RU2186539C1 - Method for vaginoplasty at vaginal aplasia - Google Patents

Abstract

FIELD: medicine, gynecology. SUBSTANCE: it is formed the lower neovaginal vestibule mucosa. It is formed the upper neovaginal department out of sigmoid flexure segment. It is formed a neovaginal bed by tunnelization of rectovesical space. Intestinal segment is descended into the formed bed. Anastomosis is formed between the upper and lower neovaginal departments being above the level of pelvic bottom. In peculiar case the bougienage is conducted before the exit of the lower neovaginal department top into the cavity of minor pelvis. Anastomosis is formed to be in fragments. Formation of the lower neovaginal department is conducted for 3-6 mo. EFFECT: decreased traumaticity level of interference. 3 cl, 1 ex

Description

 The invention relates to medicine, namely to gynecology, and can be used for surgical correction of vaginal aplasia. The proposed method can be used both with isolated aplasia of the vagina, and with a combination of aplasia of the vagina and uterus.

 Known numerous methods for creating a vagina can be divided into 3 groups: bloodless; providing for the filling of the channel formed in the rectovesical tissue with skin, pelvic peritoneum, or alloplastic materials; and also associated with the movement of the intestine into the vesico-rectal space (Okulov AB, Negmadzhanov BB Surgical diseases of the reproductive system and sextransformation operations, a guide for doctors. - M .: Medicine, 2000, 175) [1].

 The known bloodless method of forming an artificial vagina using a kolpoelongator proposed by B. Sherstnev (1987). This method uses an apparatus whose action is based on the ability of tissues to stretch under gradual controlled pressure. (Adamyan A.V. et al. Malformations of the uterus and vagina. M: Medicine, 1998, 116-117). The simplicity of the method allows it to be performed on an outpatient basis, however, the small correction efficiency is an absolute disadvantage of the method, the created recess returns to the vestibule, the walls are not sufficiently moistened.

 Intestinal colpopoiesis is known, each method of which involves resection of a portion of the intestine, restoration of intestinal patency, reduction of the resected area on the vascular pedicle through a previously created channel in the rectovesical space and its fixation to the perineal wound.

 The method of monotubular sigmoidal colpopoiesis was chosen by us as a prototype [1, 182-189]. The known method offers cutting four flaps from the mucous membrane of the vulva, tunnelization of rectovesical space, resection and reduction of a segment of the colon into the prepared bed, the formation of anastomosis between the edges of the graft and the flaps of the vaginal mucosa. The prototype method provides a fairly effective correction of the applauded vagina. However, the presence of intestinal mucosa at the entrance to the vagina is accompanied by spontaneous outflow of mucus to the perineum, trauma and bleeding of the intestinal mucosa, changes the natural appearance of the external genital organs.

 We set the task: to develop a reliable method of vaginoplasty with vaginal atresia, which allows to preserve the natural appearance of the external genital organs, to obtain a sufficient volume of neovagina, and also to exclude relapses and complications due to the presence of intestinal mucosa in the region of neointroitus.

 The technical result consists in reducing the morbidity due to a decrease in the size of the intestinal transplant, preventing complications and discomfort caused by the expiration of mucus on the perineum, as well as improving the cosmetic result of the intervention through the use of the combined method of vaginoplasty with separate formation of the upper and lower sections of neovagina and the location of the intestinal segment above the pelvic floor.

 The proposed method of vaginoplasty with vaginal atresia has the following advantages.

 The use of the intestinal segment for plastic surgery of the neovagina allows you to get its sufficient volume, to exclude relapse of the disease, as well as prolapse of the wall of the neovagina, since it suggests the presence of points of its fixation in the pelvis.

 The use of the mucous vestibule of the vagina after bougienage allows you to preserve the natural appearance of the external genital organs, as well as reduce the invasiveness of the intervention as a result of reducing the size of the intestinal segment necessary for plastic surgery, since it is not used for plastic surgery of the whole vagina, but only its upper section.

 The proposed method of combined colpopoiesis using a segment of the colon and mucous membrane of the vestibule of the vagina after it is neovaginal for plasty allows eliminating the disadvantages inherent in isolated methods of colonic colposis and bloodless colpopoiesis based on vaginal vestibulation.

 The location of the intestinal segment above the level of the pelvic floor with compression of the lower neovagina by the muscles of the pelvic floor prevents involuntary leakage of intestinal mucus to the perineum. The amount of mucus in this case decreases sharply as a result of its dehydration in the lumen of the intestinal segment. This circumstance excludes skin maceration, dermatitis, as well as other discomfort caused by the presence of mucus in the perineum. Elimination of the intestinal mucosa from neointroitus can improve the cosmetic effect of the intervention, to avoid trauma and bleeding of the intestinal mucosa, which is observed when hemming the intestinal mucosa directly to the vestibule. Pelvic floor muscles provide support for the intestinal segment and eliminate the risk of organ wall prolapse.

 The flap anastomosis, proposed in the claimed method using exactly two flaps instead of the known one-, three- and four-flap connections, allows the blood supply to the intestinal flaps prone to ischemia to the greatest degree to be maintained and at the same time the risk of anastomosis stenosis can be eliminated.

 The method is as follows.

 The combined method of surgical treatment of vaginal aplasia includes vestibuloextension in order to create a reserve of plastic material - at the first stage of treatment and anastomosis between the mucosa of the vestibule and the segment of the colon above the pelvic floor - at the second stage of treatment.

