Dr. Toby Meltzer Performs SRS

Date of Surgery: August, 1998

SRS手術過程圖示說明(涂懿美、何春蕤譯)


1. Dr. Meltzer positions the anesthetized patient in preparation for surgery. Sequential compression stockings are wrapped around the patients calves and lower thighs; these decrease the risk of blood clots in the legs.

Dr. Meltzer將麻醉了的病人安置好,準備手術。病人的大腿下部到小腿都包裹了一連串的壓力襪,以便避免血液在腿部凝結成塊。

2. The skin has been marked with purple surgical marker. Note the roughly circular area of scrotal skin; this will be harvested for use as a vaginal graft. The small triangular flap at the bottom will be incorporated into the vaginal introitus to avoid a circular scar in this location.

要切除的陰囊表皮已經用外科紫色筆標記出來。請注意,環繞陰囊的那片約略圓形區域的皮膚稍後將作為陰道植皮之用。底部那一小塊三角形的蓋皮未來將會併入陰部的開口,以避免在這個部位形成圓形的疤痕。

3. The patients genitals have been washed with antiseptic soap, and sterile drapes have been applied. The device on the left will be used to hold a ring retractor later in the operation to facilitate creation of the vaginal cavity (see frame #11). Note the transparent drape stapled to the skin with surgical staples. It incorporates a latex sheath; this allows the surgeon to insert a finger into the rectum during creation of the vaginal cavity, without contaminating his gloves or the surgical field. As it turns out, Dr. Meltzer will not need to use it during this operation.

先用消毒皂清洗病人的生殖器,然後蓋上消毒布帷。圖左的這個裝置是用來穩固環狀牽引器,以便稍後用來幫助製造陰道的甬道(見圖11)。請注意圖中固定在皮膚上的外科透明布帷,布帷上設有乳膠套,外科醫生在製造陰道時可以透過這個乳膠套將手指插入直腸以維持穩定,而不至於被肛門的污物污染手套或是手術區域。後來發現,Dr. Meltzer在這次的手術中並不需要用到那個步驟。

4. Surgery begins. Dr. Meltzer first harvests the scrotal skin graft. He uses a yellow-handled electrosurgical device, which both cuts tissue and coagulates blood vessels.

手術開始。Dr. Meltzer先切除陰囊表皮,留作稍後陰道植皮之用。這裡使用的是一把黃柄的電動外科器具,在切除組織的同時還可以封凝血管。

5. Here is what the resulting scrotal skin graft looks like. Well see it again, looking somewhat different, in frame #9.

這就是切下的陰囊表皮。後來再看到它時,樣子會有些不同(見圖9)。

6. The testicles are now isolated and removed. Here the right testicle and cord are pulled upward by an assistant as Dr. Meltzer performs the dissection.

陰囊皮去除後,睪丸就可以被獨立出來,然後移除。圖中當Dr. Meltzer在施行切除手術之時,他的助理正在將右睪丸以及韌帶部份往上拉。

7. Next Dr. Meltzer dissects the penile skin free of the underlying erectile tissue. He makes a circumferential cut around the glans, and begins to free up the penile skin. Hes holding the glans between the thumb and index finger of his left hand. Two skin hooks held by an assistant keep tension on the penile skin.

接著Dr. Meltzer將陰莖表皮與其下的勃起組織分割。他先圍繞著龜頭周圍切割,然後順勢逐步切割剝離陰莖的表皮。圖中Dr. Meltzer用左手的拇指和食指握住龜頭,一位助理則以兩個皮膚勾來保持陰莖皮膚的張力。

8. Here we see the result when the dissection is complete. Above, an assistant holds the freed tube of penile skin, ready to be turned inside out to line the vagina. Below, the remaining erectile tissue of the penile shaft lies wrapped in gauze to control bleeding.

這是陰莖表皮剝離後的結果。圖中一位助理拉住已經被剝離的陰莖表皮,預備外翻,以作為陰道的內襯。在圖的下方,陰莖殘餘的勃起組織也已裹上了紗布以控制流血。

9. Remember the piece of scrotal skin we saw in frame #5? While Dr. Meltzer has been working, his assistant has scraped it thin and has sewn it into a closed tube, using a large syringe cover as a support. In the next photograph, this whole assembly will be inserted through the inside-out penile skin tube, allowing this graft to be sewn into place.

