An SRS Operative Report by Stanley Biber, M.D., from 1984:

Many thanks to Brenda Lana Smith for permission to post this report, which documents Dr. Biber's surgical technique in '84.

REPORT OF OPERATION                                  MT SAN RAFAEL HOSPITAL
DATE OF SURGERY:  11/14/84                           Name:        SMITH, BRENDA L.
SURGEON:                   S.H.Biber M.D.                Room No:   442-2
ASSISTANT(S)            C.H.Raye, M.D.                Doctor:       Biber
                                                                               Birthdate:    06/.21/33
                                                                               Hosp.No:    84-1590
                                                                               Adm.Date:   11/13/84

PREOPERATIVE DIAGNOSIS:    Transsexual
POSTOPERATIVE DIAGNOSIS:  Transsexual

NAME OF SURGERY: Genital conversion surgery, male to female, penile inversion technique.

Under general anesthesia after routine preoperative preparation and draping, the patient in the lithotomy position, penile inversion technique genital conversion surgery is accomplished. Incision was made over the scrotum in the midline. The scrotal skin and some fascia dissected laterally and posteriorly to the perineal body. Dissection was carried anteriorly until the corpora of the penis could be secured. Dissection of the skin of the corpora was carried completely around the penis to the glans area and the glans itself was dissected out with sharp knife dissection, coned out of the corpora, so that the glans remained as a cap to the penile skin. This would later be transferred and implanted as a graft to act as a small cervix. The soft tissue, areolar tissue, and fascias were removed on both sides, exposing the testicles and cord. Ligation of bleeders in the area was accomplished with chromic catgut. Dissection of the cord was accomplished into the external ring and then pulled down out of the inguinal canal and ligated high with both a silk suture and a catgut suture. It was then severed and withdrew high into the inguinal canal. Careful dissection of the corpora was then done down to the base of the pubic arch. The corpus spongiosum with its included urethra was dissected out of the corpora cavernosa and carried down through the bifurcation to the arch, into the crus area, incising the suspensory ligament down into this area and secured hemostasis as well as could be done with fine chromic catgut sutures. The transversis muscle was similarly removed from the corpora and dissected down both sides. Once the corpus spongiosum was alleviated from the crus of the cavernosa clamping of the cavernosa at the base of the pubic bone was done with large forceps and the cavernosa removed. Very carefully, chromic catgut sutures were utilized to obtain hemostasis as these clamps were removed from the corpora cavernosa. This was at their bases. Reinforcing sutures were, of course, utilized to aid in hemostasis in this area. Once this was accomplished dissection was carried out anteriorly, separating the abdominal skin from the rectus fascia all the way to the umbilicus. Dissection was carried on both sides so as to give us the maximum amount of elasticity and additional skin to be utilized to form the perineum. Then, with the assistant's finger in the rectum, dissection was carried out through the fascia over the perineal body area and finger dissection helped develop two similar cavities on both sides of the pubic bone and with careful dissection, the perineal body in with the central ligament was approached. The incision was accomplished separating the rectum, leaving the rectal sphincter intact and continuing to separate the rectum by incising the rectourethalis muscle and central tendon all the way up. With careful dissection the periurethral area was dissected out, dissecting out the rectus fibers in the periurethral area and exposing same up to the area of the prostate. Levators were incised on both sides as this was approached and then very carefully, dissection of the rectum off the prostate was done until we encountered Denonvillier's fascia, opened the posterior layer of Denonvillier's fascia, and then separated between the anterior and posterior layer of Denonvillier's fascia high into the intersticies of the abdominal cavity. The lateral dissection was then accomplished incising further levator muscles, leaving perhaps half of the levator intact on both sides, getting down to the pedicles of the bladder and the vessels emanating to the seminal vesicles, etc., and these were ligated and severed on both sides. Then with finger dissec-

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tion we continued to form the large vaginal cavity. Hemostasis was carefully secured in all instances with fine chromic catgut sutures. Once this was done, a large pack was placed in the area and we returned to dissection above. The excess bulbar spongiosum was removed down to the urethra, very carefully at the perineal portion of the bulb and this was run over with a chromic catgut suture and locking fashion in two layers to obtain hemostasis. Then, a plastic tube was placed in the penile skin and the lower third of the penile skin was completely denuded down to the dermal area of successive areolar tissue and fascia. This was to act as skin graft within the intersticies of the vaginal cavity, however, there is and obvious dermal plexus of vein and artery in this area and we try and leave some dorsal nerve roots in the area as well, coming down to the glans tissue that remained. With this then in place a wire retention suture was then applied from the upper aspect of the abdominal skin to the symphsis itself and once this was held into position, a small incision was made in the proper area for the urethra. This was in the normal female position and the catheter along with corpora spongiosum and the remaining urethra was brought through this hole. The penile skin was then invaginated upon itself into the preformed vaginal cavity. Chromic catgut sutures held the apex of this skin in the peduncle of bladder area on both sides, in other words this was sutured into position. Once this was accomplished, the new vaginal skin of the previous penile skin was then tailored posteriorly primarily so that it would fit the vaginal cavity and closure of the posterior aspect of the orifice was accomplished primarily with chromic catgut sutures, utilizing also a chromic catgut suture from the perineal skin to the posterior aspect of the newly formed vaginal skin. Once approximately three inverting sutures were applied, we then utilized a fold of scrotal skin to form a minor labia and this was sutured upon itself with fine chromic catgut sutures. Drains were then placed into the cavity on both sides. These will be utilized for 24 hours and removed after drainage has be accomplished. Packing was then done of the vaginal cavity with two inch packing immersed in antibiotic powder. Packing was obtained and two plugs also utilized to hold the packing in position. We then tailored a labia majors, excising out the excessive scrotal skin and obtaining excellent hemostasis with fine chromic catgut sutures and the closing the external labia that were now formed with fine interrupted chromic catgut sutures. Then, our attention was then diverted to the urethra. The urethral mucosa was then opened and sutured with fine chromic catgut to the posterior aspect of the incision made in the penile skin in normal female position. This was done with fine chromic catgut sutures carried upward. The excessive corpora spongiosum from behind was then tailored to form a clitoris. We ran the corpora spongiosum with two layers of fine chromic catgut sutures, then placed in a small curve into the upper aspect of the urethral incision and made a new incision approximately a centimeter above the urethra and the excess corpus spongiosum was then pulled through this and a purse-string suture of 4000 chromic catgut placed around it and the rest of the lateral aspect of this newly formed clitoris will be sutured to the under side of the skin with fine chromic catgut of the #0000 variety, allowing the skin to form a hood around the projecting new clitoris formed of corpus spongiosum. The purse-string suture was also pursed in such fashion as-not to obliterate blood supply, but as to purse the new clitoris in outward direction.

The patient withstood the procedure well and returned to the recovery ward in good condition.

S. H. Biber, M.D.
SHB:mp
DD: 11/14/84
DT: 11/15/84