RU2140220C1 - Method of surgical treatment of malignant tumors of external female genital organs - Google Patents

Abstract

FIELD: medicine, oncology. SUBSTANCE: method includes removal of tissues in form of triangle of vulva with skin, fat and lymphonoduses of inguinofemoral region; at the first stage, inguinofemoral lumphadenectomy, and iliac lymphodenectomy by indications; separation of skin graft from top down from periphery to center; ligation of large subcutaneous vein in region of anastomosis with femoral vein without formation of stump; dissection of femoral wide fraction over edge of inguinal ligament and above tailor's muscle and musculus adductor of femur; vulvectomy with removal of surface muscles of pelvic fundus; removal of paravaginal fat; closing of wound defect by longitudinal displacement of abdomen skin and femurs; turning inside out of mucous membrane of vagina; suturing of mucous membrane with edges of skin wound of vulvectomy. EFFECT: improved quality of treatment and increased life of patient. 6 cl, 2 dwg

Description

 The alleged invention relates to medicine, namely to oncology, and can be used in the treatment of malignant tumors of the external genital organs in women.

 Despite the fact that vulvar cancer is quite rare (3 - 4% of all genital tumors), the problem remains acute, since tumors of this localization are poorly exposed to radiation treatment and chemotherapy and develop mainly in elderly women, which increases the risk of surgical intervention.

 Cancer of the external genitalia in women can affect the labia minora and labia minora, the clitoris, the large gland of the vestibule, and even the entrance to the urethra. At the same time, lymphogenous metastasis quickly develops with the involvement of the inguinal-femoral, and often the iliac lymph nodes.

 In the treatment of vulvar cancer, surgical treatment tactics are preferred. It underwent a great evolution: from tumor resection to radical vulvectomy, together with the removal of regional inguinal-femoral lymph nodes and the conduct of iliac lymphadenectomy.

 A known method for the surgical treatment of vulvar cancer, consisting, as a rule, of two stages. At the first stage, a vulvectomy is performed, and at the second, a lymphadenectomy is performed according to the Duquen method. The method is described by many authors, including A. I. Serebrov in the book "Operational Oncogynecology", publishing house "Medicine", Leningrad Branch, 1965

 This operation can be carried out in two stages and sometimes simultaneously. In satisfactory condition, the patient operation is carried out simultaneously. At the first stage, the patient is placed in a position for gynecological examination. A vulvectomy is performed, i.e. removal of the external genital organs. The operation begins with two oval cuts. One of them begins above the clitoris, passing along the outer edge of the labia majora on both sides and ends in the middle of the perineum. The second oval incision begins 1 to 2 cm above the urethra, then it continues along the base of the labia minora, around the vagina, ending at the posterior commissure. Excision of the vulva is performed to the muscles of the pelvic floor. After suturing the wound of vulvectomy, the patient is transferred to the supine position and bilateral Duchenne surgery is performed (the course of the operation is described below).

 With severe extragenital pathology, the elderly patient and a high degree of anesthetic risk, the operation is carried out in two stages. At the first stage, a vulvectomy is performed, and after wound healing (after 4-8 weeks), the second stage is performed - bilateral inguinal-femoral lymphadenectomy according to Duchenne.

 The operation aims to remove fiber and lymph nodes of the inguinal-femoral areas in a single block and is performed on both sides. Fiber of the inguinal region is exposed by a vertical incision, from the level of the anteroposterior iliac spine through the middle of the inguinal fold to the top of the Scarp triangle. The edges of the skin are separated to the sides, outward to the anterior iliac spine and inside to the middle of the pubis. The exposed broad fascia of the thigh along the periphery of the entire allocated area is dissected above the tailor and long adductors. The entire cell block is separated from the periphery to the center of the formed triangle, in the direction of the external opening of the femoral canal. In the lower corner of the Scarp triangle, a large saphenous vein is isolated and bandaged.

 The entire block with fiber and lymph nodes is separated from the surrounding tissues. Vascular lesions ligate and cross. The large saphenous vein is again ligated at the site of its inflow into the femoral vein. The shameful artery and all vessels richly represented in this area are ligating. They raise a bundle of Zsimbernatova, from which fiber with lymph nodes is extracted. Spend hemostasis, separate silk sutures are applied to the skin.

