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Section 14.6. Laparoscopically Assisted Neovaginoplasty
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Luigi Fedele, Stefano Bianchi, Nicola Berlanda, Eleonora Fontana, and Alessandro Bulfoni
Surgical creation of the neovagina has been performed for more
than a century according to various techniques and for a multitude of congenital and acquired causes of partial or total absence
of thevaginal canal. The most frequent indicationfor neovaginoplasty is the Mayer–Rokitansky–K¨uster–Hauser syndrome, or
simply Rokitansky syndrome. New surgical techniques in which
laparoscopy has replaced traditional surgery have been recently
proposed to treat rare congenital anomalies.
THE ROKITANSKY SYNDROME
The Rokitansky syndromeisa complexmalformation comprising
an absent vagina and uterus, grouped as class IE of the Buttram
and Gibbons classification of genital tract abnormalities. The
occurrence of a nonfunctioning vagina has been reported since
ancient times.Hippocratesdescribed amembranous obstruction
of the vagina in the book On the Nature of Women.Afewcenturies later, Celsius presented a complete description of vaginal
atresia.[1]Mayerin1829 [2]andRokitanskyin 1838[3]described
a syndrome thatincluded agenesis ofthe uterus andvagina dueto
an anomalous developmentofthe mullerian ducts.Subsequently,
K¨uster [4] recognized urologic associations whereas Hauser [5]
distinguished Rokitansky syndrome from testicular feminization. The exact incidence of Rokitansky syndrome is unknown,
although a recent epidemiologic study [6] estimated it to be one
in 1500 to one in 4000 people born female. Following gonadal
dysgenesis, Rokitansky syndrome is the major cause of primary
amenorrhea.
The etiology ofRokitanskysyndromeis not yet understood. It
occurssporadically but has been described in sisters with a normal
karyotype and in a pair of monozygotic twins. The majority of
patients have a normal female karyotype, although some show a
mosaicism of thesexchromosomes(45X/46XX;46XX/47XXX).It
has been hypothesized thatexposure to a teratogenic agent during
the fourth gestational week may be responsible for Rokitansky
syndrome as well as forthe frequently associated anomaliesof the
skeletal and urinary systems. Indeed, in this intrauterine stage,
the pronephric duct and the cervicothoracic somite blastema are
closely linked.
The genital anatomy of Rokitansky syndrome is distinguished
by normal external genitalia and the absence of the upper two
thirds of the vagina (Figure 14.6.1). Another common finding
is a blind retrohymenal pouch that may be as deep as 2 cm.
The uterus is absent; whereas in most cases, two fibromuscular
cords are found originating from the medial aspect of the tubal
extremities and fused along the median line, resembling a dou-
ble rudimentary uterus (Figure 14.6.2). Asymmetric and distinct
rudimentary horns are seldom found and are usually of a greater
size (Figure 14.6.3). Sometimes these horns may appear hollow
and lined with endometrial tissuethatisgenerallyhyporesponsive
to cyclic hormonal modifications. The horns may be also rarely a
site of menstruation asseen in reports ofsubjectswith Rokitansky
syndrome developing hematometra in one or both rudimentary
horns.[7] The salpinges and ovaries are usually normal, although
rarely there may be ovarian anomalies, such as occurrences of
unilateral agenesis.
Rokitansky syndrome is also distinguishedbya frequent association with malformations of the urinary and skeletal systems.
There may also be congenital cardiac anomalies. Urinary tract
malformations are present in about 40% of cases, especially unilateral renal agenesis or ectopy, which is demonstrated in around
15% of patients.[8] Skeletal malformations affect the spine, limbs,
and ribs. Recently, Pittock et al. [9] found vertebral anomalies in
44% of patients, whereas Strubbe et al. [10] showed that over
50% have some abnormalities on hand radiography. The most
frequently described combination in Rokitansky syndrome has
been uterovaginal agenesis, renal agenesis/ectopy, and cervical
somite dysplasia. Such association is also known as MURCS, and
is found in just over 10% of cases.[11]
Symptoms
If functioning endometrial tissue is present inside the rudimentary uterine bodies, cyclic pelvic pain will consequently develop
as soon as secondary sexual characteristics appear. Symptoms are
generally primary amenorrhea and sexual dysfunction. Amenorrhea is present and is associated with a normal endocrine
work-up and normal development of secondary sexual features.
Sexual intercourse is almost always problematic – in fact, not
infrequently, the presence of just a brief portion of vagina above
the vestibular area may still imply initial difficulties, but after a
certain period, sexual activity may become satisfactory due to
stretching of the ectodermal vaginal residue.
