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Vaginal aplasia and reconstruction with sigmoid graft

Authors

Abstract

This video shows the reconstruction of vagina with a colon graft in a female teenager who consulted for a primary amenorrhea. Her karyotype is 46, XY and the SRY gene is not expressed.

Catégorie

contribution

Mots-clés

Vaginal aplasia, reconstruction with sigmoid graft

Type de vidéo

Durée

10'43''

Publication

2010-06

Popularité

Favoris

Audio

Sous-titres

E-publication

WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2973.htm

Vaginal aplasia and reconstruction with sigmoid graft

1. Introduction 00'07''

The vaginoplasty is tailored with the sigmoid colon in a female teenager who consulted for a primary amenorrhea. Her karyotype is 46, XY and the SRY gene is not expressed.

2. Patient position 00'18''

The young girl is placed in a supine gynecologic position, with a slight Trendelenburg tilt. The operator stands to the patient’s right, the assistant to the patient’s left. The monitor is placed between the patient’s legs.

3. Gonadal agenesia identification 00'29''

A poorly developed tubal structure may be observed. A bilateral gonadal agenesia is found. The search for any potential gonad was achieved through the MRI and the absence of gonad was confirmed by a dissection performed at the level of the left and right kidneys. An atretic uterine structure corresponding to a fibrous strip is observed: it will be used as a guide to reach the dissection plane to lower the neo-vagina. Here, a hypotrophic right uterine artery is visible.

4. Broad ligament opening 01'28''

The broad ligament is opened to the right and to the left. The tubal structure is freed to the left. The opening of the broad ligament is pursued towards the left uterine vessels. Here we can see the dissection of the very small left uterine pedicle, which will be cauterized using a vessel-sealing device and then divided. This leads us to a median fibrous structure that will uncover the future implantation site of the neo-vagina.

5. Opening of anterior peritoneum 03'14''

The anterior peritoneum of the Douglas’ pouch is opened along the fibrous uterine strip using the Ligasure® device. It is then detached in a median avascular area posterior to the fibrous uterine strip and to the region where the cervix and the vagina should have been found. We are in a strictly median position. The region is easily detached using a peanut swab and the vulvar area is reached on the future site of the introitus. The finger of an operating assistant is used to mobilize the future site of the introitus at the level of the vulva. This helps to perfectly identify the end of the pelvic dissection, as well as the end of the future neo-vaginal implantation.

6. Colon dissection 05'36''

The dissection leads us to the terminal sigmoid colon immediately above the rectum. It is essential not to be too high and away from the rectum. Indeed, the colorectal anastomosis should be performed as easily as possible with a circular stapler passed through the endorectal route. The rectosigmoid meso is strictly respected. It is merely dissected.

7. Rectosigmoid division 06'45''

The rectosigmoid division is then carried out using the Endo-stapler, blue cartridge.

8. Graft creation 07'16''

The length of the sigmoid graft is around 10cm. The graft is perfectly vascularized. Here the upper part of the sigmoid graft is divided; it is freed from the digestive tract. It is important to place a guide wire on the distal portion of the graft in order to not twist it on its vascular axis. The future introitus is opened using the monopolar hook. The finger of an operative assistant helps to retract this region towards the abdominal cavity, hence facilitating the opening. A Step-trocar will be introduced into the introitus. This trocar type allows to perform a puncture with the Veress needle equipped with a sleeve that will be distracted using the trocar. The size of the trocar selected is 10 to 12mm. The bouginage of this perineo-vulval opening should first allow to exteriorize the proximal portion of the sigmoid colon in order to place the anvil of the circular stapler, thus avoiding a scar on the anterior abdominal wall. This maneuver is not always possible owing to the difficulties that may be encountered when lowering the sigmoid colon as caudally as possible in the perineal region, and this despite an adequate freeing of the sigmoid colon.

9. Restoration of colorectal continuity 09'00''

Once the anvil has been placed, the rectosigmoid continuity is restored conventionally. The anastomotic doughnuts are exposed. A patency control of the anastomosis is performed through a syringe injection of methylene blue into the rectum. The air-tightness of the perineo-vulval opening is ensured by leaving an ebony bougie to help maintain a correct pneumoperitoneum throughout this step of the procedure.

10. Neo-vagina 09'25''

The neo-vagina can then be lowered in the vulvar region and the vulval-sigmoid anastomosis is performed with a few stitches. A bouginage of the anastomosis helps to control the introitus satisfactorily. The cosmetic and functional aspects seem to be highly satisfactory. The length of the sigmoid graft is also appropriate. The patient will have to perform self-dilatations in the postoperative months using an ebony bougie that she will be provided with. The peritonization of the pelvis helps to retrieve a perfectly satisfying anatomy intra-abdominally. It also prevents any small bowel adhesions in the perineal region. At the end of the procedure, the bouginage of the neo-vagina can be observed subperitoneally.

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