Applicability of Sigmoid Colon Graft for Vaginal Replacement (Colovaginoplasty) at Young Age

doi:10.4236/ss.2011.28092

Paper Menu >>

Journal Menu >>

Surgical Science, 2011, 2, 422-426

doi:10.4236/ss.2011.28092 Published Online October 2011 (http://www.SciRP.org/journal/ss)

Applicability of Sigmoid Colon Graft for Vaginal

Replacement (Colovaginoplasty) at Young Age

Mohamed A. Baky Fahmy1, Hanaa Abdel Hamid M. Al Abeissy1, Mohamed M. Abdalla2

1Al Azher University, Cairo, Egypt

2Al Galaa Teaching Hospital, Cairo, Egypt

E-mail: [email protected]

Received June 9, 2011; revised A ugust 13, 2011; accepted August 25, 2011

Abstract

Objective: to evaluate the applicability, feasibility, complications, short and long term results of vagino-

plasty by using sigmoid colon graft with stapler assistance for resuming colonic continuity in children with

absent vagina. Patients and Methods: records of 15 patients 8 of them had Androgen Insensitivity Syn-

drome, 4 had congenital vaginal atresia, and 3 had Congenital Adrenal Hyperplasia, underwent sigmoid graft

vaginal reconstruction with the aid of circular stapler during the period from 2005 to 2010 were reviewed

retrospectively. Results: a neovagina was constructed in those patients who aged from 3 to 9 years (mean 4

years), where sigmoid colon was used in all patients. Hospital stay ranged from 5 to 12 days (mean 7), op-

erative time ranged from 60 min to 120 min (mean 75 min). All patients were followed up 6 monthly in the

first year and then yearly, complications occurred in 4 patients: introital stenosis in 2, and another 2 cases

had minor wound infection. The need for neovaginal dilation was indicated in 5 out of 15 patients. There was

no complications related to bowel anastomosis, no mortality in this group and the cosmetic results were ex-

cellent in all cases. Conclusion: sigmoid colovaginoplasty appears to be applicable for remedy of vaginal

atresia at any age. It is associated with a less complication rate, the long term results is satisfactory and it

seems a better technique, especially in girls who doesn’t expect sexual activity shortly after surgery.

Keywords: Vaginal Replacement, Vaginal Atresia, Stapler, Neovagina, Colovaginoplasty and Sigmoid Graft

1. Introduction

Surgical management of girls with congenital absent

vagina continues to be a major technical problem due to

a prospective functional and psychological effect of the

outcome. The majority of cases of absent vagina result

from abnormality results from congenital adrenal hyper-

trophy, müllerian duct failure, androgen insensitivity

syndrome and gonadal dysgenesis [1]. Co nst ruction of an

artificial vagina had undergone a long evolution from

conservative to various surgical methods since 1938

when Frank proposed a nonsurgical approach using

various instruments and saddle-like devices that exerted

pressure on the vaginal vestibule [2]. This method re-

placed the technique proposed by Baldwin in 1904 [3],

whereby the vagina was reconstructed using an isolated

segment of small intestine, Pratt in 1961 proposed the

use of sigmoid colon in vaginal reconstruction [4]. With

the same purpose in mind cecum had been used, others

proposed a dermatome-collected cutaneous graft, mu-

cous membrane flap harvested from the bladder, and

peritoneal fragment advanced from the Douglas pouch.

Vaginal reconstruction was also performed with skin

island flaps created in the perineal and inguinal region

[7]. It is widely accepted that staplers use for resuming

bowel anastomosis is effective in reducing operating

time and potential complications related to their use spe-

cially in the pediatric population [8]. In this study the

sigmo id graft used fo r vaginal reconstruction winning the

advantage of surgical stapler to reduce the time of re-

suming bowel continuity and to minimize the complica-

tion rate related to bowel anastomosis and the whole

procedure.

2. Patients and Method

During a period of 5 years, from 2005 to 2010 a total of

15 patients had an indication for vaginal replacement due

to different pathology was reviewed.

Abdominal ultrasound, chromosomal analysis and hor-

M. A. B. FAHMY ET AL.423

monal assay were performed preoperatively for all pa-

tients, Magnetic Resonance Imaging (MRI) and ascend-

ing cystourtherogram done for 10 patients to assess the

associated anomalies and the status of the existing geni-

tal organs. Patients with AIS (8 patients) underwent go-

nadectomy before vaginoplasty and patients who had

CAH (3 patients) underwent clitoral surgery either along

the vaginoplasty, or latter on (Figures 1 and 2).

3. Technique

The surgical procedure for creating a sigmoid colon ne-

ovagina was done basically according to the principles

described by Graziano et al. [9] with some modifications

mainly in establishing bowel continuity by stapler. Pa-

tients were admitted to the hospital 2 days before the

surgery for mechanical and antibiotic bowel preparation.

