Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана

laparoscopic approach either at the same time or in sequence. The only exception is the Abbe–Wharton–McIndoe procedure,

where the patient is first placed on her abdomen in order to obtain the graft from the patient’s buttocks. After that, the patient

laparoscopic approach. Surgical preparation should be performed accordingly. They can also be divided depending on what

tissue is used to create the neovagina: peritoneum, intestine, split-skin grafts, or vulva.

1. Abbe–Wharton–McIndoe operation

3. Davydov laparoscopic procedure

4. Laparoscopic sigmoid vaginoplasty (Ruge)

6. Laparoscopic vaginoplasty using single peritoneal flap (SPF)

Frank dil ati on (active dilation)

The patient administers dilators in increasing length and width on a daily basis to the perineal area or vaginal pouch, if one is

already present.

This change in direction is important to prevent damage to the urethral opening. The dilators should be applied twice daily for

more physiologic results with regard to vaginal pH, lubrication, and hormonal cytology throughout the menstrual cycle.

patient is instructed on how to place the dilator, which is held in the desired location with supportive underwear and regular

clothes worn on top. She then sits on the bicycle stool, leaning slightly forward, with the dilator in place for at least 2 hours

can be attempted once the largest dilator has been used for 1 to 2 months. Continued dilation should be recommended if

intercourse is infrequent. Functional success has been documented in 91.9% of patients using this method.

advantages of this treatment compared to Frank dilation are twofold: The patient does not have to press the dilator against the

vaginal pouch herself, and the neovaginal space is evenly dilated. Passive dilation has been shown to be successful and can be

suggested as an initial therapy, with operative vaginoplasty indicated for failed dilation.

This procedure entails a purely vaginal approach and uses an STSG from the buttock area.

The skin is disinfected with povidone–iodine, which is then removed.

Mineral oil is placed on the donor site. While assistants stretch the buttock area, a Padgett Electro-Dermatome (Integra,

If the buttock is not large enough to provide the entire graft, half of the length can be taken from each buttock. Pressure

should be applied evenly so that the graft is continuous.

The graft is placed in between moistened gauze.

The donor sites are dressed using diluted epinephrine (as a hemostatic agent), following a sterile dressing and a pressure

dressing. The pressure dressing can be removed after 7 days, and the sterile dressing will eventually separate and fall away.

The space between the bladder and urethra (anteriorly) and rectum (posteriorly) is dissected up to the peritoneum. Placing

a catheter in the bladder and a finger in the rectum helps to stay in the desired plane. One channel can be created bluntly on

The midportion of the medial margin of the puborectalis muscle may be incised bilaterally to prevent vaginal narrowing at

the urogenital diaphragm. This is especially important in an android pelvis, such as in the case of androgen insensitivity.

The dissection should leave some tissue beneath the peritoneum so that the graft is more likely to adhere to the site.

All blood vessels should be ligated using thin suture in order to prevent separation of the graft and subsequent necrosis.

The original McIndoe technique used a rigid balsa wood to shape the skin graft.

A newer technique, the Counseller-Flor

molds into the neovaginal space. The condom is tied off at the base at this point, using 2–0 silk, and the form is withdrawn.

The mold and the condom are both covered by a second condom and tied off.

sutures with 5–0 nonreactive suture.

It is important to not leave any gaps, because granulation tissue may develop and this can lead to contraction.

nonreactive absorbable sutures, leaving room for drainage.

A Foley catheter is placed in the bladder or a suprapubic catheter can also be used to decompress the bladder.

The labia are sutured together with nonreactive sutures to keep the mold in place.

tissue, and no necrosis. Too much pressure, specifically superiorly and posteriorly toward the cul de sac, can cause

weakening of the tissue and lead to enterocele formation.

The patient is given the following instructions: to remove the mold daily and to irrigate the vagina with saline. The patient