They Don't Just Chop it Off!

A million years ago, during my undergraduate years, one of my assignments was to watch a surgery (pre-op, intra-op, and post-op) and write about it.

My class mates jumped at the first appendectomies they could find, but I wanted something interesting. I asked around about upcoming events and one nurse failed to let me down.

“There’s a vaginoplasty happening in about an hour.”
“Oh. What’s that?”
“Sex change.”
“OK, I’m just gonna run over there now. Thanks!”

Unfortunately, the actual surgery took more hours than I had in my clinical day. I got in a little bit of trouble for losing track of time and being about 30 minutes late to our post-clinical meeting. I got out of trouble soon enough when it was my turn to talk about my day.

The following is the paper I turned in. I’ve edited it a little so it wouldn’t be so jargonish (that’s totally a word). No names were used. HIPAA works.

This all took place at Scottsdale Healthcare Osborn Greenbaum Surgery Center in Scottsdale, Arizona. I may have accidentally pilfered a pair of scrubs from them.

I warn you, this is long. But I think it’s fairly interesting. I’m biased though. ::shrug::

Introduction

My client was a 25 year old genetic male, but was regarded as female on all medical documents. Her chief complaint was gender dysphoria (perceived gender conflicts with physical sex) and the procedure planned for her was a vaginoplasty. Her past surgical history included facial feminization, including frontal sinus cranioplasty, mandibular angle reduction, and rhinoplasty (in a nutshell, her face [forehead, jaw, nose] was reconstructed to look more feminine).

Pre-operative Care

My client, previous to the operation, underwent professional counseling for years. She was referred, by her psychiatrist, to the surgeon, to have this operation done. The client understood that, after the surgery, she would have “a vagina instead of a penis… I am going to be a woman instead of a man.” Two days prior to the surgery, the physician explained the entire procedure to her, and the consent form was signed at this time as well. I believe the client was adequately informed about the procedure. She didn’t have any questions beforehand and she seemed relaxed, not at all worried. Her mom and boyfriend were with her and they were talking and laughing, which assures me that she has a positive support system.

Medications given to my client prior to surgery included mefoxin, lovenox, and catapres. Mefoxin is a cephalosporin/anti-infective drug used for peri-operative prophylaxis (preventing infection). Lovenox is an anticoagulant (blood thinner) used to prevent deep vein thrombosis (DVT) after abdominal surgery. They used this because there was a possibility that they would have to use skin grafts from the client’s abdomen during the surgery. Catapres is an antihypertensive agent (lowers blood pressure) (Lippincott Williams & Wilkins, 2004).

Baseline data of the client (vital signs, height, and weight) was obtained prior to surgery.

Intra-Operative Care

The client was given versed, which causes sleepiness and amnesia. It also relieves apprehension before anesthesia is given. The client was also given propofol, a general anesthetic, to maintain anesthesia. She was also given reglan, an antiemetic, to prevent vomiting during surgery (Lippincott Williams & Wilkins, 2004). Then she was brought to the operating room (OR). She was also given lactated ringers throughout her surgery.

The surgical team was amazing. It consisted of the circulating nurse, the nurse anesthetist, the surgical technician, the surgeon, and the surgeon’s assistant.

The circulating nurse, among other responsibilities, assists with preparing the OR, assists with transferring the client to the OR bed, positions the client, documents intra-operative care, monitors all activities requiring asepsis, measures blood and fluid loss, counts the sponges, needles, and instruments, accompanies the client to the post-anesthesia recovery area, and reports pertinent information to the recovery area nurse.

The surgical technician passes instruments to the surgeon. The nurse anesthetist administers the anesthetic to the client and is responsible for the physiologic homeostasis of the client throughout the intra-operative period (making sure the client's anesthetic is at a balanced level of safe and effective).

The surgeon’s assistant holds the retractors to expose surgical areas (acts as the surgeon's 3rd and 4th hands) and assists with hemostasis (prevents and stops bleeding) and suturing. The surgeon performs the actual surgical procedure (Lewis, Heitkemper, & Dirksen, 2004).

