Iatrogenic Vaginal Constriction

Incisions

The simplest approach to a vaginal constriction is a midline incision of the contracting scar or ridge. The midline incision is made, and the vaginal mucosa is mobilized from the underlying scar ( Fig. 60.1 ). Excessive scar tissue may be excised completely to increase the vaginal or introital diameter. When hemostasis is achieved, the wound may be left to heal by secondary intention, or the vaginal tissue may be undermined and advanced and the incision closed transversely in a tension-free manner ( Fig. 60.2 ). When a single midline incision with transverse closure is inadequate, numerous vertical incisions may be made ( Fig. 60.3 ). Separate vertical incisions are closed transversely—after mobilization of surrounding vaginal tissues—to obtain sufficient introital or vaginal diameter ( Fig. 60.4 ).

Fig. 60.5A shows a midvaginal constriction ring after an overzealous anterior and posterior colporrhaphy. The stenotic site was initially enlarged with the use of Hegar dilators passed from the lower vaginal segment into the upper segment. When the vagina was dilated to at least 10 mm, bilateral longitudinal incisions were made in the lateral aspect of the stenotic site and were taken along the vaginal axis ( Fig. 60.5B ). The tight fibrous band was completely excised, and the dissection was continued until loose connective tissue was encountered in the ischiorectal space ( Fig. 60.5C ). Some surgeons prefer to leave the space open; others prefer to close it transversely and perpendicular to the original incision, using interrupted, 3-0 absorbable sutures.