The purpose of the total simple vulvectomy is removal of the skin and subcutaneous tissues of the vulva. Total simple vulvectomy is associated with a less appealing cosmetic alteration in the vulva compared to the partial resection procedure described in Chapter 13. Total simple vulvectomy is indicated for treatment of: 1) extensive vulvar intraepithelial neoplasia that is not amenable to ablative (e.g., CO₂ laser and cavitational ultrasonic surgical aspirator) therapy or for lesions that require complete pathological evaluation to exclude an underlying invasive cancer, 2) Paget disease of the vulva without suspicion for an underlying adenocarcinoma, 3) selected cases of lichen sclerosis unresponsive to medical management, and 4) specific benign lesions such as extensive condyloma acuminata and hidradenitis suppurativa. As total simple vulvectomy is performed for preinvasive disease, concomitant inguinofemoral lymphadenectomy is not indicated. Lower genital tract dysplasia may be multifocal; therefore, a thorough examination of the vagina and cervix for preinvasive and invasive disease is a prerequisite.

As with partial simple vulvectomy, a visibly disease-free margin of the full thickness of vulvar skin and mucosa is all that is required, usually 3 to 5 mm. The classic total simple vulvectomy removes the vulvar skin and superficial fat including the clitoris with prepuce, the labia minora, the labial fat pads, and the labia majora to the junction of the hair-bearing and non-hair-bearing skin. Contemporary practice dictates a more individualized approach tailored to the extent of disease with regard to the clitoris. If the clitoris is uninvolved by disease, it should be preserved.

In preparation for total simple vulvectomy, all patients should undergo a comprehensive history and physical examination focusing on those areas that may indicate a reduced capacity to tolerate surgery or disease-related characteristics (e.g., primary lesion clinically suspicious for invasive cancer, and inguinal adenopathy) that might dictate a more radical surgical approach. Routine laboratory testing should include a complete blood count, serum electrolytes, age-appropriate health screening studies, and electrocardiogram for women aged 50 years and older. Preoperative imaging is unnecessary.

Prophylactic antibiotics (Cephazolin 1, Cefotetan 1 to 2 g, or Clindamycin 800 mg) should be administered 30 minutes prior to incision, and thromboembolic prophylaxis (e.g., pneumatic compression devices and subcutaneous heparin) should be initiated prior to surgery. The instrumentation required includes a basic vaginal surgery set and candy-cane or Allen Universal Stirrups (Allen Medical Systems, Cleveland, OH). Enemas should be administered the evening before surgery. Preoperative mechanical bowel preparation (oral polyethylene glycol solution or sodium phosphate solution with or without bisacodyl) is unnecessary unless an extensive resection is anticipated around the anus including the anal skin.

Either general or regional anesthesia is acceptable. The patient should be positioned in dorsal lithotomy position using Allen-type or candy-cane stirrups with the buttocks protruding slightly over the edge of the operating table. The vulva and vagina are prepped and a Foley catheter placed. Examination under anesthesia should pay particular attention to the size and topography of the vulvar lesion(s), the vagina and cervix (to exclude a synchronous lesion), and the inguinofemoral lymph nodes.

The outer and inner surgical margins of dissection are outlined with a surgical marking pen. The typical outer skin incision for total simple vulvectomy is oval shaped and extends from an anterior apex superior to the clitoris laterally through the skin of the labia majora and medially to meet in the midline at the perineal body (Figure 14.1). For cases of extensive disease on the posterior vulva and perianal region, the incision line extends posteriorly around the anus to the intergluteal cleft as far as necessary to encompass the disease. The inner incision circumscribes the vaginal vestibule, extends around the urethra, and may extend anteriorly around the prepuce of the clitoris if clitorectomy is not required. The incision line should be injected with local anesthetic (1% plain lidocaine or 0.25% marcaine) for the purposes of postoperative pain control and to help delineate the appropriate subcutaneous plane of dissection.