, Andreja Štolfa Gruntar1 and Miloš Petrovic´2
Department of obstetrics and Gynecology, University Medical Centre Ljubljana, Slajmerjeva 3, 1000 Ljubljana, Slovenia
General Hospital Izola, Polje 40, 6310 Izola, Slovenia
The creation of a neovagina is usually necessary in cases of vaginal agenesia, i.e. Mayer-Rokitansky-Kuster-Hauser syndrome, and in some forms of male pseudohermaphroditism such as androgen insensitivity syndrome. The described technique using pelvic peritoneum can also be applied in cases of transsexualism.
The first technique learned and used by the author was vaginal reconstruction with the sigmoid colon, which had been used in our hospital since 1955. The principal advantages with the utilisation of the colon are that after operation there are very few patients with introital stenosis, there is no need for vaginal dilation since the vaginal cavity is the sigmoid lumen itself, and the length of the neovagina is always over 10 cm and remains constant. The main disadvantages though are the following: a complex surgical intervention, involving resection of the intestine in otherwise healthy women; mucoid secretions, which can cause great discomfort to the patients; vaginal prolapse; and adenocarcinoma of the neovagina. The utilisation of bowel vaginoplasty is not suitable for patients with a short sigmoid colon, chronic inflammatory bowel disease, and renal ptosis.
Because of so many disadvantages, sigmoid colon vaginoplasty was stopped to be performed for vaginal reconstruction and the technique using pelvic peritoneal transposition has been started since 1983. It has many advantages in comparison to other vaginoplasty techniques [1–5]:
Compared to skin graft vaginoplasty, which is extensively used, with the use of pelvic peritoneum, there are no scars on the body from graft harvesting and there is no postoperative vaginal shrinking and/or stenosis of the newly constructed vagina.
The dilations and application of the mould needed to stabilise the diameter and depth of the neovagina are only temporary, since the vaginal cavity is after a certain period of time covered with normal vaginal epithelium.
Mostly only the perineal/vaginal approach is sufficient and there is no visible postoperative scar. There is only very rarely a need for additional abdominopelvic surgery.
With no bowel surgery there are no bowel-related complications. Only very rarely it happens that the rectum is opened during the formation of the vaginal cavity and is sutured as any other bowel injury.
13.1 Preoperative Laparoscopy
It is advisable to perform an exploratory laparoscopy before peritoneal vaginoplasty. This way the surgeon is able to identify any intraperitoneal abnormality and it enables him to evaluate the depth of the pouch of Douglas. The infusion of 200 ml of sterile saline solution into the pouch of Douglas is very useful. It helps us identify the peritoneal reflection when operating perineally.
13.2 Perineal Surgery
The patient is positioned as usually when performing vaginal surgery in a dorsal lithotomy position with widened lower extremities. A Foley catheter is inserted into the bladder and filled with methylene blue. A transverse incision is made at the site of the future neovaginal introitus in the vestibular part of the vagina (Fig. 13.1), between the two little dots, that mark the exit of the Mullerian ducts. The dissection of the vaginal opening/cavity is performed mainly bluntly with small and then larger instruments and fingers in the plane between the bladder and urethra ventrally and the rectum dorsally. This step is usually performed without difficulty, but it must be kept in mind that the direction is between the bladder and the rectum. Dissection by scissors is then utilised to advance the cavity cranially until the peritoneal reflection is met. It is important to widen the diameter of the newly formed cavity between the bladder and rectum to accommodate the neovagina, which is usually done with extension laterally to avoid damage of the near structures: the bladder, urethra, ureters, and rectum; this is why great care is necessary when performing the dissection. Meticulous haemostasis is utilised at every step to control bleeding, which usually poses no problem.
Transverse incision line of the vaginal introitus
The pouch of Douglas is identified with typical fluttering of the peritoneum that can be appreciated with the use of sterile saline which is infused in the peritoneal cavity laparoscopically (Fig. 13.2). The prepared field of peritoneum between the bladder and rectum should be as large as possible. Blunt preparation with a hard tampon seems to be the most efficient (Fig. 13.3).
Identification of fluttering of the peritoneum
Blunt preparation with a hard tampon of a large peritoneum field
A long aspiration needle is then introduced at the site of fluctuation into the peritoneal cavity. Aspiration of fluid confirms that the peritoneal reflection reached is the pouch of Douglas, because the saline infused accumulates at the lowest point of the peritoneal cavity (Fig. 13.4). The peritoneum is grabbed with two pincers, and an incision is performed in between and the peritoneum opened allowing the fluid evacuation down the preformed perineal cavity (Fig. 13.5). The incision is enlarged and with the aid of traction the incised peritoneum is then transposed and brought down the preformed perineal cavity and finally sutured to the introitus of the neovagina with 4–6 sutures that are placed on the margins of the incised peritoneum. Cranially the peritoneal lining of the neovagina is closed at the level of appropriate depth, which is usually around 10–12 cm deep. Two semicircular continuous sutures of absorbable material 2-0 are used for closure as shown (Fig. 13.6), and making these sutures is the most difficult step in the operative procedure because of the depth of the workplace.
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