Sigmoid colon technique
LAPAROSCOPICALLY ASSISTED SIGMOID COLON VAGINOPLASTY
The ideal genital reconstructive procedure in transfemale should provide a vagina that has an appropriate length and that requires minimal, if any, dilatation. It should not scar, stenose or contract and should provide a satisfactory cosmetic result. Reconstructing the vagina using intestinal segments creates an aesthetically pleasing vagina, which seems to be more compatible with sexual activity.
Sigmoid colon technique presents the method of choice in cases with lack of penile skin (after circcumcision), as well as a secondary (re-do) procedure after failed vaginoplasty. Advantages of this procedure include adequate vaginal length, natural lubrication, early intercourse and a low rate of shrinkage. Sigmoid colon is particularly useful because it is anatomically close to the perineum, with sufficient length and mobility of the segment that allows it to be easily brought into the perineum.
Procedure
The patient is placed in an extended lithotomy position as for a synchronous combined abdominoperineal approach. Complete removal of the penis and both testes is done in a regular fashion. Pneumoperitoneum is created and three ports are used for laparoscopic approach. The sigmoid colon is mobilized from its lateral retroperitoneal attachment, as far as possible. Before making the final selection of the sigmoid colon segment, the length of the sigmoid and its mesentery should be assessed to determine whether it can reach the perineum easily. Isolated segment of rectosigmoid should be from 12 to 14 cm long, in order to avoid excessive mucus production as well as postoperative vaginal prolapse. Rectosigmoid is harvested with its blood supply originating from sigmoidal arteries and/or superior hemorrhoidal vessels. Circular stapling device is used for the colorectal anastomosis as the safest procedure. Creation of the perineal cavity for vaginal replacement is performed using simultaneous laparoscopic and perineal approach. Very precise dissection must be done to avoid injury of rectum, bladder and urethra. Introital or perineal skin flaps are designed for anastomosis with rectosigmoid vagina. Circumferential anastomosis is avoided to prevent purse string scarring with subsequent vaginal stenosis. Urethroplasty, labioplasty and clitoroplasty is performed in a standard manner.
The neovagina is packed for 7 days, and an indwelling Foley catheter is left in place for 14 days. At discharge from hospital, patients are instructed to irrigate the neovagina once a day for 2 months and weekly thereafter and to dilate the introitus of the neovagina on a daily basis with a vaginal dilator.
Reconstructing the vagina using sigmoid colon creates an aesthetically pleasing vagina, which seems to be more compatible with sexual activity.
CASE 1
Outcome after sigmoid vaginoplasty
Good cosmetic result is achieved. An excellent depth of the neovagina.
CASE 2
Outcome one month after surgery
CASE 3
Result 9 months after surgery
Normal depth and width of the vagina is achieved.
Normal appearance of the vulva is achieved.
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