A Minimally Invasive Approach for Laparoscopic-Perineal Sigmoid Colpoplasty: Case Report and Innovations

Introduction

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a rare congenital uterovaginal agenesis caused by embryologic growth failure of the mullerian ducts. The prevalence ranges from 1 in 4000 to 1 in 10 000 newborns [1,2]. The syndrome is characterized by agenesis of the uterus and vagina in females, with normal ovaries, fallopian tubes, and 46XX karyotype [1]. The vagina agenesis has a profound psychological impact on a woman’s sense of femininity. The demand for a sexual life makes the creation of a neovagina strongly advisable. There are several techniques of vaginal reconstruction, including surgical and nonsurgical: the Frank procedure, Williams vaginoplasty, McIndoe operation, bowel vaginoplasty, and Vecchietti technique [3–6]. Laparoscopic-perineal neovagina construction by sigmoid colpoplasty is an appealing kind of bowel vaginoplasty technique because of its minimal invasiveness and good artificial effect [7,8]. The first case of sigmoid vaginoplasty by a laparoscopic-perineal approach was described by Ohashi et al in 1996 [7]. In the standard laparoscopic procedure, an auxiliary abdominal incision is usually needed to allow the colon to be exteriorized, and a purse is created for the anvil, which is necessary for the following end-to-end colorectal anastomosis.

Here, we introduced a modified laparoscopic-perineal sigmoid vaginoplasty technique. This idea was inspired by natural orifice specimen extraction surgery (NOSES), which is an intra-abdominal surgery that does not require an auxiliary incision to take a surgical sample from the abdominal wall, but through a natural orifice, such as anal, vaginal, and oral [9]. In the novel procedure, we created the purse for the anvil through the artificial neovagina tunnel but not an auxiliary abdominal incision. Therefore, it had more minimal abdominal scarring and a better cosmetic effect than does conventional laparoscopic-perineal sigmoid vaginoplasty.

Case Report

PRE-OPERATIVE PREPARATION:

The patient had a bowel cleaning program on the last night before the operation, using 140 g polyethylene glycol electrolyte powder (Wanhe Pharmaceuticals Company, Shenzhen, China). We evaluated the condition of the sigmoid colon using a colonoscopy before the operation. The colon was normal. Antibiotic prophylaxis (1.5 g of cefuroxime sodium) was administered intravenously 30 min before surgery.

PATIENT POSITION AND CREATION OF NEOVAGINAL TUNNEL:

The operative procedure was performed with the patient in the modified lithotomy position and under endotracheal general anesthesia. First, the genital reconstructive team separated the vesicourethral and rectal spaces by injecting water into the space. Then, an incision was made in the vestibular mucosa. Next, the connective tissues between the bladder and rectum were detached gradually and gently through the incision to the pelvic cavity by finger and dilators (Figure 1A, 1B).

TROCAR INSERTION:

After the preparation of the perineal space by the genital surgeons, the laparoscopic procedure was started by the laparoscopic team. A 10-mm cannula for video laparoscopy was inserted through the umbilicus. After creating a pneumoperitoneum (12 mmHg), one 5-mm cannula and one 12-mm cannula were inserted at 3 cm below the umbilicus on the right midclavicular line and in the right iliac fossa, respectively. Then, one 5-mm cannula was placed in the left iliac fossa for ancillary instruments. The abdominal and pelvic cavities were carefully explored using laparoscopy (Olympus, Tokyo, Japan). Investigation confirmed the absence of a uterus and fallopian tubes and the presence of 2 normal ovaries.

DISSECTION OF SIGMOID COLON GRAFT:

First, the peritoneum between the descending colon, sigmoid, and the psoas major muscle was dissected from the upper rectum toward the splenic flexure of the colon. The mesocolon of the descending colon, sigmoid, and upper rectum were released within the Toldt fascia. The inferior mesenteric artery and vein remained. After completely releasing the sigmoid and upper rectum, clamps were used to block the descending branch of the left colonic artery and upper rectal artery to evaluate vascularization of the future transplant. After ensuring that the blood supply for the sigmoid was good, the proximal and distal ends of the sigmoid colon were transected with endo GIA 35 staplers (Auto Suture; Tyco S.A., Elan-court, France), and the pedicle sigmoid flap was constructed (Figure 2A, 2B). The pedicle sigmoid flap in this patient was 15 cm long (Figure 2C). The distal end of the descending colon was pulled through the neovaginal tunnel using sponge forceps (Figure 2D, 2E). This is the innovation point of this modified technique, compared with traditional methods. The traditional procedures require an auxiliary incision to pull out the descending colon from the abdominal wall. In the novel procedure, the descending colon was pulled out through the artificial neovagina tunnel but not an auxiliary abdominal incision. Then, an anvil was fixed at the sigmoid stump and pulled back and replaced in the pelvic cavity (Figure 2F).

SUTURING THE SIGMOID FLAP ONTO THE DISTAL PART OF THE NEOVAGINA:

The distal end of the neovagina (the pedicle sigmoid flap) was pulled out through the neovagina tunnel using Allis forceps, paying particular attention that the blood supply of the graft was not twisted or under tension (Figure 3A). After the approximation of the distal sigmoid colon to the perineal skin, colon-cutaneus anastomosis using interrupted absorbable sutures was performed (Figure 3B). A soft vaginal mold with a diameter of 3.5 cm and a length of 8 cm was made with condoms and gauze rolls, and the mold was put into the neovaginal cavity for support. The labia majora was sutured with No. 7 silk thread, with a rubber tube to block the vaginal mold. The urinary catheter was kept in place.