The operation has the following disadvantages:
1. Quite often there are hematomas, necrosis of the edges of skin flaps, infection in the thigh and swelling due to the intersection of a large number of vessels.

 2. The lymph vessels containing cancer emboli are not completely removed, which can contribute to the progression of the cancer process.

 Currently, the most widely used method for the surgical treatment of vulvar cancer described by Ya.V. Bohman in the book "Guide to Oncogynecology", "Medicine", 1989, adopted as a prototype.

 The method consists in a simultaneous two-brigade extended vulvectomy with inguinal-femoral and iliac lymphadenectomy in a single unit. The author substantiates the feasibility of preventive lymphadenectomy with early lymphogenous metastasis and only a slight increase in operational risk.

 The patient is placed in a standard position, adopted during vaginal operations. The operation is carried out by two teams. One of them performs inguinal-femoral lymphadenectomy, and the second simultaneously vulvectomy. According to the author, this tactic reduces the operation time by almost half. Inguinal-femoral lymphadenectomy is performed with a scalpel, and vulvectomy is performed using a diathermosurgical technique (electric knife).

 An incision is made simultaneously with the external genitalia, including the clitoris and the labia majora. The incision is completed in the middle of the perineum. The second incision ovally surrounds the vestibule of the vagina and its upper edge passes above the urethra at a distance of 1 cm. In this case, the symphysis, sciatic-cavernous muscle, urogenital diaphragm, and bulbous-spongy muscle are determined.

 When performing lymphadenectomy, in contrast to Duchenne’s surgery, a transverse arcuate incision is made between both anteroposterior iliac spines. This incision is connected with the upper borders of the vulvectomy. When performing an arcuate incision, deep epigastric vessels are maintained to reduce the risk of necrosis of skin flaps in the postoperative period and improve wound healing. Then the edges of the wound are bred and, with transverse access, all the discharge lymphatic vessels and the frontal nodes are cut off.

 During these manipulations, a significant amount of fatty tissue is left on the skin of the inguinal region. Remove fiber and inguinal lymph nodes between the superficial and deep leaves of the broad fascia of the thigh. The large saphenous vein is ligated with silk and is crossed 2 cm above the site of its flow into the femoral vein. After removal of fiber with lymph nodes, the neurovascular bundle and thigh muscles remain in the scarp triangle.

 Further (according to indications), an iliac lymphadenectomy is performed. For this, an aponeurosis of the external oblique muscle of the abdomen or inguinal ligament is cut 3 cm above the inguinal ligament from the place of its attachment to the anteroposterior iliac tubercle. Then, tissues of the second stage of PB metastasis (external, internal iliac and obturator lymph nodes) are removed.

 The wound is sutured, connecting the inguinal and scallop ligaments, closing the opening of the femoral canal. The tailor muscle is sutured to the inguinal ligament. Drainages are placed in the inguinal and iliac regions, forming an active vacuum drainage.

The disadvantages of the prototype include the following:
1. Proposed by Bohman, J.V. a skin incision, in our opinion, does not fully comply with the principle of casing. Do not remove the skin with underlying fiber over the inguinal lymph nodes and lymphogenous metastasis pathways. Do not remove the diverting lymph vessels going to the inguinal-femoral lymph nodes, which may contribute to the recurrence of the cancer process.

 2. The incision requires scalping (removal of skin-fatty tissue) over a large area, which leads to necrosis of the edges of the wound and healing by secondary intention (according to Y. V. Bohman in 50% of cases).

 3. Inguinal-femoral lymphadenectomy in the position of the patient as for gynecological examination makes access to the inguinal-femoral lymph nodes extremely difficult. This does not accelerate, but, on the contrary, delays the operation, making it dangerous in terms of possible injury to the femoral vessels.

 4. The femoral artery and vein are not taken for ligature (soft turnstile), which also complicates the removal of lymph nodes and creates the risk of injury to large vessels.