Diagnosis
Diagnosis of Rokitansky syndrome is usually apparent on a clinical examination, which demonstrates normal external genitalia
and the absence of a vagina. Rectal examination often confirms
the absence of theuterusor the presence of asmallfibrousnodule.
The presence of normal pubic and axillary hair growth permits
exclusion of Androgen Insensitivity syndrome. A transabdominal ultrasound scan usually confirms absence of the uterus and,
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Figure 14.6.1. Normal external genitalia and absence of vagina in a
patient with Rokitansky syndrome.
where present, shows a median rudimentary uterus or two lat-
Figure 14.6.3. Laparoscopic view in a patient with Rokitansky syndrome. Note the absence of the uterus and the presence of two rudimentary horns.
erally displaced rudimentary horns. MRI is the imaging method
that best defines the anatomic features of Rokitansky syndrome,
especially the subperitoneal structures and possible endometrial
cavitations. Presence of endometrium withina rudimentary horn
may then be confirmed during laparoscopy by an endoscopic
ultrasound probe (Figure 14.6.4). Such demonstration permits
removaloftherudimentary horn or, ifthehornisof adequatesize,
surgery could be attempted to join the horn to the neovagina to
allow outflow ofmenstrual bloodand possibly restore gestational
capability.[12]
been applied insubjects with a relativelydeep (2 to3 cm) retrohymenal pouch. Theauthor observed that some patients with Rokitansky syndrome were able to achieve a vagina of adequate depth
and caliber solely with sexual activity. Among the most widely
known surgical approaches is probably the operation proposed by
McIndoe in 1938 [14], which requires surgical creation of a tunnel in the rectal–urethrovesical space, which is then coated with a
strip of skin taken from the buttocks or from the medial aspect of
the thigh. Among the surgical operations requiring dissection of
the rectal–urethrovesicalspaceforthe creation of a neovagina, the
Tr ea t me n t
best results can be achieved by the method proposed by Davydov
[15] and Rothman [16], in which the tunnel formed by surgi-
In spite of numerous surgical and nonsurgical techniques proposed in the past (Table 14.6.1), a standardized and internationally acknowledged treatment for correction of Rokitansky
syndrome still does not exist. All experimental methods aim
cal dissection is coated by pelvic peritoneum that is mobilized
and pulled downward toward the hymen. In Europe during the
past 30 years, the most frequently used method for creation of
a neovagina has been that proposed by Vecchietti in 1965.[17]
at creating a neovagina by means of separating the rectal–
urethrovesical space as well as maintaining an open cavity, thus
ensuring its reepithelization.Excellentresultshave been described
when the nonsurgical methodproposedbyFrankin 1938 [13] has
Figure 14.6.2. Laparoscopic view in a patient with Rokitansky syndrome. Note the absence of the uterus and the presence of two fibromuscular cords originating from the medial aspect of the tubes.
Figure 14.6.4. Laparoscopic ultrasound of a rudimentary horn to
assess the presence of endometrial tissue.
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Table 14.6.1: Methods for the Creation of a Neovagina
Author Method
Frank (1938) [13] Intermittent use of vaginal dilators
D’alberton (1972) [27] Sexual activity (“functional” method)
Ingram (1981) [28] Intermittent pressure with bicycle seat
Baldwin (1904) [29] Double ileal segment transplantation
Popoff (1910) [30] Rectal segment transplantation
Schubert (1911) [31] Sigmoid segment transplantation
Graves (1921) [32] Pedunculated skin flaps from vulva and
thigh
Frank and Geist (1927)
[33]
Brindeau (1934) [34] Perineal dissection and transplantation of
Wharton (1938) [35] Perineal dissection and insertion of a balsa
McIndoe (1938) [14] Perineal dissection and transplantation of
Williams (1964) [36] Creation of a vulvovaginal pouch
Vecchietti (1965) [17] Traction from above on the hymenal
Davydov (1969) [37] Perineal dissection and transplantation of
Cylindric dermo-epidermal flaps from
thigh
amniotic membrane and insertion of
vaginal stent for continuous dilatation
wood vaginal stent for continuous
dilatation
skin flaps and insertion of vaginal stent for
continuous dilatation
pseudomembrane
peritoneum and insertion of vaginal stent
for continuous dilatation
This technique is essentially a surgical variant of the traditional
method by Frank. Instead of applying pressure from below on
the retrohymenal tissue, constant traction is maintained from
above.
