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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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OUTCOME: RESULTS AND COMPLICATIONS
Per Communal,
20
good anatomic results were obtained with this method in 16 patients, with no significant intra- or
postoperative complications.
Functional results were assessed via a patient questionnaire that mentioned 50% dyspareunia during the first year. This
number is equivalent to other techniques. Overall, good lubrication of the sigmoid graft has been reported.
Disadvantages include excessive mucous discharge, introital stenosis, and prolapse of the mucosa. Furthermore, only small
patient numbers have been evaluated.
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Surgical Management: Vecchietti Procedure
This procedure was first described in 1965
21
with a laparotomy approach and has since then been modified in several ways,
the most important modification being the laparoscopic approach
22–24
with similar outcomes.
25
The Vecchietti technique
creates a neovagina in as short as 9 days time. Specific equipment including a traction device, acrylic olive, and ligature carrier
is required. This equipment can either be purchased (Marina Medical, Sunrise, FL) or be self-prepared.
26
,
27
In summary, an
olive-shaped dilator is placed on the perineum and pulled toward the peritoneal cavity via traction sutures anchored in the
rectus muscles and a traction device on the abdomen.
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Step 1: Laparoscopic entry and placement of probes
Three 5-mm laparoscopic ports are placed: one in the umbilicus and one each in the right and left lower quadrant, about 10
cm below the umbilicus and 10 cm lateral to the midline.
A Foley catheter is placed in the bladder with a probe to deflect the bladder, as well as a probe in the rectum.
https://t.me/med1917
Step 2: Pl acement of the olive and traction sutures
The olive-shaped dilator is placed on the perineum with its traction sutures attached.
Through one of the lower ports, the straight Vecchietti needle is introduced subperitoneally (extraperitoneally) in order to
minimize damage to intraperitoneal structures. For this, the port has to be removed and the needle guided subperitoneally
and laterally to the rectus muscle until it can be inserted into the rectovaginal space. To minimize rectal or bladder injury, the
needle can be guided by a finger in the rectum, and the bladder is deflected anteriorly.
One of the traction sutures on the olive is hooked on the Vecchietti needle and pulled back through the rectovesical space
and subperitoneally exiting outside of the body through the trocar incision.
The same procedure is repeated with a Vecchietti needle introduced through the other lower port.
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Step 3: Closure and tightening of the traction device
The peritoneum is closed using 2–0 absorbable suture.
The two sutures are attached to the traction device that is placed on the lower abdominal skin and fixed.
By tightening the traction device daily (per manufacturer’s instructions), constant traction on the olive will create
lengthening of the neovagina, at a rate of up to 1.5 cm per day.
The traction sutures and traction device are removed once the neovagina has a length of 7 to 8 cm.
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POSTOPERATIVE CARE
The Foley catheter needs to stay in place during the traction phase, and the patient is usually hospitalized for 2 to 3 days.
After removal of the olive, the patient performs continued self-dilation with dilators of increasing size per physician
discretion.
Intercourse can be allowed as early as 20 days after the olive is removed.
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OUTCOME: RESULTS AND COMPLICATIONS
Different studies evaluating the long-term outcome of the laparoscopic Vecchietti procedure overall report good sexual
satisfaction rates up to 94%, in 86 patients and low complication rates.
24
The most common complications were bladder or
rectal injury.
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Surgical Management: Laparoscopic Vaginoplasty
Using A Single Peritoneal Flap (SPF), (Video 1.2.1 )
This concept is relatively similar to the Davydov procedure, but it uses an SPF only. This peritoneal flap is obtained by
mobilization of the supravesical peritoneum to the level of the umbilicus and combined with the use of a glass mold. It was first
described by Zhao et al.
28
in 2015 in 83 patients and may be easier to perform compared to the Davydov procedure.
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Step 1: Laparoscopic creation of single peritoneal flap
Entry into the abdomen is performed via standard laparoscopy.
The space between the bladder and overlying peritoneum is injected with normal saline and dilute adrenaline (1:200,000),
which leads to bulging of the supravesical peritoneum. This bulging part is then detached from the bladder with scissors.
Landmarks for the incision are the round ligaments, medial umbilical ligaments, and the fibrous strands which would connect
any rudimentary horns.
With the help of this tissue, an SPF is formed measuring about 10 × 10 cm. This SPF is still connected to the peritoneum
close to the umbilicus.
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Step 2: Creati on of a neovaginal space via perineal approach
A neovaginal space is created by injecting the rectovesical space with saline and adrenaline (1:200,000 dilution). For this, a
10-cm long needle is inserted through the rectovesical space starting from the perineum and advanced toward the peritoneal
cavity. Next, a transverse incision is made between the labia minora, and using sharp and blunt dissection, a neovaginal
space is created up to the separated peritoneum. It is important to secure good hemostasis.
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