 5. The large saphenous vein is only ligated at the final stage of the inguinal-femoral lymphadenectomy, which complicates the latter due to bleeding of tissues and limited mobility of fiber with lymph nodes. At the same time, a stump of a vessel 2 cm long is left, which leads to the formation of a thrombus in it and an increased risk of thromboembolism. According to Ya.V. Bohman, mortality from thromboembolism in his cases is 4%. In the distal section, the large saphenous vein is ligated without taking into account its anastomosis with the deep vein of the femur, which leads to venous insufficiency and also an increased risk of thromboembolism.

 6. Dissection of the wide fascia of the thigh is performed not above the tailor muscle, but directly above the vascular bundle, which does not exclude the possibility of injury to the femoral vessels.

 7. Removal of fiber with lymph nodes included in it is performed from the lateral side and the apex of the Scarp triangle up to the center, to the place where the large saphenous vein flows, and not vice versa. This contradicts the principle of ablasticity and may contribute to further metastasis of cancer cells.

 8. A vulvectomy is performed with an electric knife, which causes coagulation tissue necrosis and leads to tissue healing by secondary intention (According to the author, in 50% of cases).

 9. Do not remove the superficial muscles of the pelvic floor, which can lead to relapse of the tumor.

 10. Do not remove paravaginal fiber, which also leads to local recurrence and metastasis of tumor cells into the pelvic lymphatic collector.

 11. Do not separate the lower third of the walls of the vagina for their tightening and stitching with the edges of the skin wound, providing a displacement of the postoperative scar from the entrance of the vagina in order to achieve further painless intercourse.

 12. The author did not use temporary vascular clamps on large main vessels, which increased blood loss and increased operation time.

 The aim of the present invention is to reduce mortality and reduce the number of postoperative complications, improve quality and increase the life expectancy of the patient.

Tasks:
1. Decrease in the level of postoperative recurrence of the oncological process.

 2. Reduction of operation time.

 3. Reducing the risk of thromboembolism.

 4. Reduction of blood loss during surgery.

 5. Postoperative wound healing by primary intention.

 6. Improving the quality of life of the patient in the postoperative period.

 7. Decrease in the level of postoperative mortality.

 The essence of the invention is to conduct an incision in the form close to a triangle, the base of which is curved downward and enclosed between the osseous ileum. The base of the triangle is between the awns of the ilium, and the apex is in the center of the perineum. Tumors with underlying tissues and vessels are removed in the direction from the periphery to the center, and the large saphenous vein is ligated when approaching it directly above its inflow into the femoral vein and in the distal section, before its anastomosis with deep femoral vein, and the broad fascia of the femur is dissected under inguinal ligament, above the tailor and long adductors. Fiber with fascia is removed with the lymph nodes from top to bottom and from the periphery to the center. With vulvectomy, the mucous membrane of the vaginal entrance, the superficial muscles of the pelvic floor and paravaginal fiber are removed, and the mucous membrane of the vagina is separated in the lower third and when the wound is sutured, the scar is moved outward from the entrance to the vagina. The closure of a postoperative defect is produced by longitudinal displacement of tissues. During surgery, vascular bundles are taken on soft ligatures (soft turnstile). The operation is carried out first by two teams in the inguinal-femoral areas, and then by one team on the vulva. A vulvectomy is performed to remove the muscles of the pelvic floor, the vaginal mucosa is separated in the lower third, paravaginal tissue is removed, and the wound defect is closed by longitudinal displacement of the skin of the abdomen and thighs, and the vaginal mucosa is widely turned out and stitched with the edges of the skin wound. During the operation, vascular bundles are taken on rubber ligatures (turnstiles). An operation in the inguinal areas is conducted simultaneously on both sides. According to the testimony of the inguinal-femoral and iliac lymphadenectomy, the internal iliac artery is ligated, and the femoral artery is temporarily squeezed. In case of metastatic lesion of the iliac lymph nodes, operative access from the side of a more pronounced lesion is carried out by pararectal access to the retroperitoneal space and dissection of the aponeurosis of the external oblique muscle of the abdomen parallel to the outer edge of the rectus abdominis muscle.

 Fatty tissue along with lymph nodes and a tumor is removed in a single block in order to exclude metastasis.