LAPAROSCOPIC SURGERY FOR CREATION
OF A NEOVAGINA
The first approach for creation of a neovagina via laparoscopy
was introduced by Semm in 1983.[18] In this case, the sole purpose of laparoscopy was to supervise the creation of a neovagina
in the vesicorectal space starting from the perineum. In 1992,
two laparoscopic versions of Vecchietti’s laparotomy procedure
were proposed. Gauwerky et al. [19] and Popp and Ghirardini
[20] described two relatively similarapproaches, which made use
of Vecchietti’s original idea – that is, a proper device producing upward traction from the retrohymenal pouch on an acrylic
olive, which acts as a wedge through the rectovesical space, thus
creating between the two viscera an adequate space that can be
maintained by dilators and sexual activity. These authors’ suggestions have not achieved popularity, probably because of their
excessive complexity.
There are only two laparoscopic procedures that have been
used experimentally on a sufficient number of subjects and can
therefore be adequately evaluated: the laparoscopic modification
of the original operation of Rothman [16] and Davydov [15]
proposed by Soong et al. [21] and the laparoscopic modification
of the original laparoscopic operation ofVecchietti [17] proposed
by Fedele et al.[22]
Laparoscopically Assisted Neovaginoplasty
through the Pelvic Peritoneum
In 1994, Soong et al. [21] first published a description of
laparoscopicallyassistedneovaginoplastythroughthe pelvic peritoneum as wellas this technique’sresultsin four patients;in 1996,
they reported a technical variation and its results in another 14
subjects.[23] The procedure is a laparoscopic adaptation of the
creation of a neovagina through the peritoneal pull-down technique according to Adamyan [24], and in its latest version, it
consists of the following steps. First, the round ligament is
cut. Loosening peritoneal incisions are then made lateral to the
infundibulopelvic ligament on each side and above the bladder
to facilitate the pulling down of the loosest, most dependent deep
cul-de-sac peritoneum to the vaginal introitus. Dissection of the
pelvic peritoneum above the pouch of Douglas is gently performed to obtain a continuation of the bilateral pelvic incisions.
Complete excision of the uterine remnant is performed after the
peritoneum is loosened. A vaginal vault is then created through
blunt dissection of the new vaginal canal, in the plane between
the bladder and rectum,by means of the surgeon’s index fingerin
the vagina, and is dissected with scissors via laparoscopy. A Kelly
clamp is then inserted transvaginally to grasp and pull down the
peritoneum, relaxed previously, and the tip of the peritoneum
is fixed with a 0 Vicryl suture to the upper edge of the neovaginal orifice on each side. A temporary vaginal stent is inserted
into the previously prepared vaginal space. The top of the reconstructed vagina is formed by approximating theperitoneum with
2-0 Vicryl suture.
The main complication occurring in this series was a rectovaginal fistula that appeared 18 months after surgery and was
repaired via laparotomy. Vaginal bleeding occurred rather frequently, especially in the first 2 months. The authors reported
good results from both an anatomic and a functional point of
view. Mean length of the neovagina was greater than 8 cm, with
a diameter of 3 cm; among the 16 patients experiencing sexual
activity after the procedure, 14 (84%) reported satisfactory sexual intercourse. According to the authors, obtaining adequate
vaginal length was not problematic, and there was no tendency
toward contraction, narrowing, or stenosis, provided that the
pelvic peritoneum was loosened extensively and that anastomosis to the hymen region was generous. No cases of enterocele or
prolapse of the neovaginal vault were reported during follow-up.
The new vaginal epithelium was squamous and had the normal
appearance of a vagina, with minimal granulation in the vaginal
cuff in 16 cases and moderate granulation in two. These observations account for the functional success of the procedure but also
explain the postcoital spotting that may persist in some patients
long after surgery.
Laparoscopic Modification of the Vecchietti Operation
Instrumentation required to perform laparoscopic modification
of theVecchietti operationincludes a thread-bearingcutting needle (Figure 14.6.5), a traction device, and a mobile intruder.
The traction device and the acrylic olive originally developed
420 — Luigi Fedele, Stefano Bianchi, Nicola Berlanda, Eleonora Fontana, and Alessandro Bulfoni
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Figure 14.6.5. Vecchietti’s straight thread-bearing cutting needle.
by Vecchietti are shown in Figure 14.6.6. The traction device and
the pluggable segmented dummy recently developed by Storz
(Karl Storz Endoscopy, Tuttlingen, Germany) are shown in Figure 14.6.7.
After the bladder is emptied by catheterization, adequate
pneumoperitoneum is obtained and a laparoscope is introduced
into the umbilicus. The traction device along with the threads
is temporarily placed on the suprapubic region, and the points
at which the threads pass are marked on the skin. Adjacent to
the markings, two ancillary trocars are introduced to allow accurate exploration of the abdominal and pelvic organs. The trocars
are then removed, and one is replaced by Vecchietti’s straight
thread-bearing cutting needle, which is passed through the loose
subperitoneal connective tissue downward and medially until it
has reached the fold between the bladder and uterine rudiment.
