Congenital or acquired absence of the vagina may be managed with progressive perineal dilation alone or with internal traction (Vechietti procedure) or surgical reconstruction. The McIndoe procedure is a perineal approach that involves skin grafting around a vaginal mold in a space developed between the rectum and bladder and requires regular dilation to maintain patency ( Fig. 83.1 ). Tissue-engineering of autologous vaginal tissue or use of autologous buccal micromucosa also permit a perineal approach, however, these techniques are primarily investigational (see further reading). Intestinal vaginoplasty is performed via a combined abdominal and perineal approach and is the authors’ preferred approach. Minimally invasive techniques have been described and may be considered for those practitioners especially experienced in both intestinal vaginoplasty and pelvic laparoscopic or robotic surgery.
Intestinal Vaginoplasty
Preoperative Preparation and Planning
Preoperative mechanical bowel preparation is recommended, especially if colon will be used. Prophylactic antibiotics should be administered according to institutional guidelines. A nasogastric tube should be maintained intraoperatively. Its maintenance postoperatively is optional.
Patient Positioning and Surgical Incision
Supine lithotomy, with the legs slightly flexed and widely abducted with slight Trendelenberg. Prepare and drape a single abdominoperineal field. Insert a urethral catheter. Make a vertical lower abdominal incision ( Fig. 83.2 ).
Operative Technique
Mobilize the posterior wall of the bladder and urethra to expose the eventual area for the neo-vagina to perineum or foreshortened vagina anastomosis ( Fig. 83.3 ). Incise the peritoneum along the white line to free the sigmoid and descending colon and continue the release proximally enough to allow mobilization for subsequent colonic anastomosis. Locate the vascular supply to the sigmoid segment using transillumination. Ideally the main blood supply will be to the middle of the segment, which should be 10 cm in length and able to reach the perineum ( Fig. 83.4 ). Divide the colon to isolate the selected segment and perform a colorectal anastomosis. This may best be achieved with the use of an end-to-end anastomotic (EEA) stapler. The assistance of a colorectal surgeon can be especially helpful if one is relatively unfamiliar with this technique. Using a bulb suction syringe, irrigate the segment with saline. If possible, the sigmoid segment should be carefully rotated 180 degrees to permit anastomosis in an anti-peristaltic fashion (i.e., distal colon will be proximal neovagina). Avoiding compromise to the blood supply to the neovagina with any mobilization of the segment is paramount.
If the sigmoid colon is inadequate for use, ileum may be used instead, which has the benefit of being of increased familiarity to the urologist. The segment of ileum chosen should be at least 15 cm from the ileocecal valve and able to be adequately mobilized to reach the pelvis. If the ileal segment will not be reconfigured, a 10-cm segment should be isolated ( Fig. 83.5 ). A 15–20-cm segment is required if the ileum is to be reconfigured into a U-shape with anastomosis of the antimesenteric sides ( Fig. 83.6 ).
