Vestibulectomy surgery is called complete right and left anterior and posterior vestibulectomy with vaginal advancement flap. Using this nomencluature, the complete surgery involves an excision of the portion of the vestibule that is several centimeters to the right and left above the urethral opening, called the urethral meatus. The complete surgery removes the entire lateral hymenal tissues to the lateral vestibular walls at Hart’s line, and involves removal of the entire posterior fourchette from the posterior hymenal remnants down to the perineum. This wide excision is necessary to remove the high density of pain nerve fibers confined to the vestibular tissues that are not found in the vulvar or vaginal tissues. The high density of nerve fibers is derived from congenital neuronal hyperplasia as in primary provoked vestibulodynia or trauma/inflammation/ genetic-induced neuronal hyperplasia as in secondary provoked vestibulodynia. The nerves are fortunately very near the skin surface so only a depth of 3 mm of vestibular skin needs to be excised. The usual surgical time is 60 minutes.

The key principles of surgery are as follows. The embryology of the vagina, vestibule and vulva are distinctly separate. As the anal mucosa of the anus connects to skin, as the buccal muoca of the mouth connect to skin, as the nasal mucosa of the nose connects to skin, etc, the vaginal opening can be safely and effectively connected to the vulva. The vestibular skin and it high density pain fibers can be completely excised.

Before any surgery, the patient is changed into a hospital gown and all jewelry and other possessions are removed and stored in a secure place or given to the partner or a family member. An intravenous line is started in the pre-operative room. The patient and partner or family member need to converse with four key hospital or surgical out- patient personnel. These include the surgeon, the anesthesiologist, the operating room nurse and the recovery room nurse. Any questions concerning the surgery are addressed. The patient undergoes a history and physical exam in the pre-operative holding area. The informed consent is signed.

The patient is then transferred to the operative suite. If the transfer is by bed, the patient can be given sedation in the pre-op holding area. Once the patient is comfortable on the operating table/bed, the anesthesiologist and operating room nurse communicate with the patient to induce general or regional anesthesia. Following the induction of adequate anesthesia, the patient is placed in the standard lithotomy position lying on the back with legs in stirrups.

The vestibule, vulva and vagina are cleansed with a povidone-iodone preparation or other preparation if there are any known allergies. The surgeon and the scrub technician have washed their hands with special soap and wear sterile gloves, gown and mask. The surgeon typically wears magnifying surgical loupes and a special focused headlight.

The patient is then covered with sterile drapes that allow exposure only of the perineum. A sterile surgical marking pen is used to mark the incision several centimeters above each side of the urethral opening to Hart’s line laterally to the junction of the posterior fourchette. The line continues to several millimeters below the hymenal remnants around the vaginal opening. Marcaine with epinephrine is administered subcutaneously within the region of the incision to provide pain control and minimize bleeding. The region is fully exposed using a surgical retractor and specialized surgical hooks.

Initially the right and left anterior vestibular tissue are excised carefully to a depth of approximately 3 mm, protecting the urethra and urethral meatus. The dissection continues to the right and left lateral vestibule from the hymenal remnants to Hart’s line. The final dissection involves the excision of the inferior or posterior portion of the right and left vestibular tissue from the posterior hymenal remnants to the posterior fourchette. At all times care is taken to excise tissue to a depth of only 3 mm, being careful not to excise too deeply. The excised vestibular tissue occurs in the first few minutes of the surgery. The specimen is sent to pathology.

The remaining portion of the surgery involves the repair. The right and left anterior repair is developed first. Skin sutures pass from the skin to the subcutaneous tissue to the floor of the right (and then left) anterior vestibule back to the subcutaneous tissue on the other side and then through the vulvar skin. The suture is then tied and redundant suture material is cut. Approximately 15 interrupted or individual sutures are used on the left, and another 15 on the right side.

Attention is then given to the right and left lateral and posterior repair. The surgeon places holding instruments on the posterior vaginal wall and under tension, uses careful blunt dissection to establish the plane in the tissue that separate the rectum from the vagina, the rectovaginal fascia. Careful dissection allows the vaginal tissue to be separated and advanced to eventually close the gap made when the right and left lateral, and posterior vestibular tissues were excised. Two rows of anchoring sutures ensure that there is no tension, and carefully secure the vaginal advancement flap in place. All anchoring sutures are passed in a vertical or longitudinal (versus horizontal or transverse) plane so that when tied there is effective advancement and not vaginal narrowing. The final mucosal repair is made with approximately 30 interrupted sutures.

Bleeding during this procedure is minimal. The wound is washed with saline. Additional local anesthetic is injected so the patient can have several hours after the procedure with minimal discomfort. Antibiotic ointment is placed on the incision area. Gauze is placed over the ointment on the incision. The patient is taken out of the lithotomy position. The patient is provided with a pad, and mesh-like panties. The patient is then transferred to the recovery. Assuming that all vital signs are appropriate, the patient can go home in a few hours. The patient is advised to ice the region for several days and soak in a sitz bath or bath for many weeks to keep the area clean, reduce swelling, reduce pain and help the stitches eventually dissolve. Post-op instructions will be provide by the surgeon.

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