Finally, an intracorporeal end-to-end colorectal anastomosis was performed by a circular stapler (Johnson & Johnson, CDH29P, USA) through the anus. One intra-abdominal drainage tube was replaced (Figure 4A–4C). The total time in the operating room was 315 min. The diagram showed several important steps of the modified operative procedure (Figure 5).

POSTOPERATIVE MANAGEMENT:

Antibiotic prophylaxis was administered intravenously for 48 h postoperatively. The patient started to fast until the first flatus on the second day after the operation, and was then fed liquids and a semifluid diet. The intra-abdominal drainage tube was removed 72 h postoperatively. Before discharge, the patient was trained to self-irrigate the neovagina using saline to prevent diversion colitis and foul odor and to use a vaginal dilator to prevent stenosis at the colon-cutaneous junction. The patient was recommended and encouraged to resume sexual intercourse 8 weeks after surgery.

Discussion

The main goal of neovaginal reconstruction is the creation of a functioning vagina. Additionally, satisfactory cosmesis is an important requirement for young women with MRKH syndrome. Various techniques for colpoplasty have been devised, and a number of operations have been reported. Among these, the free skin graft [10,11], pelvic peritoneum [12], small bowel [13], and sigmoid colon [8] have been commonly used. However, the readhesion, contracture, and stenosis of the new vagina have been the main risk factors resulting in surgical failure. Compared with small bowel, pelvic peritoneum, and skin grafts, the choice of sigmoid grafting seems to be ideal with several key advantages. First, the diameter of the sigmoid colon is nearly commensurate with that of the normal vagina. Second, the risks of shrinkage, narrowing, and stenosis of the neovagina are lower than those of the others. Third, the sigmoid colon shows relatively strong muscle tissue with continuous mucosal secretion for effective lubrication. In addition, it is more like a normal vagina, so that patients and sexual partners have a better sexual experience. Fourth, the thick sigmoid wall tolerates trauma better than do small bowel and skin grafts.

Pratt [14] described an open vaginoplasty using the sigmoid colon for the first time in 1961. However, this procedure requires a midline laparotomy because of its drawbacks of discomfort, pain, adynamic ileus, postoperative adhesions, abdominal scars, and rectal perforation. These drawbacks limit the applicability of sigmoid vaginoplasty. Ohashi et al [7] introduced vaginal reconstruction using a sigmoid autograft combined with laparoscopy for the first time in 1996. Compared with open sigmoid colpoplasty, the laparotomic-perineal approach has a shorter hospital stay, earlier recovery, minimal invasion, and smaller scars. This approach is increasingly being used by surgeons as an effective choice in clinical practice.

The laparotomic-perineal approach is a minimally invasive operation. In the standard laparoscopic procedure, an auxiliary abdominal incision (above 3–5 cm) is needed to create a purse for the anvil, which is necessary for the end-to-end colorectal anastomosis. In 2020, Wang et al [8] introduced total laparoscopic sigmoid vaginoplasty using an intra-abdominal endto-end anastomosis without an auxiliary abdominal incision. They placed the anvil into the proximal colon cavity through the anus before transecting the sigmoid colon. However, it is necessary to make a small incision on the sealed bowel wall to create a purse for the anvil, which can increase the risk of intraabdominal infection.

In our case, we performed a technique similar to that used in the NOSES procedure. We exteriorized the proximal descending colon stump out of the pelvic cavity via the artificial neo-vagina tunnel to accommodate the anvil of the circular stapler under direct vision. This technique may have a lower abdominal infection risk than the total laparoscopic sigmoid vaginoplasty reported by Wang [8]. The patient recovered early and was discharged on day 4 after the operation, without any complications. The patient was very satisfied with the vaginoplasty and cosmetic effect. However, long-term outcomes need further follow-up. We believe this is a promising laparoscopicperineal surgery, because it has a better cosmetic effect than traditional methods. It will be an alternative treatment for patients with MRKH syndrome.

In addition, there are some limitations and key factors for this modified procedure. First, preoperative colonoscopy and CT scans are necessary to fully evaluate the situation of the sigmoid colon to avoid transplanting an unhealthy sigmoid.

Second, oral laxatives should be taken 1 day before surgery to decrease the risk of abdominal or pelvic infection caused by fecal contamination during the operation. Third, this novel procedure is more complicated than the usual procedure. The mesocolon of the descending colon, sigmoid, and upper rectum needs to be completely released so the proximal end of the descending colon could be pulled out through an artificial neovagina tunnel without tension. Forth, there is a risk of damage to the blood vessels of the descending colon while it is pulled out through the neovagina tunnel. Therefore, the technique requires the surgeon to have accumulated experience in laparoscopic colonic surgery, especially in NOSES surgery.

Conclusions

In conclusion, we performed a modified laparoscopic-perineal sigmoid vaginoplasty, which is a reliable and effective method that satisfies the requirements of a functional neovagina and cosmesis. We believe that this procedure will be an ideal alternative for certain patients in need of vaginal reconstruction.