perineal reconstruction

Perineal reconstruction is used for the surgical treatment of neonatal malformations. When the child's external genitalia is ambiguous at birth, it must be noted whether it is a gender deformity, and the physician should determine the gender as soon as possible. Surgery to correct gender must be done as soon as possible. There are four main types of gender confusion at birth: 1 female pseudohermaphroditism; 2 male pseudohermaphroditism; 3 true hermaphroditism; 4 mixed gonad hypoplasia. Treatment of diseases: female pseudohermaphroditism in children with gender deformity Indication Perineal reconstruction is applicable to: 1. Children with both sexes need to undergo perineal reconstruction during their infancy as a female. 2, male pseudo- and hermaphroditism and true hermaphroditism children, if the external genital, secondary sexual characteristics and sexual psychology close to women, child support from childhood, requiring the external genitalia to be female, is also suitable for perineal reconstruction. Preoperative preparation Do endocrinology and sex chromosome examination, and if necessary, do sex with a gonadal biopsy. I have the same hypospadias surgery. Surgical procedure 1, clitoris truncation (1) The corpus cavernosum that extends from the pubic symphysis branch into two halves constitutes an enlarged clitoris. Make an annular incision at 2.0 mm from the clitoris head. (2) Cut the midline of the dorsal skin to the proximal side and cut the Buck's fascia. The dorsal cord-like protrusions on both sides of the midline are carefully dissected on the surface of the tunica albuginea, which is a bundle of neurovascular bundles composed of bilateral arteries and central veins. Continue to dissect proximally to the cavernous foot and then remove. The skin of the clitoris head and the cavernous body retain only the distal part of the size of the normal clitoris head and cover the skin, retaining the neurovascular bundle. Wound bleeding, hot gauze compression or light electrocautery to stop bleeding, be careful not to hurt too much tissue to protect the clitoris from erection. (3) The proximal and distal ends of the severed sponge are anastomosed. Intermittent sutures were made with 5-0 synthetic absorbable sutures. (4) Excessive clitoris skin can be pulled down to make a labia minora, in order to retain sensitive clitoris skin. The clitoris truncation is often performed concurrently with low vaginoplasty. 2, low vaginoplasty (1) Incision: After the clitoris is truncated, the skin of the clitoris is divided into two equal parts and cut down, and the clitoris head is redone. The "U" shaped skin incision is made as a flap outside the labia scrotum pleat. The extent to which it needs to be expanded. The U-shaped flap was inverted in the perineal shape and the anal wide base level, and the urethra was inserted into the balloon catheter. (2) Lift the "scarf" flap of the labia scrotal flap and labia minora, and suture the visceral mucosa on the medial side. The "U" shaped flap of the rectal base is turned down and dissected backwards toward the anus. At this point, a finger can be inserted into the rectum, away from the posterior wall of the vagina for anatomy, and damage to the rectum and vaginal wall should be avoided. The vagina was cut back in the midline, and flaps A and A' were placed with 5-0 synthetic absorbable sutures for intermittent sutures. Make two small incisions on both sides of the vagina, and then further transfer the labial scrotal flap to the perineum and suture the edge of the "U" shaped flap. (3) At this time, the reconstructed labia becomes longer, and the central part of the labia scrotum pleat is often rich. It can be pulled to the two side incisions of the vaginal wall, widening the vaginal opening, and the narrowing of the vaginal opening is the most common long-term complication after surgery. . If the skin of the clitoris is longer, it can be further utilized to increase the mucosa on both sides of the genitourinary sinus. 3, high vaginoplasty (1) The U-shaped flap and the U-shaped flap of the labia scrotum are turned upside down from the rectum. (2) When dissecting the posterior wall of the urethra, the balloon catheter can be lifted to avoid injury to the external sphincter, where a firm prostate tissue can be encountered. The vagina is then separated from the urethra and transected. The urethra is sutured, but not too tight, to avoid stenosis, and not too loose to prevent the formation of a diverticulum. Remove the urethral probe and insert the balloon catheter into the bladder. The vagina is released upwards to the retroperitoneum. Fingers are inserted into the rectum to avoid damage to the rectum and the posterior wall of the bladder. (3) The vaginal opening is usually narrow, so the vaginal opening must be cut. The perineal posterior flap can be anastomosed to the deep, and the anterior and posterior flaps of the genitourinary sinus are pulled into the vagina and the incision is made. complication 1, clitoris necrosis The clitoris truncation can cause ischemia and necrosis of the clitoris head due to damage to the dorsal nerve and vascular bundle. The prevention and treatment measures are to pay attention to the preservation of the dorsal nerve vascular bundle during the operation. 2. Urinary incontinence When the vaginal opening is performed in the urethral sphincter for high vaginoplasty, the urethral sphincter can be damaged and urinary incontinence can be caused after surgery. During the operation, the vagina must be separated from the urethra, and the urethral sphincter should be preserved to avoid postoperative urinary incontinence. 3, vaginal stenosis Long-term vaginal stenosis can be complicated by vaginalplasty. The vaginal opening is enlarged by the scrotal scrotal flap during operation, and the vaginal opening is expanded regularly after operation.