Through a small abdominal Pfannenstiel incision or an

existing abdominal scar, the descending and sigmoid

colon were mobilized. The mesentery was examined to

Figure 1. A case of adrenoge nital hyperplasia.

Figure 2. A case of androgen insensitivity syndrome.

identify vascularisation and to evaluate the length of the

sigmoid loop which will be used for vaginal construction.

A 10 cm to 12 cm segment of the sigmoid colon con-

taining at least 2 sigmoid arteries was isolated on its

vascular pedicle for transposition to the perineum, and

the mesenteric defect was closed.

Depending on the individual patient’s vascular anat-

omy, either an iso-peristaltic or anti-peristaltic orienta-

tion was used. The proximal end of the sigmoid segment

was closed with interrupted absorbable sutures and fixed

to the vestigial remnants of the Mullerian ducts or to the

uterosacral ligaments. The continuity of the colon was

restored by an appropriate size (from 21 mm to 28 mm)

curved disposable intraluminal gastrointestinal anasto-

mosis (GIA) stapler, and we preferred the Curved De-

tachable Head (CDH) type (By Ethicon Endo—Surgery,

one of Johnson & Johnson Company) where the handle

introduced from the anus, with minimal anal dilation to

join the head of stapler at the proximal bowel (Figure 3).

We performed the abdominal procedures first, and af-

ter the preparation of the sigmoid loop, the upper side of

the rectovesical space was opened and enlarged to con-

tain the distal end of the sigmoid loop, in cases of vagi-

nal atresia a surgical plane was created between the ure-

thra, bladder and rectum by sharp dissection, but in GAH

cases the sigmoid graft connec ted to the vaginal remnant.

The mobilized sigmoid loop was brought down to the

perineal canal without tension to create a colon-perineal

anastomosis with interrupted absorbable sutures. To

prevent early retraction, the lateral portions of the sig-

moid neovagina were also fixed to the levator ani mus-

cles with interrupted absorbable sutures. Finally, the ne-

ovagina was packed with Povidone-iodine soaked gauze,

which was removed 24 hours after surgery, and an in-

dwelling Foley’s catheter was left in place for 2 to 3 days.

At discharge fro m the hospital pa tients were instr ucted to

irrigate the neovagina daily for 3 weeks and weekly there-

Figure 3. Curved disposable intraluminal GIA stapler for

bowel.

M. A. B. FAHMY ET AL.

424

after with Povidone-iodine solution. Calibration of the

neovagina done 2 weeks after discharge and during the

follow up visits, and if there is any need for dilatation it

is scheduled two weekly under local anesthetic. All pa-

tients had been followed up from 6 months to 4 years in

six months intervals for the first year and then yearly.

4. Results

A total of 15 girls aged from aged from 1 to 8 years

(mean 3), 8 of them had Androgen Insensitivity Syn-

drome (AIS), 4 had congenital vaginal atresia, and 3 had

CAH (Figures 4 and 5).

Operative time ranged from 60 min to 120 min (mean

75). Hospital stay ranged from 5 to 12 days means 7 days.

All patients were followed up from 6 month to 4 years

(mean 2 years), and calibration done 2 weeks after dis-

charge and during the follow up visits, by an appropriate

size Hegar’s dilators, the need for neovaginal dilation

was evaluated and it was indicated in only 5 out of 15

patients for 4 sessions in 5 and for 6 sessions in 3 pa-

tients with local anesthetic. Excessive mucous discharge

observed in 6 patients (older one) but it abstained gradu-

ally with the neovaginal wash by Povidone-iodine solu-

tion.

Complications occ urred in 4 patients, introital ste nosis

in 2 patients, one of them lost during the follow up due to

Figure 4. Age distribution at su rgery.

Figure 5. Cases distri b utio n.

some social pro blems b ut came back into s ight with ti ght

stenosis which necessitates redo of the introital wound,

and 2 cases had minor wound infection which managed

conservatively without any surgical intervention and

without sequels. There was no complications related to

bowel anastomosis, and there is no mortality in this

group of patients. All patients had functional adequate

patency and lubricant neovagina, with good patient sat-

isfaction and the vagina had good appearing introits,

mucus production decreased 3 to 4 month after the op-

eration (Figure 6).

As the tradition in our society that the girls had no

sexual activity outside marriage, so it seems difficult to

assess the sexual function of the reconstructed vagina,

which dictates a further follow up to evaluate the sexual

activity and functional effectiveness of the neovagina

latter on.

5. Discussion

Vaginal reconstruction may be indicated in cases of

Mayer-Rokitansky-Kuster-Hauser Syndrome [5], where

the vagina is congenitally absent, intersex and for other

cases of Androgen insensitivity Syndrome. Reconstruct-

ing the vagina in the children and young adults may be a

great technical challenge. Patients were more likely to

present after puberty with primary amenorrhea or failure

of intercourse, but recently the gender assignment to a

neonate with ambiguous genitalia became crucial [7].