 The position of the patient during lymphadenectomy should be on his back with legs stretched forward and divorced, and with vulvectomy, in the position for gynecological examination. Reduction of operation time occurs due to simultaneous operation in the inguinal areas.

 The method is as follows.

 The patient is placed in a position on her back, her legs are rotated outward and slightly bent at the knees. Under intubation anesthesia, two teams of surgeons simultaneously produce groin-femoral lymphadenectomy on both sides. Access is carried out by an arcuate incision connecting the two anterior-superior iliac spine bones, passing 3-4 cm above the bosom. The second incision is made from the anteroposterior arch-like arches down the front and inner thighs both on the right and on the left, crossing the Ken line on 8 - 10 cm below the inguinal ligament (For vulvectomy, this incision will continue to the middle of the perineum).

 Thus, the incisions in the inguinal regions have the form of a triangle facing its apex to the vulva. We believe that such incisions provide good access to both the inguinal-femoral and iliac lymph nodes. This incision allows you to remove tissue lying from the pubis to the front-upper edge of the spinous process of the ilium. With this incision there is no need for too thorough "cleansing" of the skin from subcutaneous fatty tissue, as this would increase the risk of necrosis of skin flaps. In FIG. Figure 2 shows the difference between our cut on the skin and the cut proposed by Ya.V. Bohman.

 When the flap is removed from top to bottom, the broad fascia of the thigh is dissected along the edge of the tailor muscle, from the front-upper edge of the spinous process of the ilium to the top of the Scarp triangle, as well as along the inguinal ligament. At the same time, all subcutaneous vessels located on the front surface of the thigh are bandaged. The fascia edge is retracted inward to the adductor muscle, opening the neurovascular bundle. The femoral artery is taken on a soft ligature (soft turnstile) below the inguinal ligament by 2 cm, but always higher than the discharge of the deep femoral artery. If there is a suspicion of a metastatic lesion of the lymph nodes in the vascular bundle, the femoral vein is also taken for soft ligatures, which allows metastatic tumors to be removed with greater care and less risk of injury to the femoral vessels.

 In the femoral triangle, fatty tissue is separated with the lymph nodes enclosed in it from top to bottom and from the periphery to the center. Then the external shameful and superficial hypogastric arteries are crossed and ligated at the site of their departure from the femoral artery. Exfoliate the entire tissue block from top to bottom and from the periphery to the center.

 A vascular clamp is applied to the large saphenous vein at the site of its inflow into the femoral. A vein is crossed and stitched over the femoral vein without stump formation, which reduces the risk of pulmonary embolism. If bleeding occurs from the arterial vessels of the femoral triangle, a temporary compression of the femoral artery is performed. The cut out flap of the wide fascia of the thigh is cut off over the long adductor muscle from the pupartic ligament to the apex of the scarp triangle.

 Having displaced up the pupartic ligament, the cellulose cord is pulled out from under the Zhimbernatovy ligament. Remove all fiber with lymph vessels and the Pirogov lymph node, which is carefully examined and sent together with the removed fiber for an urgent histological examination. Sinking down the Scarp triangle, fatty tissue with lymph nodes surrounding the entire vascular bundle is removed. Bandage and cut off the lower end of the large saphenous vein, but always above its anastomosis with a deep femoral vein. Thus, all fiber and lymph nodes of the inguinal-femoral region are separated by a single block in the direction of the vulva. In the volume of tissues removed, all the lymph vessels that drain from the vulva fall, which virtually eliminates relapses.

 At the same time, the same operation of the inguinal-femoral lymphadenectomy is performed by the second team of surgeons on the other hand. Then, fiber is carefully removed above the symphysis, together with all adjacent laparoid lymph nodes. In cases where an urgent histological examination of the lymph nodes reveals cancer metastases in them, an iliac lymphadenectomy is performed.

 To this end, parallel to and above the inguinal ligament, the superficial fascia is dissected by a section of 12 to 15 cm in length and then an aponeurosis of the external oblique muscle of the abdomen. Move it up and dissect the transverse fascia. After its dissection, they penetrate into the layer of loose fiber, carefully moving the peritoneum, enter the retroperitoneal space.