Because it is difficult to separate the peritoneum from the rudiment, the thread-bearing needle is brought out of the peritoneal
cavity and reinserted in the subperitoneum immediately below
the uterine rudiment. At this point, the direction is changed
from lateromedial to craniocaudal so that the cutting needle
crosses the spacebetween the bladderand rectum and reaches the
pseudo-hymen. Before perforating the pseudo-hymen, the
laparoscopist should guide the tip of the instrument, aided by
the insertion of middle finger inserted in the rectum (Figure
14.6.8A). At the same time, the integrity of the bladder is checked
by cystoscopy. The pseudo-hymen is perforated centrally, and
the threads attached to the mobile intruder are hooked (Figure
14.6.8B). When the needle is withdrawn, the threads are brought
back into the peritoneal cavity andarethenbothbrought outward
Figure 14.6.6. Vecchietti’s original instrument setforcreationofaneovagina.
Figure 14.6.7. Instrument set recently developed by Storz for creation
of a neovagina.
Laparoscopically Assisted Neovaginoplasty — 421
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A
C
Figure 14.6.8. Surgical steps of the laparoscopic Vecchietti operation. The thread-bearing cutting needle crosses the recto-vesical space guided
by the operator’s finger. At the same time, the integrity of both the rectum and the bladder is checked (A). The pseudo-hymen is perforated and
the threads hooked (B). The needle is withdrawn and the threades are brought inside the pelvis (C) and then passed subperitoneally through the
abdominal wall (D).
B
D
and passed subperitoneally through the abdominal wall (Figure
14.6.8C,D).
In the last stage of the procedure, the threads are attached
to the traction device and its tension is graduated. When the
traction device is first positioned, traction onthe mobile intruder
must be applied to allow downward movement of the olive by
approximately 1 cm if countertraction is applied. Subsequent
traction must be gradual and progressive, as excessive traction
could cause necrosis of the foveal epithelium, whereas limited
traction would not allow lengthening of the vagina. Graduation
of traction is therefore empiric, but it canbe evaluated adequately
using the degree of distention of the two springs on the traction
device as a reference. Correct traction is achieved if the tension
of the two springs is constantly intermediate between maximum
and minimum tension and identical on both sides.
The traction device and mobile intruder are removed after
the neovagina has progressed to at least 7 to 8 cm in depth,which
may be obtained between the sixth and ninth day after surgery.
Patients can be discharged from hospital 48 to 72 hours after
surgery and then may be seen every 48 hours to adjust the thread
tension. Adequate analgesic therapy is usually necessary on the
day the traction is readjusted.
After this initial period, all women are instructed to use dilators, starting with the smallest and keeping it inserted in the neovagina for approximately 8 to 10 hours per day during the first
month. Although there are various types of dilators, we recommend those that are soft and blunt (Figure 14.6.9). The decision
to progress to a larger dilator is made by the physician at follow-up
examination. After the first month and the start of sexualactivity,
the use of dilators is recommended for shorter periods of time,
taking into consideration the frequency of intercourse as well as
the width, length, and epithelialization of the neovagina.
The dilators are made of soft latex, measure 10 cm long, and
come in three diameters: 1.5, 2, and 2.5 cm. After use, they are
422 — Luigi Fedele, Stefano Bianchi, Nicola Berlanda, Eleonora Fontana, and Alessandro Bulfoni
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washed and sterilized with antiseptic solution or otherwise simply washed and covered with a condom. Intercourse is generally
allowed 20 days after removal of the acrylic olive.
Results
From June 1993 to November 2004, we performed the laparoscopic creation of a neovagina in 106 patients with Rokitansky
syndrome. Anatomic success was defined as a neovagina 6 cm or
longer allowing easy introduction of two fingers within 6 months
after corrective surgery. The report of satisfactory sexual intercourse was considered a functional success. The anatomic and
functional results of the laparoscopic creation of a neovagina are
shown in Table 14.6.2. Anatomic success was obtained in 104
(98%) of the 106 operated patients. In two subjects, the operation did not succeed. One patient refused to use vaginal dilators
after the operation. In the other patient, asmall rectal perforation
was observed 2 days after the operation. Consequently, the Vecchietti device was removed, and the lesion healed spontaneously
without need for surgical repair; the patient was scheduled for a
repeat procedure after a few months.
