keeping in mind the blood supply is coming from the inferior side of things. And then you sew that into place. You can put a suction catheter in underneath it as you've seen here. You could do that bilaterally for bilateral mid-vaginal stricture as is seen here. This is what it looks like intraoperatively. Ultimately, we want to look at it looking like something like that. Here's our final result looking in and that's our cosmetic result at the end. Not normal, but it didn't start out that way and you have to counsel people about that it may be different. It's going to be drier because it's keratinized skin within the vagina with intercourse. Those flaps will atrophy a little bit so they won't be kissing, if you will, or touching later on, but right now they're a little swollen and edematous just from what we've done. This is what a vaginal agenesis patient looks like, normal anatomy. You see where the catheter is, there's just nothing there. The difference between this and an imperforate hymen is they have no pain with vaginal agenesis because they lack a functional uterus so there's no blood up above. This is the little sponge mold that I tend to fashion the night before. We cover it with a condom and then we harvest a split thickness skin graft to cover it up. We sew that graft on each edge and ultimately we'll put that in the vagina and keep it there for about eight days and then go back and take the condom covered mold out. Let's go to our next video which is a mac and dough video. Go ahead and play that, please. The initial procedure starts with the patient in a left lateral decubitus position. A dermatome set at 17 thousandths of an inch is used to obtain a skin graft from the right buttock. Epinephrine soaked lap sponges are placed on the wound for 10 minutes. At a separate Mayo stand, a sterilized sponge rubber mold is covered with a condom. The excess air is deflated from the condom utilizing a needle. This is done to prevent ballooning of the condom and skin graft when one places the mold in the vagina. The skin graft is then placed over the mold and is secured to the drape with a towel clamp. The edges of the graft are brought together, first with interrupted sutures and then with a running 4-0 suture. The same procedure is then accomplished on the opposite side of the graft. The final result is a temporary mold that is on average around 5 inches in length and 3 inches in diameter. After 10 minutes of direct pressure utilizing epinephrine soaked sponges, the graft site is then covered with an op-site dressing. This is generally left in place for a week to 10 days. Once the wound has been covered, we are now ready to proceed with the vaginal dissection. The initial dissection begins with a catheter in the bladder to drain urine throughout the case. A horizontal incision is made beneath the urethra, identifying the plane between the bladder and rectum. Sharp dissection is used for the first several centimeters. Once this has been dissected, one generally enters an avascular plane. Sponges are then placed in the vagina and cautery and an occasional suture are used to obtain hemostasis as one proceeds with the dissection. Once the dissection has been carried deep enough, ratex sponges are placed in the vagina to gauge the depth that one has obtained. Typically, if one can place 6 to 8 sponges in the vagina, this will be an adequate depth and diameter to accommodate the temporary mold. The vagina is then irrigated and hemostasis is meticulously obtained. It is critical that one obtains adequate hemostasis prior to placement of the skin graft. The vagina is then irrigated and hemostasis is meticulously obtained. Once the cavity has been adequately dissected and hemostasis verified, one can measure the depth of the cavity utilizing the permanent mold. Once this has been established, the skin graft with the temporary mold is placed within the dissected space. The labia are then sewn closed and the patient returns for the second phase of the operation one week later. One week later, the patient has now returned for removal of the temporary mold. Coker clamps are placed on the condom covered sponge rubber mold and gentle traction in a to-and-fro manner is utilized to free the mold from the underlying skin graft. Carefully, one places diva retractors in the neovagina and the vaginal space is then copiously irrigated. Once the space has been adequately irrigated, one assesses the degree of take of the skin graft. Interrupted threovicral suture is then used to secure the skin graft in a clock face manner to the vaginal opening. Excess skin graft is then trimmed. To demonstrate the depth of the neovagina, a lubricated lucite dilator is placed within the vaginal space. Measurement reveals that the vaginal space has a depth of approximately 5 inches. Triple sulfa cream is then placed within the vagina and the permanent mold is placed. The mold has openings on both ends for drainage and cleaning purposes and is tapered in the anterior and posterior planes so that this will fit beneath the urethra to allow ease of voiding. The mold measures approximately 4 1⁄2 inches in length and is gently inserted within the neovagina. The permanent mold is taken out and cleaned by the patient twice a day. Topical triple sulfa cream is applied. The patient will wear this permanent mold for a period of 6 to 12 months or until a point in time that they may use a vaginal dilator as well as sexual intercourse to maintain vaginal depth and diameter. Okay, so the next slide shows what that neovagina looks like after about 6 months. It gets nicely vascularized. They wear that mold for 6 to 12 months and really that skin does quite well over time. So I think a good procedure and the right patient. What about abdominal approaches? You can use the sigmoid on occasion. It is colon so you do get a little mucus production but let's just go over a few technical points. This is looking abdominally from above. We've harvested a segment of the sigmoid. The posterior sutures you see being brought down to the perineal area and you want to do that ahead of time and sort of parachute them