Partial Vulvectomy / Wide Local Excision of Vulvar Lesion
[Right / Left / Midline] vulvar lesion at the [anatomic location], with [biopsy diagnosis / clinical concern]
Same
[Partial simple vulvectomy / Wide local excision of vulvar lesion]
[***, MD/DO]
[Resident/PA name]
[General endotracheal / Monitored anesthesia care / Regional with sedation]
The patient is a [age]-year-old [female] with a [symptomatic / suspicious / biopsy-proven] lesion of the [right / left / midline] [vulvar site]. Prior biopsy demonstrated [pathology / was nondiagnostic]. Excision was recommended for [definitive diagnosis / treatment]. The operative plan, risks, benefits, alternatives, and potential effects on adjacent structures were discussed, and informed consent was obtained.
A [X × Y]-cm lesion involved the [right / left / midline] [vulvar site] at approximately [clock-face position] and measured [X] cm from the nearest relevant anatomic structure. The planned peripheral margin measured [X] [mm / cm]. The selected deep plane was [superficial subcutaneous tissue / adipose tissue]. The resulting defect measured [X × Y × Z] cm.
The patient was positioned in dorsal lithotomy with pressure points padded. Anesthesia was induced, a surgical timeout was completed, and the vulva, perineum, and [vagina] were prepared and draped. [No urinary catheter was required / A Foley catheter was placed and left to drainage / A Foley catheter was placed for the procedure and removed at completion.]
Examination under anesthesia confirmed the findings above. The lesion and intended peripheral margin were marked with attention to adjacent critical anatomy. The incision and anticipated closure were planned to preserve uninvolved structures and minimize tension.
The marked perimeter was incised sharply through the skin. The lesion was elevated with gentle traction and dissected through the dermis and subcutaneous tissue to the planned [superficial subcutaneous / adipose] plane. The dissection followed the marked perimeter and maintained a consistent deep plane. Adjacent critical structures were not involved and were protected. The specimen was removed intact without entering the lesion.
The specimen was oriented with [a suture at the [clock-face] position / a short suture at *** and a long suture at ***] and sent to pathology. [No separate margins were submitted. / Separate margins were obtained from [location], labeled, and submitted individually.] The wound was irrigated, and hemostasis was achieved.
The defect measured [X × Y × Z] cm. The deep and subcutaneous tissues were reapproximated in [number] layers with [suture], reducing dead space and tension. The skin was closed with [interrupted / mattress / running subcuticular] [suture]. The closure was hemostatic and without undue tension or distortion of adjacent anatomy. All counts were correct.
None
[Partial vulvectomy / Wide local excision] specimen, oriented with [marking scheme], sent to pathology
[No separate margin specimens / Separate [location] margin specimen(s) sent to pathology]
[X] mL
[None / Foley catheter / [type and size] drain positioned at ***]
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Right / Left / Midline] vulvar lesion at [site], with [biopsy diagnosis / clinical concern]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Partial simple vulvectomy / Wide local excision of vulvar lesion]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General / MAC / Regional]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a [symptomatic / suspicious / biopsy-proven] lesion of the [right / left / midline] [site]. Prior biopsy demonstrated ***. Excision was recommended for [definitive diagnosis / treatment]. The operative plan, alternatives, and relevant risks were discussed, and consent was obtained.
FINDINGS: [X × Y]-cm lesion at the [right / left / midline] [site], approximately *** cm from the nearest relevant anatomic structure. Planned peripheral margin *** [mm / cm]. Deep plane: [superficial subcutaneous tissue / adipose tissue]. Final defect: *** cm.
DESCRIPTION OF PROCEDURE:
The patient was positioned in dorsal lithotomy, and a timeout was completed. The vulva and perineum were prepared and draped. [No catheter / Foley placed and left to drainage / Foley removed at completion.]
Examination under anesthesia confirmed the findings. The lesion and intended margin were marked with attention to adjacent critical anatomy.
The marked perimeter was incised sharply. The lesion was dissected to the planned [superficial subcutaneous / adipose] plane and removed intact. Adjacent critical structures were protected. The specimen was oriented with [marking scheme] and sent to pathology. [No separate margins were submitted. / Separate margins from *** were submitted individually.]
