This is the first report on a novel use of razor-type dermatomes to enable quick and thin vaginal dissection with less bleeding in colpoclesis. Colpocleisis has been regarded as an old-fashioned surgery for pelvic organ prolapse (POP), but it is gaining some popularity in rapidly aging societies as a good option for sexually-inactive elderly patients, especially in those with multiple comorbidities. However, despite the assumed low-invasiveness, colpocleisis sometimes involves long operating time with more bleeding. This is because, in order to get proper tissue fusion, vaginal epithelium must be thoroughly removed, and deeper dissection can damage larger blood vessels. In cases with post-hysterectomy prolapse, vaginal wall tends to be thin and have scars and adhesions with peritoneum; thus, vaginal dissection becomes difficult and unintended opening of peritoneum may occur. To streamline the vaginal dissection process in colpocleisis, we introduced the usage of electric and razor-type dermatomes which are originally used for skin grafting and debridement, and compared operating time, intraoperative bleeding and the thickness of dissection using our procedures versus using scissors.

In the dermatome group, 23 women underwent total colpocleisis with vaginal dissection using dermatomes since March 2017; 5 done with electric dermatomes (Zimmer Electric Dermatome, Zimmer Biomet Holdings, Inc.) and razor-type dermatomes (FEATHER Disposable Dermatome, FEATHER Safety Razor Co., Ltd.), 18 done with razor-type dermatomes. In the control group, 20 women underwent total colpocleisis with vaginal dissection using Metzenbaum scissors during 2015 and 2017. All patients were parous sexually-inactive women with post-hysterectomy prolapse.
Under hydrodissection with 1:1,000,000 diluted epinephrine saline, vaginal wall was distended by pulling it by Allis forceps and pressing it by gauzes from behind. Electric dermatomes, set at depth of 0.5 mm and width 2.5 cm were manipulated by a trained plastic surgeon. Razor-type dermatomes were manipulated by a urologist who had no experience with dermatomes. Serial purse-string sutures and perineoplasty were done similarly in both groups. Operating time and intraoperative bleeding were compared between the two groups. Pathology and the thickness of dissection were investigated in vaginal specimens dissected with electric dermatomes, razor-type dermatomes and Metzenbaum scissors. All values were expressed using the mean ± SD and analyzed by non-paired t test. Differences were considered to be significant at p < 0.05.
Fig. 1: Razor-type dermatome

Patient demographics and other baseline characteristics between the dermatome group (n=23, mean age 75.7 ± 7.4) and the control group (n=20, mean age 75.2 ± 5.9) showed no significant differences. All patients in the dermatome group and 18/20 patients in the control group underwent concomitant perineoplasty. Both operating time and bleeding significantly decreased in the dermatome group compared to the control group; total operating time including perineoplasty was 53.2 min (SD 9.5) vs. 76.4 min (SD 17.2), operating time of colpocleisis was 35.3 min (SD 10.3) vs. 62.4 min (SD 21.3), and intraoperative bleeding was 15.2 ml (SD 38.0) vs. 62.3 ml (SD 51.3). Hemostasis was not needed after dissection with dermatomes unlike with scissors. None in the dermatome group and 2/20 patients in the control group had unintended peritoneal opening. Pathological investigation revealed that there were significant differences in the thickness of vaginal dissection (minimum to maximum); with electric dermatomes 0.22 mm (SD 0.02) to 0.66 mm (SD 0.29), with razor-type dermatomes 0.58 mm (SD 0.38) to 1.47 mm (SD 0.75), and with scissors 2.46 mm (SD 1.05) to 6.60 mm (SD 2.70). Dissection with scissors often removed not only the epithelium and submucosal layer but also the muscle layer, which was minimal with razor-type dermatomes and never occurred with electric dermatomes. Although electric dermatomes enabled the thinnest and most uniform dissection, it was difficult to press the blade closely to the vaginal wall especially in small prolapse, and razor-type dermatomes or scissors were needed to manage leftover tissues. 
Fig. 2: Dissection with electric dermatomes (A), razor-type dermatomes (B) and scissors (C). Scale bar = 1.0 mm

Using dermatomes in vaginal dissection of colpocleisis was helpful to shorten mean operative time by 27 min and to reduce intraoperative bleeding by 47 ml. Dissection was the thinnest with electric dermatomes, but they are more difficult to get used to and are expensive (machine $13,200, disposable blade $54). Razor-type dermatomes enable thinner dissection compared to scissors, easy to handle even for first-timers, and inexpensive (disposable, $1.3).

Razor-type dermatomes enable quick and thin vaginal dissection with low cost and to make colpocleisis even less-invasive (less operating time, less bleeding). So, they can be recommended as a desirable tool for colpocleisis, a prolapse operation mainly for frail elderly patients.