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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Step 3: Descent of the peritoneum
The dissected peritoneum is opened and pulled toward the vulva using four vicryl sutures.
It is then connected with the vulvar epithelium. Commonly a mold measuring approximately 3.2 × 11 cm long is used.
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One or two absorbable purse-string sutures are then used via abdominal approach to close the peritoneum over the mold.
https://t.me/med1917
Step 4: Securing the mold
Labial sutures are placed to keep the mold in the desired location for 1 week.
A Foley catheter is placed to decompress the bladder for the same time period.
https://t.me/med1917
POSTOPERATIVE CARE
The patient is instructed in changing and cleaning the mold: After the first week, the mold is removed only for showering and
urination/defecation. After that the utilization (wearing) time of the mold is gradually decreased on an individual basis.
Intercourse can be undertaken after 5 to 7 weeks postoperatively. Once regular intercourse has been established, the mold
can be used less frequently.
https://t.me/med1917
OUTCOME: RESULTS AND COMPLICATIONS
Willemsen and Kluivers
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evaluated the long-term results using the Frank and Davydov procedure in 160 patients, of which
68 underwent the Davydov procedure. The mean time until complete epithelialization of the neovagina was reached with
the Davydov procedure was 11 months with a mean functional vaginal length of 7.8 cm. Complications overall were rare
and mainly included the formation of granulation tissue, fistulas, and strictures of the neovagina. However, one patient died
in the surgical group. The cause of her death was determined to be hepatotoxicity secondary to anesthetic medications.
One advantage using peritoneum was that this tissue functions like vaginal epithelium with regard to hormonal changes and
lubrication during intercourse.
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Surgical Management: Laparoscopic Sigmoid
Vaginoplasty (Ruge Procedure)
This procedure uses sigmoid colon for epithelialization of the neovagina. The surgical approach can either be simultaneously
vulvar and abdominal (either open or laparoscopic) in most reports, or via abdominal approach only.
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Originally described as
an open abdominal procedure via Pfannenstiel incision, it is now often performed laparoscopically. This technique requires a
mechanical intestinal preparation with polyethylene glycol and a rectal enema 36 hours preoperatively.
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Step 1: Laparoscopic creation of a vaginal space
Standard laparoscopic abdominal entry is performed.
Starting from the pouch of Douglas toward the peritoneum, the space between the bladder and rectum is dissected, using
sharp and blunt dissection. It can also be created starting at the perineum working toward the peritoneal cavity.
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Step 2: Preparation of the sigmoid graft
The sigmoid colon is mobilized and a 15- to 20-cm long loop above the rectosigmoid junction is visualized. The goal is to
obtain a pedicle on a single artery, usually the third inferior sigmoid artery. Examining the vascular anatomy can be done by
transilluminating the mesosigmoid.
The distal sigmoid border is delineated with a GIA
TM
60 mm Stapler (GastroIntestinal Anastomosis Auto Suture, US
Surgical Corp, Norwalk, CT).
The proximal sigmoid border can be attached to a surgical clamp.
End-to-end anastomosis on the remaining sigmoid is performed via a PCEEA 28 or 31 mm forceps (Premium Plus Circular
End to End Anastomosis, Auto Suture, US Surgical Corp, Norwalk, CT).
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Step 3: Anastomosing the graft
The isolated sigmoid segment is pulled toward the perineum through the previously created channel. It is important to avoid
any traction on the supporting blood vessels.
The colovestibular anastomosis is connected using interrupted polyglactin 3–0 sutures.
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Step 4: Securing the graft
Two polyester stitches are used to secure the top portion of the neovagina to the promontory fascia.
The mesosigmoid and the abdominal cavity are closed in the standard fashion.
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POSTOPERATIVE CARE
A Foley catheter is placed for 3 days postoperatively, and perioperative antibiotics are continued for the same time frame.
One month postoperatively, an exam under anesthesia is performed, followed by a second exam in the office 1 month later.
It is important to check for graft integrity and granulation tissue. If healing has occurred, either intercourse or Hegar dilators
(usually once every 2 to 3 days, #26 or #27 size) can be attempted.
https://t.me/med1917
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