down there because that's the hardest area to get at. So that's what you see there. You see the dilator in the vagina and just the orientation. So we're going to bring that in and tie those off because it's hard to place them one by one with the segment down there. It just gets in your way. And then if you put a speculum in, that's what it looks like from above. Let's go to our last video clip and it's a short one if we can play that on a sigmoid neovagina. So you see the sigmoid segment. There's the stapled end. I have a colon and rectal surgeon help me with this. You need to preserve the IMA pedicle which you see right there. You don't want too much of a segment, too much length or you'll pool a lot of mucus up above. So that's just a learning experience. We've already tied those posterior sutures. I'm showing you the anterior part that now we'll sew on. You'll see here it would be really hard to get in posteriorly and put stitches in and tie them down right now. So you want to do that in advance and bring it down and tie them individually. You see that suture in my hand is the anterior vaginal wall, what's left there. And I've placed that already just to orient it, get it in place. There's the dilator to orient me to the vagina. And now we're just going to continue to sew the sigmoid on from about 9 o'clock over to 3 o'clock to secure it in place. This is what it looks like then from below. We've got a speculum in. We had some vagina to work with and then we've got the upper colon segment to give us additional length. Think of that picture from above. The orientation of the vagina is going to go up instead of its usual downward axis. It's going to go up towards the sacral promontory as you'll see the dilator put in. So the orientation is a little bit different. There's the dilator going in, self-lubricating because of the mucosal secretions. That's somewhat of a downside of it is you get secretion for a while. You can douche and irrigate that out or even bring them in the office and essentially do a cysto, except do a vaginoscopy and irrigate the vagina out so you see excellent depth. Where these are trouble is where you hook them up to either the perineum or the vagina. That's where it's going to want to scar down. Okay, what can happen, back to the slides here, you can get a mucosal prolapse. Sometimes you can isolate that and resect it locally vaginally or you can do a sacrocopopexy. The difficulty here though is you see when you put a dilator in that sigmoid segment, it gets very thin and so I get really hesitant to use any polypropylene mesh here. I used a biologic in this case and at the end of it kind of here's what you see. It's better, it's not perfect, but it's staying up inside and she did quite well with that. But if you do sigmoids at times you'll have to get creative in managing some of those issues. Lastly, let's end with biologics. I have no relationship to Cook Medical, but I love this product. Biodesign is porcine small intestinal submucosa and you want the four-ply layer. Four-ply is what you want to use if you want to use this instead of a skin graft in smaller areas. It really, really works well. Here's a couple examples. Here's an apical erosion after a sacrocopopexy from elsewhere. We resected the mesh back, but if you close this area, you really narrowed it down and so what we ended up doing is leaving it open and putting a patch of Surgis's Biodesign in there, kind of like quilting a little bit. That's what it looks like in six to eight weeks after. It really heals quite nicely and takes on the characteristics of the surrounding tissue. Where else is it useful? Here's a patient who had a problem with mesh. You see multiple erosions along the posterior wall, a lot of bunching up. We got the mesh out, but if you close the epithelium, again, you were going to narrow her down to about a one-finger vagina. So instead of closing the epithelium, we just put a patch in of the Biodesign, as you see here. You want to undermine the edges, tuck it in, kind of like you were tucking your shirt or a blouse in your trousers, and then tack it down like that to allow it to heal adequately. And then we'd have her dilate right away to help keep things open. Here's just another example of that. Works very, very nicely as a small little skin graft, but you have to use the four-ply. If you get thicker, six- or eight-ply, it's too thick and the body doesn't like to interact with it. It doesn't work as well, and it'll probably slough that. So four-ply is the way to go. Here's the last illustrative case. This was a right medial lateral episiotomy that came to our institution that had broken down. She'd been packing it and cleaning it for a while. It was looking good. We went to try to close this with one of our chief residents, and it just wasn't going to come together. It had separated too much. So we used a piece of bio-design to cover up that wound. This is what it looked like intraoperatively, because you weren't going to get epithelium to epithelium here. This is what it looks like at two weeks. Those are the vicral sutures there. You can see the remodeling of the base of the wound already is looking great. This is at six weeks. This is at nine to ten weeks. Not a perfect cosmetic result, but a lot better than what we started with, and bio-design has worked really, really well for me in situations like that. I would think about using it if you needed a small area to graft, to maintain the capacity of the vagina without having to harvest a skin graft. So with that, just a couple take-home points. One, avoid constriction when you operate. So when you're doing a posterior repair, feel it. Monitor it intraoperatively as you put your stitch in. Make sure your diameter is okay, that you haven't tightened her down too much. See the patient back for the postoperative visit. We usually do that at about six weeks, but whatever your practice is, see them back, because that will help prevent the scarring of an anterior-posterior incision line or some of the filmy adhesions that might get more solid in someone with atrophy. You can help prevent that