 In a situation where we have a metastatic lesion of the ileal collector, for lymphadenectomy in the area of aortic bifurcation, it is better to cut the aponeurosis of the external oblique muscle of the abdomen parallel to the rectus abdominis muscle. This access to the retroperitoneal space will make it possible not only to perform iliac lymphadenectomy, but also to remove paraaortic lymph nodes. To this end, skin with fatty tissue is separated slightly higher and an aponeurosis is cut parallel to the rectus abdominis muscle at a distance of 17-17 cm from one side (preferably from the side of the vulvar tumor).

 Lymphadenectomy begins slightly higher than the iliac artery bifurcation, dissecting the thin fascia covering the lumbar muscle. Above the iliac vessels, the lymph nodes with fiber are removed from the inside out from the entire iliac space. If there is a need to remove paraoartal lymph nodes, lymphadenectomy begins above the aortic bifurcation.

 The difficult moment is the removal of lymph nodes located in the bifurcation area of the common iliac vein, because they are intimately connected with the walls of venous vessels. Next, the lymph nodes located in the obturator fossa between the external iliac vein and the walls of the pelvis are removed.

 With increased bleeding during iliac lymphadenectomy, the internal iliac artery is temporarily squeezed, which significantly reduces blood loss during both iliac lymphadenectomy and especially during vulvectomy. The integrity of the aponeurosis of the external oblique muscle of the abdomen and both upper corners of the skin wound are sutured with silk threads. The iliac and inguinal-femoral areas are drained with separate silicone tubes, discharged through separate punctures on the thigh and connected to a vacuum system.

 Then the patient is transferred to a position as for a gynecological examination. After additional processing of the surgical field, one team of surgeons continues the operation. Directly vulvectomy is performed in two sections. The first incision is a continuation of the incision made with inguinal-femoral lymphadenectomy, which goes from the inner surface of the thigh towards the perineum, widely covering the base of the labia majora at a distance of at least 3 cm from them. The same incision is repeated on the other hand. Both incisions converge on the perineum 2 cm above the anus. The depth of the incision reaches the deep muscles of the pelvic floor.

 When a tumor is localized in the clitoris or a locally advanced process, the entire surface layer of the pelvic floor muscles, including the sciatic-cavernous muscle, is removed. An internal incision of vulvectomy is performed 0.5 to 1 cm higher from the external opening of the urethra. Then it goes along the line of entry into the vagina and ends at the posterior commissure. The vaginal tube is separated from the surrounding tissue to a depth of 3 cm around the circumference, excluding the urethra. At the same time, paravaginal fiber is removed in the lower third of the vagina.

 Thus, the drug, consisting of the skin of the vulva, cellulose with lymph nodes and fascia of the inguinal-femoral areas, as well as the superficial muscles of the pelvic floor, is removed in a single block.

 For the purpose of hemostasis and to weaken the tension of the edges of the wound, immersed catgut sutures are applied. The extensive wound surface resulting from the removal of skin above the inguinal regions is closed by longitudinal displacement of the skin from the anterior abdominal wall downward.

 The skin of the abdomen has a well-developed network of blood supply, has good mobility, so closing a tissue defect, although difficult, is possible. The defect under the symphysis is restored by longitudinal displacement of the skin of the abdomen and the skin of the upper inner thigh surfaces. The vaginal mucosa, separated in the lower third, is tightened and sutured to the edges of the skin wound. This slightly reduces the tension of the skin flap and the surgical scar is displaced outward from the entrance of the vagina, which ensures further painless intercourse.

 The area of vulvectomy is actively drained through a separate puncture with two thin silicone tubes, one of which is carried out under the suture above the urethra, and the second on the perineum. The tubes are connected to a vacuum system.

 In the postoperative period, it is necessary to keep the legs connected and brought to the anterior abdominal wall with a constant thin catheter in the bladder for 5-6 days. This technique reduces tissue tension, promoting wound healing by primary intention.

 The proposed method has been tested for 5 years, in a clinical setting for 34 patients, including 6 patients aged 40 to 50 years old, 18 patients from 51 to 60 years old, 9 patients from 61 to 70 years old, and 71 patients 80 years old 3 patients.