While the topic of discussion during the surgery was centered on the surgeon’s new summer house in New York, it was obvious that everyone’s main focus of attention was on the client. Everything flowed together, mainly because of the terrific teamwork employed. The surgeon’s assistant would ask if he needed to hold the retractors at a different angle, the surgeon would nod approval without taking his eyes off of his work and, without missing a beat, the surgical technician would adjust the position of the lights so the surgeon could see better at the new angle.

Many safety measures were employed during this operation. First, transferring the client from the stretcher to the bed required locking the wheels to prevent the stretcher from moving and the client from falling. The client was put into restraints to prevent falls, and also to keep the client from harming herself or a member of the surgical team. Aseptic (sterile) technique was used throughout the procedure to prevent infection. An endotracheal tube was inserted to ensure an effective airway throughout the procedure (Lewis, Heitkemper, & Dirksen, 2004).

The procedure itself was remarkable. The initial incision was made to the scrotum. A piece of the scrotum was cut out and made into part of the new vaginal lining, as was the skin around the penis. The surgeon made many incisions and, from what the circulating nurse explained to me about the procedure, the surgeon tries to use as much of the male genitalia as possible to reconstruct the new female genitalia. Certain sensitive nerves and a small amount of erectile tissue are saved and relocated so that the client will have a sexually functional vagina. Basically, the entire penis is reconstructed into a functioning vagina.

Post-Operative Care

Unfortunately, time was not on my side, and I was unable to stay for the entire surgery, let alone the post anesthesia care. However, I did go online and research some material regarding postoperative care.

Immediately following the operation, the client is in the care of the surgeon and the hospital recovery environment. The majority of vaginoplasties done by top surgeons are fully successful, with no major complications. However, sometimes complications do occur. These include minor infections and bleeding. These minor complications are easy to detect and are under control before the woman leaves the hospital (http://ai.eecs.umich.edu/people/conway/TS/SRS.html, 2003) (WARNING Images Not Safe for Work or if you like to think of the children!).

More serious complications include major infection or bleeding, and damage to the bladder, prostate, or major nerves during the dissection to form the vagina. One of the most feared complications is formation of a vaginal-rectal fistula. This occurs when, by accident, the rectal wall is cut through while forming the vaginal cavity. This fistula allows excrement to bypass the anal stricture and exude from the vagina. This causes an increased risk of infection and impairs healing of the fistula. The only way to correct the damage is to perform a colonoscopy. This often leads to closure of the neovagina, in turn requiring a complete redo of the vaginoplasty using skin grafts (http://ai.eecs.umich.edu/people/conway/TS/SRS.html, 2003) (WARNING Images Not Safe for Work or if you like to think of the children!).

Once released from the hospital, it is important that the woman ensures that her neovagina heals properly, maintains its size, and remains functional. In order to make this possible, the woman must dilate frequently using a vaginal stent(http://ai.eecs.umich.edu/people/conway/TS/SRS.html, 2003) (WARNING Images Not Safe for Work or if you like to think of the children!).

Again, this was an incredible experience for me. Although I was unable to witness the entire procedure, I was still amazed at the amount of teamwork and concentration went into the surgery. One nursing action I know is important when caring for a peri-operative client is assessment. It is important to assess both the physical and psychological aspects of the client and make doubly sure that the client doesn’t have any questions or concerns before starting.

I really didn’t know what a vaginoplasty was before today. I am grateful for the experience of being able to see at least part of one, as I was told that it is not a common procedure. I only wish I could have been involved with the entire procedure, from admittance to discharge.

fin

I apologize for the lengthiness of this blog. However, I hope some found it interesting and informative.


Comments, ratings, and feedback are always appreciated!




References

Lewis, S. M., Heitkemper, M. M., and Dirksen, S. R. (2004). Medical-Surgical nursing (6th ed.). St. Louis, MO: Mosby, Inc.

Lippincott Williams & Wilkins (2004). Nursing 2004 drug handbook (24th ed.). Springhouse, PA: Springhouse.

Conway, L. Vaginoplasty: Male to female sex reassignment surgery. (2003). Retrieved March 26, 2004 from http://ai.eecs.umich.edu/people/conway/TS/SRS.html
(WARNING Images Not Safe for Work or if you like to think of the children!)