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Vagina and Urethra

Anterior Repair and Kelly Plication
Site Specific Posterior Repair
Sacrospinous Ligament Suspension of the Vagina
Vaginal Repair of Enterocele
Vaginal Evisceration
Excision of Transverse Vaginal Septum
Correction of Double-Barreled Vagina
Incision and Drainage of Pelvic Abscess via the Vaginal Route
Sacral Colpoplexy
Le Fort Operation
Vesicovaginal Fistula Repair
Transposition of Island Skin Flap for Repair of Vesicovaginal Fistula
McIndoe Vaginoplasty for Neovagina
Rectovaginal Fistula Repair
Reconstruction of the Urethra
Marsupialization of a Suburethral Diverticulum by the Spence Operation
Suburethral Diverticulum via the Double-Breasted Closure Technique           
Urethrovaginal Fistula Repair via the Double-Breasted Closure Technique
Goebell-Stoeckel Fascia Lata Sling Operation for Urinary Incontinence
Transection of Goebell-Stoeckel Fascia Strap
Rectovaginal Fistula Repair via Musset-Poitout-Noble Perineotomy

Sigmoid Neovagina

Watkins Interposition Operation

Sigmoid Neovagina

The use of intestine for a neovagina adds an additional procedure to the formation of a neovagina. Traditional techniques for neovagina have included myocutaneous flaps, skin grafts, skin grafts applied to omental cylinders, and combinations thereof. The normal nonirradiated sigmoid colon may represent an ideal structure to become a neovagina. Unlike the small intestine, which has excessive necrotizing secretions, the mucosa of the sigmoid colon has secretions that are less necrotizing and less copious. The advantages of the sigmoid neovagina over skin grafts of various kinds are (1) it has its own inherent blood supply through the superior hemorrhoidal artery and sigmoid branches of that artery; and (2) it has distensibility through compliance unavailable in skin grafts. Although blood supply can be a positive aspect of sigmoid neovagina, the blood supply is critical. If for some reason the inferior mesenteric artery or the superior hemorrhoidal branch of the inferior mesenteric artery is compromised, the blood supply to the neovagina will be lost. A negative feature of sigmoid neovagina is that it requires an intestinal anastomosis between the descending left colon and the remaining rectum.

Points of Caution.  Adequate mobilization of the descending colon must be achieved to prevent tension on the anastomosis. Adequate visualization of the superior hemorrhoidal artery and its sigmoid branches must be obtained.

The use of the vaginal form is controversial. There are those who believe that packing or a vaginal form is not necessary. Other surgeons routinely use foam rubber covered with a condom as a vaginal form to maintain dilation of the colon and/or neovagina.


Figure 1 shows a view of the pelvis in which a total supralevator exenteration has been performed. The stump of the urethral meatus, the stump of the vagina at the level of the introitus, and the stump of the rectum at the level of the peritoneum are noted.

Sigmoid neovagina is begun by mobilizing the left colon including the splenic flexure of the transverse colon. The inferior mesenteric artery and its branches, the left colic artery and the superior hemorrhoidal artery, are carefully identified. A segment of sigmoid colon approximately 14 cm long is selected. The colon is transected, the marginal artery of the colon is divided, and the incision is extended along the dotted line into the mesentery. At this point, several branches of the superior hemorrhoidal artery that feed the sigmoid branches are identified. An incision is made in the mesentery to the sigmoid colon neovagina, leaving several branches of the superior hemorrhoidal artery intact to act as blood supply for the entire colonic segment neovagina via the margin artery of the colon. IVC indicates the inferior vena cava.

The transection into the mesentery and parallel to the colon within the mesentery but beneath the network of marginal vessels to the colon is necessary for the segment to be rotated into the antiperistaltic position to reach the vaginal introitus. That is, the proximal end of the sigmoid neovagina is rotated 180°, and the distal end of the colon now becomes the proximal end of the neovagina. This 180° rotation prevents excessive tension on the superior hemorrhoidal artery, jeopardizing its integrity.

The proximal end of the sigmoid colon is pulled through the vaginal introitus. A prolapse of colon protruding approximately 3 cm out of the introitus is created, and sutures are placed between the colonic wall and introitus. A 3-4 cm segment of prolapse is essential because in the immediate postoperative period there will be tendency for retraction. If the surgeon transects the colon flush with the introitus, there will be postoperative retraction and stricture. Note here that the rectal stump is still in place for a very low end-to-end anastomosis between the left colon and the rectum with the EEA stapler, performed in the routine manner as seen in the section Colon.

The completed operation shows a soft foam rubber vaginal form in the sigmoid neovagina, which is protruding 3-4 cm outside the introitus and is sutured into place for a minimum of 2-3 weeks. Excess prolapsed colon can be trimmed with an electric cautery as an out-patient procedure. After the wounds have healed, we do not continue to use the neovaginal foam rubber form. Sexual intercourse is allowed as soon as the patient's wounds have healed and it becomes comfortable.



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