Example
Patient Fedorchenko Galina Mikhailovna, 44

 Case history N 2434, was admitted to the city oncology clinic of Krasnodar with a diagnosis of Vulvar cancer (T3N1M0).

 Pathological diagnosis: PIP - 19023-28 - squamous cell carcinoma, keratinizing form.

 Tumor localization: the tumor was located on the clitoris with the transition to the labia minora and labia majora.

 The operation has been completed. Extended vulvectomy.

 30 minutes before surgery, the patient was premedicated.

 The patient on the operating table in the supine position, legs slightly deployed and slightly bent at the knees. General intubation anesthesia is given. The surgical field is treated with a solution of chlorhexedine. A swab with an antiseptic solution is inserted into the vagina. A catheter was placed in the patient's bladder. The operation was performed simultaneously by two surgical teams located to the right and left of the patient. The first skin incision is made in an arcuate manner between the anterior iliac spine, extending 3-4 cm above the fold. The second incision from the anteroposterior spine to the right and left is made in an arcuate direction in the perineum. The arc is curved downward, at the intersection of the Ken line, the distance from the incision to the inguinal ligament is 8 - 10 cm. Later, during a vulvectomy, this incision will continue to the middle of the perineum.

 Starting from the upper edge, from the anteroposterior spine of the ilium, a single block on the right and left simultaneously two surgical teams separated the skin flap with fatty tissue, blood vessels and lymph nodes. At the same time, the broad fascia of the thigh was dissected above the tailor muscle, in the direction from the anteroposterior edge of the spinous process of the ilium to the top of the Scarp triangle and along the lower edge of the inguinal ligament. The subcutaneous vessels on the anterior surface of the thigh were ligated. Then, the entire excised block was exfoliated downward, exposing the neurovascular bundle. A clamp of Satinsky was applied to the safeno-femoral anastomosis, a large saphenous vein was ligated and sutured at the place where it entered the femoral vein without the formation of a stump. The neurovascular bundle was taken on rubber ligatures, pulled up and removed fiber with lymph nodes from top to bottom and from the periphery to the center. Crossed the sacred artery at the site of its discharge from the femoral artery. Bandaged the second end of a large saphenous vein above her communicants with a deep thigh vein. After that, the cut out flap of the broad fascia of the thigh was cut off over the long adductor muscle from the pupartic ligament to the top of the Scarp triangle. The Pupartov ligament was displaced upwards, the cellular cord with lymph nodes, including the Pirogov-Rosenmüller-Kloke lymph node, was removed. The resulting material was sent for urgent histological examination. The same activities were simultaneously carried out by the second team on the other hand. Removed fiber from the paroxysmal lymph nodes above the symphysis.

 In connection with the detection of cancer cells in the inguinal lymph nodes during histological analysis, it was decided to perform an inguinal lymphadenectomy. For this purpose, the superficial fascia and aponeurosis of the external oblique abdominal muscle were cut 2 cm above the pupartic ligament with a 14 cm section. The transverse fascia was dissected and entered the retroperitoneal space. Iliac lymphadenectomy began above the iliac artery bifurcation. Dissected the thin fascia over the iliac vessels. Fiber and lymph nodes were removed from the inside outwards from the entire iliac space, including in the obturator fossa. Hemostasis due to significant bleeding. The hypogastric artery was bandaged on both sides. A thin silicone drainage connected to a vacuum system was placed in the iliac region. Skin from the pubis was removed from top to bottom within the fascia. The first moment of the operation was completed by restoration of the aponeurosis of the external oblique abdominal muscle with silk. Separate vacuum drains were placed in the inguinal-femoral region. The skin was sewn with individual silk seams.

 The second moment of the operation: the patient was placed in a position for a gynecological examination. Re-treatment of the external genitalia with an antiseptic. The operation was continued by one surgical team. Symmetrical sections were continued from the inner thighs to the middle of the perineum, widely circling the base of the large half of the lips. The depth of the incision reached the pelvic floor muscles.