All patients started experiencing sexual intercourse within 30
days after removal of the device. One hundred and three patients
(97%) reported satisfactory sexual intercourse starting from 6
months after surgery. Only three patients (2.8%) did not obtain
functional success. Two of these patients failed to achieve a satisfactory sexual life because of inadequate length of the neovagina.
A third patient complained of unsatisfactory intercourse 1 year
or more after surgery despite having an anatomically adequate
vagina. She had been diagnosed with Rokitansky syndrome dur-
Table 14.6.2: Results of Laparoscopic Treatment for Creation
of a Neovagina in 106 Patients
Number of patients Percent
Anatomic success
≤6 months 97 (91.5%)
6–12 months 2 (1.9%)
No success 2 (1.9%)
Functional success
≤6 months 40 (37.7%)
6–12 months 53 (50.0%)
≥12 months 10 (9.5%)
No success 3 (2.8%)
∗
Presence of a neovagina at least 6 cm long allowing easy introduction
of two fingers.
†
Report of satisfactory sexual intercourse.
Source: Fedele L., unpublished data
∗
†
ing adolescence but had waited until she was 34 to request the
creation of a neovagina.
Vaginoscopy, Schiller’s test, and vaginal biopsies were also
performed in some patients to compare the epithelium of the
neovagina with that of a normal vagina. Vaginoscopy showed a
vaginal-type epithelium with passive reaction to the Schiller test,
coating 90%of the neovagina 6 months after surgery. All biopsies
of theneovaginashowedanormalsquamousstratifiedepithelium
Figure 14.6.9. Different sets of vaginal dilators. The original Vecchietti dilators (left), Storz dilators (center), and blunt and soft dilators (right).
Figure 14.6.10. Histologic characteristics of a neovagina (lower image)
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and a normal vagina (upper image). The two epithelial layers are very
similar. (Hematoxylin & eosin, original magnification ×100.)
of adequate thickness, rich in glycogen and very similar to that of
the normal vagina (Figure 14.6.10).
Compared with the other laparoscopic modifications of Vecchietti’s procedure, we believe the approach proposed by our
group to be the most advantageous. In fact, our approach does
not require dissectionofthe urethral–vesicorectal space, provides
an almost entirely subperitoneal route for the traction threads,
and is performed in a single laparoscopic stage without the need
for a perineal stage.
Finally,thisprocedureholdstwoother important advantages.
In case of failure, a new surgical operation can be undertaken by
any other technique. In addition, if uterine transplantation [26]
becomes available in the future, Vecchietti’s approach seems the
best approach to permit adequate grafting of the transplanted
organ in the pelvis.
REFERENCES
1. Robert M, Goldwyn MD. History of attempts to form a vagina.
Plast Reconstr Surg. 1977;59:319–329.
2. Mayer CA.Uber Verdoppelungen des Uterus undihreArten, nebst
Bemerkungen uber Hasenscharte und Wolfsrachen. J Chir Augen-
heilkd. 1829;13:525–564.
3. Rokitansky C. Uber die sogenennten Verdoppelungen des Uterus.
Med Jb Osterreich Staates. 1938;26:39–77.
4. K¨uster H.Uterus bipartitus solidus rudimentariuscum vagina solida. Z Geburtshilfe Gynakol. 1910;67:692–718.
5. Hauser GA, Schreiner WE. Das Mayer–Rokitansky–Kuster–
Syndrom.Uterusbipartitus solidus rudimentarius cumvagina solida. Schweiz Med Wochschr . 1961;91:381–384.
6. Aittomaki C, Eroila H, Kajanoja P. A population-based study
of the incidence of mullerian aplasia in Finland. Fertil Steril.
2001;76:624–625.
Laparoscopically Assisted Neovaginoplasty — 423
7. Deligeoroglou E, Christopoulous P, Creatsas G. A unique case of
descending salpingitis and functioning endometrium in a mullerian remnant inawoman with Mayer–Rokitansky–K¨uster–Hauser
syndrome. Fertil Steril. 2005;83:1545–1547.
8. Willemsen WNP. Renal-skeletal-ear and facial anomalies in combination with the Mayer–Rokitansky–K¨uster syndrome. Eur J
Obstet Gynecol Reprod Biol. 1982;14:121–130.
9. Pittock ST, Babovic-Vuksanovic D, Lteif A. Mayer–Rokitansky–
K¨uster–Hauser anomaly and its associated malformations. Am J
Med Genet A. 2005;135:314–316.
10. Strubbe EH, Thijn CJ, Willemsen WN, Lappohn R. Evaluation of radiographic abnormalities of the hand in patients with
the Mayer–Rokitansky–K¨uster–Hauser syndrome. Skeletal Radiol.