 At the first stage of treatment, bougienage of the mucous membrane of the vestibule of the vagina is carried out, forming the lower section of the vagina for 3-6 months. In this case, bougie is used from 6 to 12 cm long with a gradual increase in length by 1 cm in diameter from 1 to 4 cm with a gradual increase by 0.5 cm. Bougie with conical or blunt ends is used. A complete set of dilators of the vestibule of the vagina includes 14 bougie.

 During the first week, doctoring is carried out with the help of the thumb of the hand. The created depression is then stretched by the patient herself. The manipulation time from 10 to 40 minutes is gradually increased as the mucosa becomes accustomed to pressure and pain disappears.

 The bougie is introduced into the introitus at an angle of 45 degrees in the direction from top to bottom to create the greatest pressure on the most extensible posterior wall of the introitus and exclude injury to the urethra and bladder. After reaching a depth of the lower part of the vagina of 4 cm, the patient sits on a bougie, which abuts against a dense roller located between her legs.

 To improve tissue stretching, the procedures are accompanied by an application, for example, an estrogen-containing ointment (folliculin 1 ampoule of 10,000 units per 30 ml of liquid paraffin).

 Probing is performed until the top of the lower part of the neovagina exits into the pelvic cavity, beyond the muscles of the pelvic floor and the formation of the lower part of the neovagina is 4-6 cm deep.

 At the second stage of treatment, surgery is performed aimed at the formation of the upper section of the neovagina from the sigmoid colon segment.

 Produce a lower middle laparotomy. A section (segment) of the sigmoid colon is resected with a length of 10-12 cm on a vascular pedicle containing 1, 2 or 3 supply vessels.

 The proximal end of the resected intestine is sutured tightly with a double-row suture. Intestinal patency is restored by applying end-to-end anastomosis.

 Transverse transintroital access dissects the apex of the lower part of the vagina formed during bougienage into 2 flaps - front and back. The rectovesical space is opened and a tunnel is formed between the rectum and the bladder to the level of the peritoneum of the small pelvis - the bed for the neovagina. The intestinal segment is reduced to the formed bed of the vagina, avoiding torsion, tension and compression of the mesentery. The distal end of the intestinal segment is cut longitudinally in the sagittal plane, bypassing the mesentery, with 3-4 cm deep sections with the formation of right and left flaps symmetrical relative to the plane of the section. In other words, the distal end of the intestinal segment is cut longitudinally at 6 and 12 hours from the end face facing the perineum. The anterior and posterior introital flaps are sutured into the corners of the sections of the intestinal segment and form a flap anastomosis with an extended connection line above the level of the muscles of the pelvic floor. Anastomosis connects the upper section of the neovagina formed from the intestinal segment with the lower section of the neovagina formed from the mucous membrane of the vestibule of the vagina after bougieurage. The neovaginal dome is connected to the peritoneum of the pelvis. The abdominal cavity is sutured tightly. A gauze swab impregnated with dioxidine and petroleum jelly is placed in the neovagina for 5 days.

 Clinical example.

 Patient G. 16 years old with a diagnosis of: Anomaly in the development of genital organs. Rokytansky-Küster-Mayer syndrome. Vegetative dystonia in a mixed type, functional cardiopathy.

 With a gynecological examination: the external genitalia are developed correctly, female type hair. The clitoris is not enlarged. The introitus is represented by a recess in the probe 4-5 cm. The vagina is absent. In rectal-abdominal examination, the uterus is in the form of a cord.

 Ultrasound examination of the genitals: the uterus is located in the middle, in the form of a rudimentary cord of 28 • 4 • 10 mm. The vagina is not visualized. To the left of the uterus is an oval formation 23 • 13 mm - the ovary.

 The patient was treated according to the proposed method. At the first stage, vaginal bougienage was performed for three months with ovestin and one week with folliculin. Formed lower section of neovagina measuring 7 cm.

 At the second stage of treatment, a resection of the sigmoid colon, sigmovaginoplasty by the proposed method was performed. In surgery, the distal part of the resected intestinal segment is hemmed to the tissues of the lower part of the vagina, formed during bougieuding above the level of the pelvic floor. The proximal part of the upper vagina - the intestinal segment is sutured tightly. Tampon in the neovagina. The course of the immediate postoperative period is smooth.

 According to the results of control vaginography, 1 and 6 months after the operation, the neovagina is of sufficient capacity: 12-14 cm in length and 3.5-4 cm in width.

Claims (4)

 1. A method of vaginoplasty for vaginal aplasia, including the formation of the lower part of the neovagina by bugging the mucous vestibule of the vagina, the formation of the upper part of the neovagina from the sigmoid colon segment, the formation of the neovagina bed by tunneling the rectovesical space, the lowering of the intestinal segment into the formed bed and the formation of anastomosis between the upper and lower parts neovagina above the level of the pelvic floor.  2. The method according to claim 1, characterized in that the bougienage is performed until the top of the lower neovagina exits into the pelvic cavity.  3. The method according to claims 1 and 2, characterized in that the anastomosis is formed by a patchwork, for which the apex of the lower part of the neovagina is first dissected with the formation of the anterior and posterior flaps, the distal end of the intestinal segment is longitudinally dissected in the sagittal plane and the anterior and posterior sutured into the corners of the incisions patches of the lower neovagina.  4. The method according to claims 1 to 3, characterized in that the formation of the lower part of the neovagina is carried out for 3-6 months, using bougie lengths of 6 to 12 cm and a diameter of 1 to 4 cm with conical or blunt ends and a gradual increase in length and diameters of 1 cm and 0.5 cm, respectively.