V07-03: Robotic ileo-vaginoplasty in a patient with congenital vaginal agenesis.
Vaginal agenesis is a rare congenital disorder of female genital tract, with patient usually presenting to us in late adolescence. Vaginal reconstruction using bowel segment, in view of its invasive nature, is usually offered when dilatation and/or prior vaginal reconstruction attempts using graft or local flap has failed. Traditionally, this is accomplished using open surgical approach. We describe here our experience of robotic-assisted ileovaginoplasty in a patient with vaginal agenesis, and as per the published literature, it is the first reported case of vaginal reconstruction performed minimal invasively.
The index patient is a case of Meyer Rokitansky-Kuster-Hauser syndrome presenting to us with vaginal agenesis with previously failed, but compliant to, vaginal dilatations and inadequate vaginal depth resulting after buccal mucosal graft vaginoplasty.
With the patient in low lithotomy position, abdominal access was made using Hassan’s technique. After appropriate port placement and docking of the robot, the isolation of ileal segment (future vagina) and closure at its abdominal end and subsequent bowel anastomosis was accomplished successfully robotically. However, in view of dense adhesions (resulting from prior vaginal reconstruction) a safe plane could not be developed safely into the perineal space. Subsequently, we completed the pull-down of the ileal segment using both abdominal (using Pfannenstiel incision) and perineal approach. There were no intra-operative complications. The EBL was 5 ml. The total operative time was 462 minutes, with console time being 160 minutes. A vaginal stent was placed in the ileal segment, and another catheter placed into the introitus post-operatively and secured tight. Nasogastric tube was removed day 2. Sips of clear liquid diet started day 2, regular diet was started on day 3. Patient was discharged on day 5. Patient was advised to activity as tolerated with avoidance of exertion and straining. A follow-up Cystoscopy and examination under anesthesia performed 2 weeks later revealed a vaginal depth of 12 cm. A 22 F vaginal dilator could be placed without any difficulty. The patient reports successful dilatation after removal of vaginal stent.
Robotic reconstruction of vagina using bowel segment in select patient, is safe and feasible, but possible with formidable surgical experience.