1987;16:227–231.
11. Strubbe EH, Cremers CW, Willemsen WN, et al. The Mayer–
Rokitansky–K¨uster–Hauser syndrome without and with associated features: two separate entities? Clin Dysmorphol. 1994;3:192–
199.
12. Fedele L, Bianchi S, Berlanda N, Bulfoni A, Fontana E. Laparoscopic creation of a neovagina and recovery of menstrual function
in apatientwith Rokitansky syndrome: acasereport. Hum Reprod.
2006;21(12):3287–3289. Epub 2006 Aug 17
13. Frank RT. The formation of anartificial vagina without operation.
Am J. Obstet Gynecol. 1938;135:1053–1055.
14. McIndoe AH, Bannister JB. An operation for the cure of congenital absence of the vagina. J Obstet Gynaecol Br Emp. 1938;45:
490–494.
15. Davydov SN. 12-year experience with colpopoiesis using the peritoneum. Gynakologe. 1980;13:120–121.
16. Rothman D.Theuseof peritoneum in the construction of a vagina.
Obstet Gynecol. 1972;40:835–838.
17. VecchiettiG. Creationof anartificialvaginainRokitansky–K¨uster–
Hauser syndrome. Attual Obstet Gynecol. 1965;11:131–147.
18. Semm K. Pelviskopische Kontrolle der neovaginalen Operatiostechnik uber eineGliederoptik. Alete Wissenschaftlicher Dienst.
1983;93:24–27.
19. Gauwerky JFH, Wallwiener D, Bastert G. An endoscopically
assisted technique for reconstruction of a neovagina. Arch Gynecol
Obstet. 1992;252:59–63.
20. Popp LW, Ghirardini G. Creation of a neovagina by pelviscopy. J
Laparoendosc Surg
21. Soong YK, Chang FH, Lee CL, Lai YM. Vaginal agenesis treated
by laparoscopically assisted neovaginoplasty. Gynecol Endosc.
1994;3:217–220.
22. Fedele L, Busacca M, Candiani M, Vignali M. Laparoscopic creation of aneovaginain MayerRokitanskyKuster Hauser syndrome
by modification of Vecchietti operation. Am J Obstet Gynecol.
1994;171:268–297.
23. Soong YK, Chang FH, Lai YM, et al. Results of modified laparoscopically assisted neovaginoplasty in 18 patients with congenital
absence of vagina. Hum Reprod. 1996;11:200–203.
24. Adamyan LV. Therapeuticandendoscopic perspectives.In: Nichols
DH, Clarke-Pearson DL, eds. Gynecologic, Obstetric, and Related
Surgery. 2nd ed. St. Louis: Mosby; 2000:1209–1217.
25. Fedele L, Bianchi S, Berlanda N, Fontana E, Raffaelli R, Bulfoni
A, Braidotti P. Neovaginal mucosa after Vecchietti’s laparoscopic
operation forRokitanskysyndrome: structural andultrastructural
study. Am J Obstet Gynecol. 2006;195(1):56–61.
26. Altchek A. Uterus transplantation. Mt Sinai J Med. 2003;50:154–
162.
27. D’Alberton A, Santi F. Formation of a neovagina by coitus. Obstet
Gynecol. 1972;40:763–764.
28. Ingram J.M. The bicycle seat stool in the treatment of vaginal
agenesis and stenosis: a preliminary report. Am J Obstet Gynecol.
1981;140:867–873.
. 1992;2:165–173.
424 — Luigi Fedele, Stefano Bianchi, Nicola Berlanda, Eleonora Fontana, and Alessandro Bulfoni
https://t.me/med1917
29. Baldwin J.F. The formation of an artificial vagina by intestinal
transplantation. Ann Surg. 40:398–403, 1904.
30. Popoff DD. Russk. Vrach. St Petersburg 1910;60:1512–1514.
31. Schubert G. Uber Schidenbildung bei Angeborene Vaginal Defekt.
Zentralbl Gynacol. 1911;35:1017.
32. Graves WP. Surg Clin N Amer. Chapter I, 1921;611–612.
33. Frank RT, Geist SH. The formation of an artificial vagina by a new
plastic technique. Am J Obstet Gynecol. 1927;14:721–728.
34. Brindeau A. Kunstliche Scheide mit Hilfe einer reifen Eihaut. Zen-
tralbl Gynak. 1934;59:1196–1197.
35. Wharton LR. Asimple method of constructing a vagina. Ann Surg.
1938;107:842–849.
36. Williams EA.Congenitalabsence of the vagina.A simple operation
for its relief. J Obstet & Gynecol Br Commonw. 1964;71:511–512.
