Question

Laparoscopic Vaginoplasty - With Absent Vagina, Can She Have Her Own Genetic Baby With MRKH Syndrome?

Dr.Pragnesh Shah · Accepted Answer

Patient s parent s visits to us when their daughter does not menstruate after the age of 15-17 years of age for her fertility concern & for planning surgery before her marriage. This operation is advised for Phenotype female i.e. normal secondary sexual characters & Genotype XX.

Objective:

In-patient with absent uterus is evaluated for associated renal malformations by USG & SOS IVP. As compared to commonly practiced method (skin graft from thigh & putting on neo vagina) patient s on peritoneum is utilized for covering neo-vagina for Vaginoplasty. Vaginal space is dissected in usual way from below and laparoscopic access helps in avoiding injury to bladder & rectal injury. This technique gives two cms wide vagina & 8-10 cms long vagina and good quality of sexual function and patient discharged on the next day with minimum postoperative care. This surgery requires lot of experience & expertise.

Benefits of Laparoscopy Surgery:

Shorter Hospital stay,
Earlier return to your routine work,
Cosmetically vary small scar,
Less pain after operation,
Best fertility enhancement & Fertility results following Laparoscopy,
Video-live operative file available in CD/DVD for future reference (Transparency about surgical procedure).
The possibility of post-operative adhesion formation will be less, and the possibility of pain because of post-operative adhesions will also be less.
The special advantages with our technique are:

Next day discharge,
No plastic surgery for skin graft so no post-operative dressings,
User friendly post-operative care by patient by using vaginal stent every night following operation till she starts actual sexual relation with her husband 6 weeks after laparoscopic Vaginoplasty.
Pre-operative Check Lists:

Lab. Investigation for Surgery (Urine complete & Blood complete, HbsAg, HIV, R.B.S.); Pelvic Trance vaginal USG report for renal malformation.
Operation planned at about 1.5 to 2 months prior to her proposed Marriage.
Enema & preparation/shaving of local parts.
No. Of Cuts on Abdomen:
Three cuts: all of 5 mm size.

Average Stay in Hospital:
24 hours.

Average Duration of Surgery:
40-60 minutes

Average Blood loss during Surgery:
10-30 cc

Average time after operation to resume normal activities/work:
Within 24 hours.

Anesthesia:
General Anesthesia (Patient will not feel any pain in Operation Theatre during surgery)

Operative Procedure:

Inside the Umbilicus small needle is introduced and Co2 gas is insufflated inside abdomen. Rather than creating a large incision and opening up the body, tiny incisions are made and a laparoscope is inserted. This slim scope has a lighted end. It takes pictures actually fiber optic images - and sends them to a monitor so the surgeon can see what is going on inside.

Performing laparoscopy usually only requires three tiny incisions less than one half inch, (about 5-10 millimeters) in length. One incision is made inside the navel, and another is usually made near the bikini line. The first incision allows a needle to be injected into the abdomen so carbon dioxide gas can be pumped inside the cavity of the abdomen, which helps to keep intestines & omentum up and away from organs. This allows the surgeon a better view and more working space to maneuver the laparoscope and surgical tools as needed. Using small incisions rather than opening the abdomen lessens recovery time as well as discomfort and makes surgical scars less noticeable.

Vaginal space is dissected in usual way after putting Folly s catheter in urethra and rectal probe in rectum by 3 cms long incision at labia minora. Laparoscopic light & pnumo helps during vaginal dissection. Peritoneum is cathched with two artery forceps, opened from below under laparoscopic guidance and edges of the catched peritoneum is circumferentially mobilized down till we can take tension free stitch with dissected & pulled peritoneum & labia minora by few No1/0 Vicryl figure of 8 stiches. Then vagina is closed with mop to prevent leakage of pneumoperitoneum from below and laparoscopically neo fornices are created at the level of pelvic brim by purse string stitches taken to close vaginal upper end with No-1 Vicryl stitch & approximating with extra corporeal knot. This technique gives two cms wide vagina & 8-10 cms long vagina and good quality of sexual function and patient discharged on the next day & with minimum requirement of postoperative care.

Post-operative Course:

Patient remains drowsy/sedated for 2-3 hours after laparoscopy but conscious & pain free.
Patient can take fluids 3-4 hours after laparoscopy & light food after 4-6 hours.
She may feel little abdominal & shoulder pain after laparoscopy for 24 hours but it cam be relived with pain killer tabs.
Most of the patients can walk normally without support and can take normal diet 6-8 hours after the laparoscopy.
She can be discharged on the same day of the operation.
Few patients may feel nausea & vomiting after laparoscopy, which can be very well controlled with injection in post-operative room.
Folly s catheter is removed on next day.
Patient is advised to prepare vaginal stent from 10/20 cc syringe with gauze pieces applied around it and then condom is applied on it and then xylocaine jelly with soframycin applied on stent which is advised to put the same in vagina gently every night, till she starts actual sexual relation 45 days after operation.
Patient can do her normal activity within 24 hours after laparoscopy. Patient is advised to take antibiotics & analgesic tabs. for 5 days following laparoscopy.
Patient is advised to report to doctor for severe pain or bleeding or fever in postoperative period (Day-1 to Day-5) immediately.
Patient is advised to come for follow up 7 days after the Laparoscopy for dressing.

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