Most investigators, however, suggest timing for surgery

from the newborn to 3-year-old period. Reasons for this

early intervention include better compliance with dila-

tions, lessening of the parents concerns regarding their

“anomalou s” child, and the assu mption that the child later

in life does not remember early interventions [6-7].

Numerous surgical and non-surgical methods have

been proposed to create a vaginal tunnel, the aim of any

Figure 6. Postoperative.

M. A. B. FAHMY ET AL.425

method is to provide a canal of adequate length, which is

lined with mucous membrane, characterised by a low

tendency to stenosis and comfortable during sexual ac-

tivity. Although used as a first-line of treatment for dec-

ades, skin grafts and dilation techniques are associated

with a high incidence of shrinkage, lack of lubrication

and dyspareunia [10].

Intestinal transplant methods to create a functioning

neovagina were advocated more than 100 years ago; the

advantages of these methods include adequate vaginal

length, natural lubrication, early intercourse and a low

rate of shrinkage [3]. Most segments of the intestinal

tract have been used to create a neovagina, but the sig-

moid colon is particularly useful because it is anatomi-

cally close to t he perineum, it is s ufficiently lon g and the

mobility of its vascular pedicle allows it to be brought

into the perineum [11].

Also the bowel vaginoplasty utilizing sigmoid colon

offers some advantages over skin grafts because of dis-

tensibility and sel f lubricating pro perty with no tendency

for neovagina stenosis, but it has the drawbacks of a

laparotomy with visible scars, possibility of bowel leak-

age/obstruction and problem of mucous secretion [12].

Also the sigmoid segments of the colon could be liable

for inflammatory bowel disease [13], primary adenocar-

cinoma has been reported, so vaginoscopy should be

used for any case of postoperative bleeding, pain, or

suspected mass .There have been reports of mucosal

prolapse, as well as of stenosis [14].

The Vecchietti technique [15] and its laparoscopic

varia nt re quir es a va gina l d i mple o f 3 - 4 c m, a long t ime

and rigorous cooperation by the patients to achieve ac-

ceptable results [15].

In the last decades, due to the progress in anesthesia,

antibiotic use and the reduction of risks associated with

colorectal anastomosis, the sigmoid graft technique has

became the first-line choice for the treatment of vaginal

agenesis in both children and adults [16]. A sigmoid ne-

ovagina is cosmetically pleasing, offers natural lubrica-

tion and during creation can be anchored to prevent

prolapse.

A collective analysis of 202 patients from 7 recent se-

ries of bowel neovaginoplasty found a complication rate

of 35% and a re-operation rate of 4%. These rates of

complications are not comparable to those reported for

skin gr aft vaginoplasties [1 0].

In this study we used the sigmoid graft as a preferable

procedure in 15 patients aged from1 to 8 years (mean 3

years), a historical cohort study of those consecutive pa-

tients who underwent neovagina reconstruction were

presented.

A dedicated database was reviewed for the etiology of

vaginal malformation, surgical complications and post-

operative follow-up, where Androgen Insensitivity Syn-

drome (AIS) was the common cause of vaginal atresia (8

pati ents), 4 had congenital vaginal atresi a (Figure 5).

In this small series the introduction of surgical stapler

for resuming the bowel continuity enabled to shorten the

time of surgery (60 min to 120 min, mean 75), to reduce

the hospital sta y which ranged from 5 to 12 days means 7

days, and we claim that it is al so li mits the complications

of bowel anastomosis to nil.

But other complications encountered in 4 patients, in-

troital stenosis in 2 patients, one of them had a tight

stenosis which necessitates redo of the introital wound,

and 2 cases had minor postoperative wound infection

which managed conservatively with local wash and sys-

temic antibiotic for 5 days without any surgical interven -

tion and without sequels. There were no long term com-

plications or impediment related to bowel anastomosis,

and there is no mortality in this group of patients. All

patients had functional adequate patency and lubricant

neovagina, with good patient satisfaction and the vagina

had fine appearing introits and mucus production de-

creased 3 to 4 month after the operation.

6. Conclusions

Vagina could be reconstructed with better success rate

and low complication rate by using sigmoid colon, it

does not require moulds, dilatation, lubricant, and the

vagina gro ws with t he child and could be used in differ -

ent diagnosed vaginal atresia, especially in girls who

doesn’t expect sexual activity shortly after surgery. The

use of stapler to reestablish the bowel continuity seems

to minimize the time of the technique and decline the

rate of complications related to bowel anastomosis. The

long-term satisfaction with the sigmoid neovagina for

intercourse, especially in girls had their vagina con-

structed before puberty, still requires long-term evalua-

tion.