 The second incision was made 1 cm higher and away from the urethra, sinking down the line of entry of the vagina to the posterior commissure. A single unit removed the entire preparation consisting of skin, vulvar tissues, subcutaneous fat with lymph nodes, and a superficial layer of the pelvic floor muscles. A thorough hemostasis was performed. The entire surface layer of the muscles of the pelvic floor, including the sciatic-cavernous muscle, has been removed. The vaginal tube was separated around the circumference to a depth of 3 cm while maintaining the urethra and paravaginal fiber was removed. The removed block included the skin of the pubis, vulva, fiber of the pubis and inguinal-femoral areas, together with lymph nodes and fascia. The skin of the anterior abdominal wall and hips is carefully displaced in the longitudinal direction, the wound surface is closed and sutures are applied. Above the entire symphysis region, the wound is covered by the skin of the abdomen, the rest of the wound - by the skin of the upper inner thighs. The vaginal mucosa was tightened and sutured with the edges of the skin wound in order to reduce the tension of the skin flap and shift the surgical scar outside of the vaginal entrance. Drainage tubes were installed in the vulvectomy area: one under the suture above the urethra and the second on the perineum. The tubes are removed through a separate puncture and connected by a vacuum system. The patient's legs were tied together and slightly bent at the knees. A catheter was inserted into the bladder.

 Wound healing occurred by primary intention. On the fifth day the catheter was removed, on 9 - 11 the sutures were removed. Discharged from the hospital on day 18 in satisfactory condition. Control examinations were carried out with a frequency of 1 time per year for three years after surgery. Complaints of mild swelling of the legs.

 The proposed method for the surgical treatment of malignant external genitalia in women is certainly very traumatic due to the large volume of surgical intervention. However, its invasiveness is lower compared to the method widely used in practice according to Ya.V. Bohman. An advantage of this proposal is that of the 34 operated patients, 26 had a life expectancy of 3-4 years after surgery. In addition, the technology of this operation allows to reduce blood loss relative to the prototype, to reduce the time of surgery and the risk of thromboembolism. Most of the women after surgery felt satisfactory without presenting any particular complaints.

Claims (6)

 1. A method for the surgical treatment of malignant tumors of the external genitalia in women, including the removal of vulvar tissue, tissue with lymph nodes of the inguinal-femoral and iliac regions, characterized in that the vulvar tissue with skin, tissue and lymph nodes of the inguinal-femoral region is removed in the form of a triangle, the basis of which is the line between the two upper awns of the ilium, and the apex is the middle of the perineum, and at the first stage of the operation, an inguinal-femoral and, according to indications, iliac lymphadenectum is performed the mission, the skin flap is separated from the top to the bottom and from the periphery to the center, and a large saphenous vein is ligated in the proximal region directly in the anastomosis with the femoral vein without stump formation and in the distal section, above its anastomosis with deep femoral vein, a wide fascia of the femur is dissected along the edge of the pupartial ligament and above the tailor and adductor muscles of the thigh, a vulvectomy is performed with removal of the superficial muscles of the pelvic floor, separating the vaginal mucosa in the lower third, and the paravaginal cell is removed atku and wound defect is closed by the longitudinal displacement of the skin of the abdomen and thighs, vaginal widely evert and stitch the edges vulvectomy skin wound.  2. The method according to claim 1, characterized in that the operation in the inguinal areas is carried out simultaneously.  3. The method according to claim 1, characterized in that the vessels in the femoral triangle are taken on rubber ligatures.  4. The method according to claim 1, characterized in that the large saphenous vein is crossed without the formation of a stump.  5. The method according to claim 1, characterized in that with increased bleeding during iliac lymphadenectomy, the internal iliac artery is ligated, while the inguinal-femoral lymphadenectomy is performed, temporary compression of the femoral artery during bleeding from the vessels of the femoral triangle is possible.  6. The method according to claim 1, characterized in that with metastatic lesion of the iliac lymph nodes and, if necessary, lymphadenectomy at the level of aortic bifurcation and above, surgical access is performed by dissecting the aponeurosis of the external oblique muscle of the abdomen in the place of its attachment to the rectus abdominis muscle.

Images