37. Davydov SN. Colpopoiesisfrom theperitoneum of the uterorectal
space. Akush Ginekol (Mosk). 1969;45:55–57.
15 LAPAROSCOPIC TREATMENT OF CHRONIC
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PELVIC PAIN
Section 15.1. Presacral Neurectomy
James E. Carter
Presacral neurectomy is useful in the treatment of severe, disabling dysmenorrhea secondary to endometriosis andpelvic pain
associated with pelvic inflammatory disease.[1] The efficacy of
presacral neurectomy for the relief of midline dysmenorrhea was
confirmed by a randomized study performed at the Johns Hopkins University School of Medicine.[2] Tjaden used the surgical
technique first described in 1899 by Jaboulay [3] and Ruggi.[4]
Black [5] estimated a 75% to 80% success in 9937 cases of presacral neurectomy. Laparoscopic techniques forpresacralneurectomy have been described by Perez [6], Biggerstaff[7], Carter [8],
Chen [9], and Nezhat.[10]Kwok [11] reviewed laparoscopic presacral neurectomy and concluded that patients for whom this
operation is recommended should be carefully selected. They
should have midline dysmenorrhea as the main symptom and
should have failed or not tolerated medical therapy. Presacral
neurectomy has been shown to have long-run effectiveness for
the treatment of severe dysmenorrhea due to endometriosis.[12]
As has been pointed out by Stones and Jacobson [13,14], a percentage of womenwith chronic pelvicpain and/or dysmenorrhea
do not respond or respond poorly to medical treatment. Surgery
may represent the final therapeutic option for these patients. In
a prospective double-blind randomized, controlled study, Zullo
et al. [15] demonstrated the effectiveness of presacral neurectomy for women with severe dysmenorrhea due to endometriosis who had been treated with conservative laparoscopic surgical
intervention. The authors continued to follow their patients for
an additional year and published on the 2-year success of this
procedure. They found a significant reduction in the frequency
and severity of dysmenorrhea, dyspareunia, and chronic pelvic
pain observed 24 months after surgery. The addition of presacral
neurectomy was also associated with significant improvement in
quality of life. In the conclusion to the study, Zullo et al. [12]
stated, “We demonstrate that presacral neurectomy is a safe and
useful surgical procedure to improve the cure rate and the quality
of life in patients with severe dysmenorrhea treated with laparoscopic conservative surgery based on along-term followup oftwo
years, but chronic constipation and/or urinary urgency may be
consequences of this therapy.”
ANATOMY
Pain impulses from the cervix, the body of the uterus, and the
proximal fallopian tube are transmitted through afferent fibers
that accompany sympathetic nerves into the spinal cord at the
thoracic and lumbar levels. The sympathetic nerves that emerge
from the uterus pass through the uterosacral ligament along the
cardinal ligament and join the pelvic plexus. Parasympathetic
fibers from S1 through S4 travel with the phrenic nerve through
the pelvic plexuses (Frankenh¨auser ganglia) lateral to the cervix
to reach the bladder, rectum, and uterus.
The presacral nerve is a plexus of nervesknownasthesuperior
hypogastric plexus. Kwok[11]elegantlysummarizedtheanatomy
of the pelvic autonomic nerves as originally described by Curtis
[16]:
The lumbar and lower thoracic sympathetic ganglia, and
the superior, middle, andinferior hypogastric plexus pro-
vide the afferent pathways for the pelvic viscera. How-
ever, an exception to this is the pain afferent fibers from
the ovaries and distal fallopian tubes, which travel to the
ovarian plexus, and then via the infundibulopelvic liga-
ments to theaortic andrenal plexuses. Thesigmoid colon
sends visceral afferents to the inferior mesenteric plexus.
Interruption of the presacral plexus will affect a decrease
in central pain perception and perhaps also a change in
the function of the sigmoid colon. Pain afferents from
the uterus and cervix and proximal part of the fallop-
ian tubes travel with the sympathetic nerves and travel
via the uterosacral and cardinal ligaments to join with
the pelvic plexus. (Frankenhauser’s ganglion, uterovagi-
nal ganglion)
The fibers from the pelvic plexus course proximally to
become the inferior, the middle hypogastric plexus over
the sacral promontory,and then the superior hypogastric
plexus. The ‘presacral nerve’, the common name for the
superior hypogastric plexus, is a misnomer because it is
actually pre-lumbar in position and lies in front of the
fifth lumbar vertebrae. In addition, it is usually not a
nerve but rather a nerve plexus. It is a single trunk in only
approximately 20% of the anatomical sections.[11]
The presacral nerve is a direct extension of the aortic
plexus below the aortic bifurcation. This plexus spreads
out behind the peritoneum in the loose areolar tissue lying
over the fourth and fifth lumbar vertebrae. Between the
vertebrae and the presacral nerve lies the middle sacral
artery, which may be traumatized during surgical dissection. In a series of 30 cadaveric dissections, Curtis et al.