7. References

[1] D. M. Powell, K. D. Newman and J. Randloph, “A Pro-

posed Classification of Vaginal Anomalies and Their

Surgical Correction,” Journal of Pediatric Surgery, Vol.

30, No. 2, 199 5 , pp. 271-276 .

do i:10.1016/ 0022- 3468( 95)90 573-1

[2] R. T. Frank, “The Formation of an Artificial Vagina with-

out Operation,” American Journal of Obstetrics & Gyne-

cology, Vol. 35, 1938, pp. 1053-1055.

[3] J. F. Baldwin, “The Formation of an Artificial Vagina by

Intestinal Transplantation,” Annals of Surgery, Vol. 40,

No. 3, 1904, pp. 398-403.

[4] J. H. Pratt, “Sigmoidovaginostomy: A New Method of

Obtaining Satisfactory Vaginal Depth,” American Jour-

M. A. B. FAHMY ET AL.

426

nal of Obstet rics & Gynecolog y, Vol. 81, No. 3, 1961, pp.

535-545.

[5] G. E. Griffin, C. Edwards, J. M. Madden, M. J. Harrod,

and J. D. Wilson, “Congenital Absence of the Vagina the

Mayer-Rokitansky-Kuster-Hauser Syndrome,” Annals of

Internal Medicine, Vol. 85, No. 2 , 1976, pp. 2224- 22 3 6 .

[6] R. J. Miller and L. L. Breech, “Surgical Correction of

Vaginal Anomalies,” Clinical Obstetrics and Gynecology,

Vol. 51, No. 2, 2008, pp. 223-236.

do i:10.1097/ GRF.0b013e31816 d2181

[7] J. M. Schober, “Long-Term Outcomes and Changing

Attitudes to Intersexuality,” BJU International, Vol. 83,

No. S3, 1999, pp. 39-50.

do i:10.1046/ j.146 4-410 x.1999.0830s3039.x

[8] G. Mattioli, M. Castagnetti, P. Repetto, et al., “Co mplica-

tions of Mechanical Suturing in Pediatric Patients,”

Journal of Pediatric Surgery, Vol. 38, No. 7, 2003, pp.

1051- 10 54. doi:10.1016/S0022-3468(03)00190-8

[9] K. Graziano, D. H. Teitelbaum, R. B. Hirschl and A. G.

Coran, “Vaginal Reconstruction for Ambiguous Genitalia

and Congenital Absence of the Vagina: A 27-Year Ex-

perience,” Journal of Pediatric Surgery, Vol. 37, No. 7,

2002, pp. 955- 960. doi:10.1053/jpsu.2002.33815

[10] A. Rajimwale, P. D. Furness, W. O. Brant and M. A.

Koyle, “Vaginal Construction Using Sigmoid Colon in

Children and Young Adults,” BJU International, Vol. 94,

No. 1, 2004, pp. 115-119.

doi:10.1111/j.1464-4096.2004.04911.x

[11] W. H. Hendr en and A. Atala, “Use o f Bowel for V aginal

Reconstruction,” The Journal of Urology, Vol. 152, No. 2,

1997, pp . 752-755.

[12] R. Lenaghan, N. Wilson, C. E. Lucas and A. M. Ledger-

wood, “The Role of Rectosigmoid Neocolporrhaphy,”

Surgery, Vol. 122, No. 4, 1997 , pp. 856-860.

doi:10.1016/S0039-6060(97)90098-2

[13] D. P. Froese, R. Haggitt and W. G. Friend, “Ulcerative

Colitis in Autotransplanted Neovagina,” Gastroenterol-

ogy, Vol. 100, No. 6, 199 1, pp . 1 749 - 1 7 5 2.

[14] M. Urrsic-Vrscaj, J. Lindtner, J. Lavomovec et al.,

“Adenocarcinoma in Sigmoid Neovagina,” European

Journal of Gyneacological/Oncology, Vol. 15, No. 1,

1994, pp. 24- 2 8.

[15] F. Borruto, S. T. Chasen, F. A. Chervenak and L. Fedele,

“The Vecchietti Procedure for Surgical Treatment of

Vaginal Agenesis: Comparison of Laparoscopy and

Laparotomy,” International Journal of Gynaecology and

Obstetrics, Vol. 64, No. 2, 1999, pp. 1 5 3-158.

doi:10.1016/S0020-7292(98)00244-6

[16] J. C. Goligher, “The Use of Pedicled Transplant of Sig-

moid for Vaginal Construction,” Annals of the Royal

College of Surgeons of England, Vol. 65, No. 6, 1983, pp.

353-355.

Appendix

Abbreviation

Androgen Insensitivity Syndrome (AIS), Congenital Ad-

renal Hyperplasia (CAH), Gastrointestinal Anastomosis

(GIA), Curved Detachable Head (CDH).