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

Non-Obstetric Traumatic Vulvar Hematomas in Premenarchal and Postmenarchal Girls

BACKGROUND

Traumatic non-obstetrical hematomas of the vulva are rare, and most reports only involve adult patients. There are no data on presentation, management, and outcomes from either conservative or surgical management in pediatric and adolescent patients. The objective of this project was to compare the etiology, treatment, and outcomes of traumatic vulvar hematomas occurring in premenarchal and postmenarchal young women.

METHODS

A retrospective chart review was performed on females aged 0-24 years seen at a tertiary care academic center using ICD 9 and 10 codes for traumatic vulvar hematoma from 2006-2019. Data describing their clinical presentation and course were collected. IRB approval was obtained.

RESULTS

Twenty patients, aged 3-23 years (median age of 13.5 years) were identified. All 8 premenarchal patients presented with a straddle injury, whereas only 50% of postmenarchal patients were found to have a straddle injury. Other etiologies among postmenarchal patients included consensual sexual intercourse and recent vulvar surgery. Hematoma diameter ranged from 1-3 cm in premenarchal patients and 0.4-7 cm in postmenarchal patients. Associated perineal lacerations were reported in 50% of the premenarchal girls and 8% of postmenarchal young women. Of the 8 premenarchal patients, 5 were managed conservatively, and 3 were taken to the operating room for repair of perineal lacerations; 1 patient also underwent evacuation of a 3-cm hematoma. Of the 12 postmenarchal patients, 5 had surgical intervention, 2 for pain secondary to large 7-cm hematomas and 3 for suspected vulvar abscesses, which were identified as hematomas after drainage. One patient in each group required a Foley catheter for comfort. Two postmenarchal patients required a second surgery for further wound management. One premenarchal patient with surgical treatment required a follow-up exam under anesthesia. Four patients were admitted for pain and postoperative observation, 1 of whom was premenarchal. Eleven patients were seen for follow-up, and 10 were doing well. One postmenarchal patient in the conservative management group returned to the Emergency Department with continued pain 10 days later.

CONCLUSIONS

In this study that examined traumatic vulvar hematomas in premenarchal and postmenarchal young women, the only mechanism of injury in premenarchal girls was straddle injury, and surgical intervention was usually needed only for repair of perineal lacerations, not a primary hematoma. In the postmenarchal patients, surgical intervention was undertaken for larger hematomas and suspected vulvar abscesses. Our study suggests that most hematomas up to 3 cm in premenarchal patients and up to 6 cm in postmenarchal patients can be managed conservatively.

Clinical outcome of multidisciplinary treatment of vulvar necrotising fasciitis

OBJECTIVE

Vulvar necrotising fasciitis (VNF) is a severe soft tissue infection associated with substantial morbidity and high mortality. At Stony Brook Medicine, US, patients with known or suspected VNF are treated by a structured multidisciplinary team consisting of members of the Departments of Emergency Medicine and Medicine, the Divisions of Gynecologic Oncology, Burn and Surgical Intensive Care Units, Infectious Disease and Plastic Surgery, and the nursing, nutrition, physical/occupational therapy and social work services.

METHOD

This is a retrospective review of patients presenting to Stony Brook University Hospital with VNF over an 18-month period.

RESULTS

A total of 10 patients were treated for VNF during the study period. All patients were treated by the structured multidisciplinary team, including extensive initial surgical debridement by the gynaecologic oncologists. All patients survived to discharge.

CONCLUSION

The results of this review demonstrated that prompt diagnosis, rapid implementation of appropriate antibiotic coverage, surgical debridement of necrotic tissue, and comprehensive care delivered by a structured multidisciplinary team contributed to positive clinical outcomes and decreased the risk of death from VNF.

A Novel Technique for Securing a Bolster For Skin Grafting after Extensive Vulvar Resection

Patients with stage III hidradenitis suppurativa of the vulva and adjacent areas, unresponsive to other therapies, may require extensive surgeries. These include excision of diseased areas on the buttocks, vulva, groins, and abdomen, followed by delayed skin grafting. Negative pressure wound therapy has been used over grafts, but it can be difficult to maintain a seal when extensive areas have been resected. We present a novel technique to bolster skin grafts for optimal success. A total vulvectomy and resection of the buttocks, groins, and abdomen are first performed for stage III HS, incorporating all diseased tissue. Negative pressure wound therapy is applied and changed on postoperative day 3–4. On postoperative day 7, split-thickness skin grafts are applied. The skin grafts are covered by Adaptic gauze (3M Company, Minn.), cotton, and a layer of Reston foam (3M Company, St. Paul, Minn.) which is cut to fit the size of the wound. Ostomy skin barriers (Hollister Incorporated, Libertyville, Ill.) are placed on the skin surrounding the excised areas. Pediatric Foley catheters are then placed through the ostomy skin barriers and tied together to prevent movement of the bolster. The use of ostomy skin barriers and pediatric Foley catheters to secure bolsters has not previously been described. We demonstrate a well-tolerated technique, using common surgical supplies, to provide consistent uniform pressure over the graft site. This technique also allows for easy bedside dressing change(s) when indicated.

Vulvoperineal Hidradenitis Suppurativa: Diagnosis, Treatment, and Management of Deformities

Importance

Hidradenitis suppurativa (HS) is a chronic, inflammatory disorder affecting skin of intertriginous areas that is often encountered and treated by nondermatologic specialists.

Objective

The purpose of this literature review is to provide a comprehensive, clinical source of information on HS as it relates to incidence of disease, pathophysiology, diagnosis, and overall management of this condition.

Evidence Acquisition

Sources were obtained through a comprehensive literature search using PubMed and PMC. Various terms were used to query the database, including "hidradenitis suppurativa," "pathogenesis," "prevalence," "management," "surgery," "perineal," and "vulva."

Results

Underreported prevalence and unknown pathogenesis have subsequently led to variable approaches in clinical management, often employing a combination of medical and surgical management.

Conclusions

Early diagnosis and treatment of HS may lead to better disease control and minimize patients' associated morbidity related to disease.

Relevance

Knowledge of vulvoperineal hidradenitis is necessary for gynecologists and primary care physicians to ensure early diagnosis, management, and referral for optimal patient outcomes.

Oncologic feasibility for negative pressure wound therapy application in surgical wounds: A meta-analysis

Negative pressure wound therapy (NPWT) decreases postoperative complications of various surgeries. However, the use of NPWT for oncological surgical wounds remains controversial. To evaluate the association of NPWT with oncologic recurrence in surgical wounds without residual malignancy, we analysed studies that compared NPWT with conventional non‐pressure dressings for cancer surgical wounds without residual tumour by August 12, 2020. We compared tumour recurrence rates and postoperative complications between the two procedures. The six studies included 118 patients who received NPWT, and 149 patients who received conventional non‐pressure wound care. The overall quality of the included studies was high based on the Newcastle–Ottawa scale score of 7.5. Tumour recurrence after NPWT was not significantly different compared with conventional non‐negative pressure wound care (9.3% versus 11.4%, P = 0.40). There was no significant heterogeneity between the studies (I² = 3%). Although NTWT was associated with a lower complication rate compared with the control group, the result was non‐significant (P = 0.15). Application of NPWT in oncologic resection wounds without residual malignancy revealed no difference in local recurrence and may reduce the risk of postoperative complications compared with conventional non‐negative pressure dressings. NPWT can be considered an alternative method for reconstruction in challenging cases.