[16] reported 75% of the time the superior and middle
hypogastric plexus lie onthe left, 25% in the midline, and
none on the right. On the right of the presacral nerve, lie
the right ureter and common iliac vein and artery.On the
left lie the sigmoid colon, inferior mesenteric vessels, and
the left ureter. The left ureter is seen less commonly in
surgical dissections because it is obscured by the sigmoid
colon.[11]
425
426 — James E. Carter
https://t.me/med1917
When performing presacral neurectomy, the surgeon will
encounter variable anatomic findings. For this reason, the nervebearing tissue, especially on the left, should be thoroughly
exposed when performing the procedure.[17] In 8% to 15% of
dissections, the mesocolon was over the area of the presacral
nerve, making neurectomy difficult or impossible.[17] Labate
[18] found a single nerve in 8% to 13% of dissections. In 75 dissections, he found a plexus in 84% of the cases, parallel nerve
trunks in 8%, and single nerves in 8%.
Within the interiliac trigone, the common iliac artery and
ureter are on the right and the common iliac vein is on the left.
The inferior mesenteric, superior hemorrhoidal, and midsacral
arteries are in the center of the prelumbar space. This trigone
is defined caudally by the sacral promontory and laterally by
the common iliac arteries. The superior edge of the triangle is
delineated by the aortic bifurcation. Centrally and to the left,
multiple nerve fibers, sometimes in bundles, run caudally from
the aortic plexus above and through the interiliac trigone to form
the superior hypogastric plexus. These fibers, representing the
presacral nerve, are buried in loose areolar tissue. They display
no particular patterns and vary among individuals. Both ureters,
which lie to the right and left of the trigone, are identified before
transection of the nerve bundle continues. The left ureter is more
difficult to see because it lies underneath the rectosigmoid and
mesocolon.
INDICATIONS
Ringer’s solution
infused under
peritoneum
for hydrodissection
Cruciate
incision
sites
Colon
Inferior
mesenteric a.
Figure 15.1.1. The peritoneum over the promontory is elevated with
grasping forceps, and a small opening is made with the CO
scissors or any other cutting modality.Thesuction–irrigator is inserted,
and the peritoneum is elevated by hydrodissection. The peritoneum is
excised horizontally and vertically, and the opening is extended cephalad until the bifurcation of the aorta is seen. From Nezhat et al.[28]
Sacral
promontory
AO
IVC
Peritoneum
lifted
R. common
iliac a. & v.
Ureter
laser or
2
The presacral neurectomy is indicated for patients who have
disabling midline dysmenorrhea and pelvic pain and have not
responded to appropriate and adequate medication. The operation is likely to relieve pain in 50% to 75% of patients. When
associated with complete resection of endometriosis, cure rates
are improved.
Presacral neurectomy does not alleviate adnexal pain because
ovarian innervation originates from the ovarian plexus, a meshwork of nerve fibers that arise from the aortic and renal plexuses
and accompany the ovarian artery throughout its course.
TECHNIQUE
After associated pelvic abnormalities have been treated, the steep
Trendelenburg position is used and the patient is tilted slightly to
the left. The aortic bifurcation, common iliac arteries and veins,
ureters, and sacral promontory are identified. The peritoneum
overlying the promontory is elevated with grasping forceps, and
a small opening is made with the CO
laser, scissors, or other
2
cutting modality (Figure 15.1.1).
The suction–irrigator is inserted through this opening, and
the peritoneum is elevated by hydrodissection. The peritoneum
is incised horizontally and vertically, and the opening is extended
cephalad to the aortic bifurcation (Figure 15.1.2). Bleeding from
the peritoneal vessels is controlled with the bipolar electrocoagulator. Retroperitoneal fatty tissue is removed before the
hypogastric plexus is reached. The mesocolon does not cover
the sacral promontory in most patients. If the mesocolon covers
the sacral promontory, the procedure is more difficult, and the
surgeon must avoid injuring the inferior mesenteric artery and
L. common
iliac vein
Sigmoid
colon
R. common
iliac a. & v.
Figure 15.1.2. Retroperitoneal fatty tissue is removed before the
hypogastric plexus isreached. Hemostasis is achieved with bipolarelectrocoagulation. From Nezhat et al.[28]
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