還記得我們在圖5看到的那塊陰囊表皮?Dr. Meltzer進行手術的同時,他的助理便將這塊陰囊表皮刮薄,以一支大型皮下注射器套作為支撐,將切下的陰囊表皮縫成一端封閉的管狀。在下一張圖中,這整個成品都會被放進由那個外翻的陰莖表皮縫成的管道內,以便把這個管狀植皮縫到適當的位置。

10. Here the syringe cover carrying the scrotal skin graft has been inserted through the inside-out penile skin tube. The graft is being sewn to the edge of the penile skin. This lengthens the skin tube, which will be used to line the vaginal cavity.

在這裡,套著陰囊植皮的皮下注射器套已經放進了陰莖表皮做成的管道內,植皮正在被縫進陰莖表皮管道的邊緣。這樣一來就拉長了陰莖表皮管道,稍後可以用來當作陰道的內襯。

11. Its time to create the vaginal cavity. In this photograph, Dr. Meltzers left index finger is in the cavity, checking its depth. We can also see two special techniques Dr. Meltzer uses to make this difficult dissection easier. First, he inserts a Lowsley prostatic retractor through the penis, allowing him to manipulate the prostate gland during the dissection. The T-shaped handle of this retractor is visible in Dr. Meltzers right hand at the top of the frame. Second, he uses a Bookwalter pediatric ring retractor system to keep the vaginal cavity open as the dissection progresses. Two retractors attached to the bottom of the ring maintain downward and lateral pressure within the cavity.

接下來就要製造陰道了。如圖,Dr. Meltzer用食指測試開口處的深度。圖中顯示Dr. Meltzer使用兩種特殊技巧來進行這個複雜的切割手術。首先,他將Lowsley前列腺牽引器插入陰莖,以便在進行切割時方便操控前列腺,圖片上方還可以在Dr. Meltzer的右手中看到牽引器的T形手把。其次,Dr. Meltzer用了Bookwalter小兒科環形牽引器系統來保持陰道張開,以利整個切割手術進行,環底附著的兩個牽引器則維持了陰道向下和側面的壓力。

12. With the vaginal cavity complete, Dr. Meltzer cuts into the corpus spongiosum at the base of the penis, opening the urethra. He inserts a Foley catheter through the urethral opening into the bladder. The surrounding tissue will be trimmed back further later in the operation to create the new urethral meatus, or opening.

當陰道的甬道做好後,Dr. Meltzer切開陰莖根部的海綿組織,以便打開尿道,他將一根Foley導管穿進尿道口,放進膀胱內。在接下來手術創造新的尿道和尿道口時,這些周圍組織都要重新修整過。

13. Dr. Meltzer now begins to strip the erectile tissue from the penis. Eventually this will leave only the glans and a thin pedicle containing the dorsal blood vessels and nerves. Dr. Meltzer cuts into the erectile tissue from both the left and right sides to begin this process.

Dr. Meltzer現在開始從左右兩側切入,將陰莖周圍的勃起組織剝除。最後將只留下龜頭以及一片薄薄的、背側有血管和神經的肉莖。

14. Soon only a ribbon-like pedicle connects the glans to the rest of the body. Carefully preserved blood vessels and nerves within the pedicle keep the glans tissue viable and sensate.

現在龜頭只靠著一條像緞帶一般的肉莖來和身體連結,但是被小心保存在這條肉莖內的血管和神經將繼續活絡龜頭的組織和感覺。

15. Dr. Meltzer begins to shape the glans tissue to form the clitoris. The bottom one-half of the glans has been cut away. The edges of the cut surface are sewn together, producing a clitoris of the desired size.

Dr. Meltzer開始將龜頭組織塑成陰蒂,他先將龜頭的下半部切除,然後將切口的邊緣縫合,製造了一個大小適當的陰蒂,相連的肉莖則將提供陰蒂所需的神經和血液。

16. In this photograph, the skin of the lower abdomen has been freed from the underlying tissue, up to the level of the navel. A retractor pulls the skin upward. Freeing this skin will allow the attached penile skin, which is hidden by the retractor, to be pulled down far enough to enter the vaginal cavity. The pedicle containing the nerves and blood supply of the clitoris has been folded over on itself, and the clitoris has been sewn into its final position.