and deal with it right then. Post-op, what happens if you're dealing with one of these situations? You've got to get that patient to work with you. They've got to be compliant. I like to use a lot of vaginal estrogen cream afterwards. I like to see them every week or two. Make sure we're maintaining the diameter and the depth. They have to use a stent or a dilator to help keep it open. I have them usually dilate twice a day, in and out several times, again, depending on what the indication is. But it's only going to scar down and get tighter. You've got to use your dilator to keep things open. If it's scarring down, intervene early. Don't let it get mature, if you will, in that scar. Go back and take her to the OR, stretch it out, open it back up, and have her keep dilating if it's stricturing back down on you. To summarize, I want to emphasize be able to recognize and evaluate these conditions. Avoid overcorrection or constrictions at the time of surgery. We don't need to add to the problem. We need to avoid it, and we can do that interoperatively if we're watching and checking what we're doing. If you're opening things up, use estrogen cream. See them back every week or so, and they have to use dilators daily, right from the get-go, to prevent constrictions because it's only going to want to scar down. We've got to splint it and keep it open and let it heal that way. We want to acknowledge the patient that's having these issues and not just say, oh, take a dilator home, it'll get better, and sort of leave them because it generally doesn't get better. Acknowledge there's an issue, and if you're not comfortable dealing with it, find someone in your community that can. So with that, Ludmilla, I'll turn it back over to you if there's any questions. We've got a few minutes, and if we go over, I think, for a few minutes, that's fine, too. We have a couple of questions, and one of them is Dr. Casadente is asking if you ever had used Acell instead of harvesting skin grafts. In line with that, there is a question, did you use any of Biodesign around your mold? And I'm assuming the question is related to the McIndoll. So I guess if you can comment on this. Yep, so Acell has a product, and there's been a number on the market. I've never used Acell or Biodesign for a McIndoll to line the whole vagina. I've used it in smaller areas as analogous to a skin graft. One of the concerns I have is thickness. The Acell product, at least as it was sold for prolapse repair, is too thick to use. I believe it's a six or eight ply, and I wouldn't want to use that thick a product. I've really contemplated using Biodesign, the four ply, for a McIndoll. I've had some colleagues elsewhere use it. One thing that is different about it is that it doesn't adhere to the wound bed in a McIndoll situation like a skin graft does. It doesn't have the fibrin, I think, and stuff. So if I used it, I would probably want to use the condom covered mold in there for a longer period of time to try to get it to adhere and begin remodeling. Because once you pull it out, what I've heard from people is often the graft comes right out with it. And so I've been hesitant to do it because the skin graft is a little disfiguring, but boy, it works really, really well inside the vagina if you do it well. So that's my experience, mainly with Biodesign for smaller skin graft areas. The other question is about the hemostasis during the dissection for McIndoll. Of course, you want it as good as possible, but what level is acceptable? A little losing or it should be bone dry? Yeah, you're always going to have a little bit of bleeding there. You don't want where it's pooling in the vagina when you sort of step back and look because if that bleeding continues, it's going to bleed behind your skin graft and you're going to slough that skin graft. It won't take then. So you're going to have some. I don't use epinephrine or anything inside there or a hemostatic agent because I don't want to impair healing. But the sponge mold that we use when we kind of squeeze it down and put it in will expand a little bit. Think of like squeezing a Nerf football and then it goes back to the football shape. The mold's the same way and that helps really give some hemostasis there too, but you don't want to leave any obvious bleeding or any significant bleeding behind or it'll slough your skin graft. You'll lose that. And where do you get the sponge from? Is it a special kind of sponge? Yeah, you know, the old days it used to be called a hernia block and I don't know where our supply people get it, but I double a piece of that up and sew it together and whittle it down so that it's going to fit in there. I do that the night before. Some people just take a condom and stuff it with a bunch of Raytex or a salt sponge or something is what other people I've seen do. Some have tried different balloons, although when you put fluid in them they get a little heavy, so some people just use air. You don't want obviously your balloon to fail as it's in there healing, but you can get creative. The take-home point if you're going to do things like that is you've got to get it big enough to begin with. It just doesn't easily get bigger without pretty aggressive dilation, so if you think it's a little small, keep dissecting. Get it bigger because the natural healing response is going to make it smaller with time and that's why wearing the mold helps prevent that. But if you're questioning is it big enough, I'd probably keep dissecting and get it bigger to help that patient. You don't want it too small or it's just not going to be functional. Well, thank you very much, Dr. Gebhard. That was a great presentation. On behalf of the AUG's Education Committee, I would like to thank you again and thank everybody for joining us today. Our next webinar will be Pelvic Flow MRI presented by Dr. John Delancey on April 11th. We'll see you then. Great. Thanks, everyone.

surgical management

constricted vagina

obliterated vagina

Dr. John Gebhardt

female pelvic medicine

reconstructive surgery

causes of constriction

diagnostic process

treatment options