The wound was irrigated and hemostasis obtained. The ***-cm defect was closed in *** deep/subcutaneous layers with ***, followed by [interrupted / mattress / running subcuticular] skin closure with ***. The closure was hemostatic and without undue tension or distortion of adjacent structures.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Partial vulvectomy / Wide local excision] specimen, oriented ***; [no separate margins / separate margins from ***]
COMPLICATIONS: None
DRAINS: [None / Foley / ***]
DISPOSITION: Stable to PACU
Signed: .ME, .MYDEGREE
.TODAYVariants
Total Simple Vulvectomy
A total simple vulvectomy was performed for [extensive / multifocal / confluent] vulvar disease. The involved epithelium and underlying superficial subcutaneous tissue were removed according to the mapped disease distribution while preserving [the clitoris / urethral meatus / vaginal introitus / anus / specified uninvolved vulvar tissue]. The specimen was divided or oriented as [***] for pathologic mapping. The resulting defects measured [***]. Closure was accomplished by [layered primary closure / local tissue rearrangement / skin graft / planned secondary-intention healing] as described, without undue distortion of the urethral meatus, introitus, or anus.
Radical Local Excision / Partial Radical Vulvectomy
Radical local excision was performed for [biopsy-proven invasive carcinoma / other oncologic indication]. The tumor measured [X × Y] cm and was located [X] cm from the [clitoris / urethral meatus / vagina / anus]. The intended gross peripheral margin was [X] [mm / cm], with the reason for any anatomic modification documented as [***]. Dissection continued to the planned deep plane of [perineal fascia / other], keeping the specimen intact and avoiding narrowing beneath the tumor. The [clitoris, urethra, vagina, and anus were uninvolved and preserved / following adjacent structure was resected as documented: ***]. The specimen was oriented by [marking scheme], and any separately submitted peripheral or deep margins were labeled by location. [Groin-node assessment was not performed / Groin-node assessment was performed as a separate procedure and is documented separately.]
Anterior, Periurethral, or Clitoral Lesion
The lesion was located [anteriorly / adjacent to the clitoral hood or clitoris / adjacent to the urethral meatus] and measured [X] cm from [landmark]. [A Foley catheter was placed to identify and protect the urethra.] The intended excision was modified at [location] to preserve [the clitoris / clitoral neurovascular tissue / urethral meatus / urethra] while meeting the planned treatment goal. Dissection near the urethra and clitoris was performed sharply with limited thermal energy. At completion, the [clitoris and prepuce / urethral meatus and urethra] remained [intact and normally positioned / altered as specifically described]. [The urine stream or urethral patency was assessed by ***.] Any planned resection or reconstruction of these structures is documented separately.
Posterior, Perineal, or Perianal Lesion
The lesion involved the [posterior fourchette / perineum / perianal vulva] and measured [X] cm from the anal verge. Its relationship to the perineal body, anal sphincter complex, and anorectal mucosa was assessed by [inspection / palpation / rectal examination]. [A finger in the rectum was used during dissection to define and protect the anorectal wall.] The specimen was separated from the [perineal body / anal sphincter / anorectal mucosa] without injury. At completion, the anal sphincter and anorectal mucosa were [intact / involved or repaired as separately described], and rectal examination demonstrated [***].
Flap or Graft Reconstruction
The [X × Y × Z]-cm defect could not be closed primarily without unacceptable tension or distortion. Reconstruction was performed with a [V-Y advancement flap / rotational flap / local advancement flap / split-thickness skin graft / other]. The design, dimensions, pedicle or blood supply, inset, and donor-site closure were documented as [***]. The reconstruction was [well perfused / viable by *** assessment] without tension at completion. A [type and size] drain was positioned at [location] and secured with [suture], and [a bolster or dressing] was applied.
Secondary-Intention Healing
Primary closure was not performed because of [periurethral location / contamination / excessive tension / limited defect size / other]. Hemostasis was confirmed, and the [X × Y × Z]-cm defect was left to heal by secondary intention. The wound was treated with [topical agent / nonadherent dressing / packing / other]. [A Foley catheter was left in place because ***.] The planned wound-care instructions and follow-up were [***].
Charting Tips
- Record lesion laterality, precise vulvar subsite, clock-face position, dimensions, focality, and distance from the clitoris, urethral meatus, vaginal introitus, and anus when relevant.
- Document the peripheral margin actually marked and the deep tissue plane actually used. If anatomy required a narrower or asymmetric excision, identify the location and reason rather than implying a universal margin measurement.
- State whether the clitoris, urethra, vagina, anal sphincter, and anorectal mucosa were uninvolved and preserved or intentionally resected and reconstructed.
- Give pathology an unambiguous orientation scheme and list each separately submitted peripheral or deep margin by its exact location.
- Describe the final defect dimensions, closure layers, suture material, tension, dead-space management, and any effect on the urethral meatus, vaginal introitus, or anus.
- Include catheter, drain, flap, graft, donor-site, bolster, dressing, or secondary-intention details only when applicable.
- If sentinel-node mapping or inguinofemoral lymphadenectomy was performed, document it as a separate procedure rather than treating it as an automatic component of the vulvar excision.