如圖,下腹皮膚已經和其下的組織分開,以一個牽引器往上拉到肚臍的高度。將下腹皮膚拉開是為了讓(圖中被牽引器擋住的)陰莖皮可以被向下拉到足以進入陰道的程度。另一方面,連接陰蒂的那條肉莖也已經被反摺,好把陰蒂縫到應有的位置上。

17. Now its time to place the skin graft into the vaginal cavity. Dr. Meltzer inserts a large curved retractor into the tube of penile and scrotal skin to help guide it smoothly into the cavity. His right hand holds the retractor; his left is at the opening of the vaginal cavity.

現在可以將植皮放進陰道了。Dr. Meltzer將一支彎嘴牽引器插入陰莖陰囊合成的植皮管道,引導這個管道順利的進入體腔。Dr. Meltzer的右手握住牽引器,左手則在陰道的開口處。

18. After some trimming, Dr. Meltzer sews the vaginal skin graft to the skin of the perineum, anchoring it in place.

經過一些修整,Dr. Meltzer將陰道植皮縫進會陰的皮膚內,固定好。

19. Dr. Meltzer makes a small incision in the skin of the new vulva to accommodate the clitoris, which we see here sewn into position. A second lower incision is also visible; this will be the new urethral opening. A weighted retractor is in the vaginal cavity.

Dr. Meltzer在新陰戶的皮膚上開一道口子,陰蒂就放在這裡。我們在這張圖片中可以看到縫好後的樣子。第二個切口較低,也可以在這裡看到,這是新的尿道口。陰道內有一個加了重量的牽引器。

20. Now the urethral tissue has been trimmed, and has been brought through the lower incision in the vulva, creating the new urethral meatus. A Foley catheter in the urethra marks this opening, which is very close to the opening of the vagina. We can see that there is still a lot of excess scrotal skin, which must be trimmed to create the labia majora.

現在尿道的組織已經修整好,並且從會陰上較低的那個開口拉出來,開闢成一個新的泌尿管道。尿道上的Foley導管就顯示了尿道的開口,位置非常接近陰道的開口處。那裡仍然有很多剩餘的陰囊皮膚必須被修整,以創造大陰唇。

21. In this photograph, Dr. Meltzer has trimmed the skin of the labium on the right (patients left), and is beginning to close the incision with sutures. A drain tube extends from the upper end of the labium; this will drain any accumulated blood or fluid during the first few days after surgery.

圖中Dr. Meltzer已經修整好了右邊陰唇的皮膚(也就是病患的左邊),開始縫合切口。從陰唇上端延伸下來一條排除液體的管子,這條管子在術後的幾天內都會排出這個區域累積的淤血或體液。

22. With both labia trimmed to shape and sutured, Dr. Meltzer inserts a speculum into the vagina in preparation for inserting the vaginal packing.

在兩片陰唇都修整出形狀而且也縫好之後,Dr. Meltzer插入一個擴張器到陰道內做為陰道塑形的準備。

23. In this photograph the gauze packing has been placed in the vagina; its white color marks the vaginal opening. Dr. Meltzer now begins placing the temporary stitches that will hold the labia together for a few days. These temporary sutures will compress the labia, reducing bleeding and swelling.

這張照片中,陰道填入了紗布,圖中露出的一點點白紗布就標示了陰道的開口。Dr. Meltzer現在開始暫時縫合陰唇,這種暫時的縫合可以施壓陰唇,以減少流血和腫脹,數天後再拆除。

24. The labia have now been sutured together almost completely. The drains and the Foley catheter come out at the top. Except for the applying the final dressings, the operation is complete.

現在陰唇已經幾乎完全的縫在一起了,排除多餘淤血體液的管子和Foley導管從頂端冒出來。除了最後的包紮之外,整個手術已經完成了。

25. This photograph, from a different patient, shows what the result will look like when it has healed. A second-stage labiaplasty will be necessary to hood the clitoris and create the labia minora.

這張照片是另一個病人的,它顯示了手術癒後的樣子。第二階段的陰唇整型手術將蓋住陰蒂並創造小陰唇。



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