October 2000 Volume 5, Issue 5 Editor: James E. Carter, M.D., Ph.D., F.A.C.O.G

Laparoscopic Creation of Neo-Vagina
Submitted by: Dr. Nutan Jain
Vardhman Infertility and Endoscopy Centre
A-36, South Civil Lines
Muzaffarnagar, (U.P.) India
drnutan@vardhmanhospital.com  

Patients of Mayer Rokitansky Kuster-Hauser syndrome suffer from Mullerian agenesis and absent vagina. Several modes of creation of a vagina exist. With increasing laparoscopic skills and as all procedures are being attempted endoscopically, we modified Vecchietti’s method of creating Neo-Vagina Laparoscopically. We did not have exact bead and traction devises used by Vecchietti’s. We, in fact, used our own innovations to get excellent results, according to the infrastructural facilities we have.

Laparoscopic Method: The laparoscopic method consists of applying glass bead at the vaginal dimple and by graduating tension applied abdominally, the glass bead is pulled up creating a neo-vagina by deep invagination of recto-vesical space.

Operative Technique: We use a moderate sized glass bead to which # 2 Vicryl is threaded. This Vicryl is now threaded into a straight needle. From the vaginal end, the surgeon pierces the hymenal dimple and the needle is brought into the peritoneal cavity along with the Vicryl threads under direct laparoscopic control. Laparoscopically, the Mullerian ridge is delineated and the bladder is identified by putting a 2.7 mm hysteroscope in it. The rectum is identified by rectal probe. So with direct laparoscopic control and identifying the bladder and rectum separately, the thread bearing straight needle is made to pierce the hymenal fossa bringing both Vicryl threads inside the peritoneal cavity. The straight needle is removed out of the abdomen by one of the accessory ports. Then the aim is to bring these Vicryl threads over to the abdominal wall and apply traction on them by help of a traction device. To achieve this a micrograsper (2.7 mm) is used. It enters 3 cm lateral to the midline above the pubic hair line in a sub peritoneal plane. Safety of the bladder is continually monitored by micro-hysteroscope, acting as a cystoscope. Micro forceps are made to puncture the peritoneum very close to the #2 Vicryl thread, which is grasped and pulled out in the sub peritoneal plane and out on the abdominal wall. The same procedure is repeated on the contralateral side. Then both of these threads are attached to a traction device and every alternative day graduated tension is given pulling the bead upwards and creating a neo-vagina. The bead and traction device are removed after 10 days. After this the lady uses dilators of increasing diameters for a period of three weeks.

Satisfactory vaginal length of 7 cm is achieved and after three weeks, successful coitus is allowed. Our technique differs from Vecchietti’s in that we prick the hymenal fossa from outside inwards and at all times the thread bearing needle is under direct laparoscopic control. We use micrograspers and a straight needle rather than any other special devices. The traction device is also our own innovation.

The benefits of laparoscopic approach are many. Firstly, there is no need to dissect the recto-vesicle space, a surgical step which carries several risks and complications. Secondly, it does not cause any scars such as those associated with the technique using skin grafts. It is of a very short duration and does not require any plastic surgery and finally the neo-vagina gets coated by iodine positive squamous epithelium similar to that if a normal vagina. Hence, we have found that laparoscopic creation of the vagina is a simple, safe and effective method, which does not require much dissections or skin grafting and offers anatomically and functionally good results.

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